No. 15. August 19, 1826.

LECTURESON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispensary, Aldersgate-street.

LECTURE XXXVII.

Of Hydrothorax.

Gentlemen,THIS name is given to a dropsical ar-

cumulation of serous fluid in the sac otthe pleura. The disease may exist on

either side, and that singly. Hut morecommonly, flnid is found on both sidesafter death, though uneqnally. Whenfluid is found on the lett sid of the chest,there is generally some also in the peri-cardium.The symptoms of hydrothorax are laid

dnan by Dr. Cullen with much clearness.There is dyspnœa: (by which you are tounderstand simply difficult breathing,without any allnsion to the cause inducingit, which may he very various) ; difficnltyin lying in the horizontal position, withsudden starting from sleep, aud a dreadof suffocation; often with palpitation ofthe heart. The face is pale, and oftenbloated ; the feet and ancles commonlyaxell; and the nrine is scanty. Whenthe quantity of fluid accumulated in thechest is very large, fluctllation may some-times he perceived between the riba, orwhen the trunk of the body is stronglyagitated. The pulse is hard, frequent,and often irregular. The tongue is dryand turred in most cases ; and there isgenerally conglr, and more or less of painsi tile chest.

It has been attempted to discriminate.nween hydrotorax and hydropspericar-

b) satrng that, in the latter, the pa.

tient breathes most easily upon leaningforwards over a table, or the like ; while,in hydrotorax, the breathing is easiest inthe erect posture: the supposition being,that in those postures respectively, thefluid gravitates most out of the way ofthe heart and lungs. It is doubtful, how-evpr, whether this distinction can bemuch relied upon. But, in fact, the twoaffections are mostly combined in thesame subject.

Theory.—Hydrothorax is very generally(I believe I mtght say itivariabiv) the con-sequence of inflammation of the pleura.It is not, however, in the most recentand active stage of the inflammation, thatserous accumulation is apt to take place ;but in milder states of the disease, andwhen the inflammation is on the declinebut in general before it has wholly sub.sided.

Prognosis.—Although this, upon thewhole, is unfavourable, mauy cases ofhydrothorax do well under proper treat-ment. Success depends upon the degreeof injury the parts may have sustainedin then’ organisation ; and this again,upon the degree and duration of the in.flammation in which the disease is found-ed. If the disease is recent, the patientnot far advanced iii life, and the habitand general strength tolerably good, youmay entertain a reasonable prospect ofsuccess. But in general, the circum.stances altogether are the reverse of this ;and the disease, therefore, in most in-stances, proves fatal.

Treatment.—Your first object shouldbe to iuquire into the existence of inflam.mation, because, if this be present, no

good can be done till it, removal is ac-

complished. The presence of iuflamma-tion is ascertained by the common signs,viz., pain in the chest, a quick and hardpnlse, and dryness and foulness ot the

tongue, with thirst. If these signs pre-sent themselves, the common remediesfor inflammation are to be resorted to.If the subject is not far advanced in life.and still retains a moderate share ofgeneral strength, as is not unfrequently

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the case, bloodletting is to be consideredas the most important of our means of!cure. Great caution, however, is neces-sary in the application of this herculeanremedy, so as not to carry it to an im- ’Bproper length. You must constantly bearin mind, that the inflammation in thesecases is of a chronic and often indolentkind, in which large bleeding is whollyinadmissible, What I wish to recommendis, very small and repeated bleedings, atintervals of a few days ; hardly ever ex-ceeding four or five ounces at a time.This practice, applied under proper cir-cumstances, you will find to be not onlysate, but in many cases effectual, as Iknow from repeated trials. And where,from the iujnry done to the structure, bythe long continuance of the disease, a.

cure is impossible, bloodletting is still ca-pahle of affording relief. In addition to;this, Misters are often useful.The good effects of this plan are, that’

the pain in the chest is relieved, the fe-brile symptoms abated, and the appe-tite improved: respiration becomes easier,and the sleep is rendered more refreshing.;ldot unfrequently, in addition to these,advantages, the effnsed fluid begins to be;taken up spontaneously, so that no fnr-,ther remedies are required. Should this,however, not be the case, we may haverecourse to the usual diuretics ; as the;squill, combined perhaps with calomel,nitre, or the acetate of potass, but parti- cularly the infusion of digitalis, which hasthe double advantage of being anti-in-flammatory, as well as most powerfullydiuretic. Should these not succeed, theelaterium,. cautiously administered, as inquarter or half-grain doses, will often dowonders in promoting absorption. If thesemeans altogether fail, the failure is per-haps to be ascribed rather to the disor-

ganization of the parts concerned, thanto the insufficiency of the remedies em-ployed.

Of Inflammation of the Substance of theLungs.

When the substance of the lungs is at-tacked by inflammation, exclusive of thepleura, there is but little pain experi-enced, and not at all in proportion to thedegree of the disease. There is common-

ly, however, more or less of pain felt, andwhich may be variously seated in the

chest, according to the seat of the in-flammation. Sometimes the pain shootsthrough from the front to the back, andis often felt under the shoulder blade;sometimes about the top of the shoulderor clavifie ; and not nnfreqnently aboutthe middle of the arm. These pains in

the back, shoulder, and arm, ar- oftenmistaken for rheumatism, especially bythe patient himself, so that yon must beon your guard against this. Instead ofpain, there is at times ouly a sense of

( weight or oppression complained of.When you have not pain to gnide youto the seat of disease, your judgmentmust be formed chiefly from the state offunctions, that is, from the state of re.spiration principally, though other func.tions will be often disturbed also, as Ishall presently mention.

Theory.—Now to understand this, youhave only to recollect that inflammation,in so loose a texture as that of the lungs,must of necessity, be attended with aswelling of the part inflamed. This will

! produce pressure upon both the blood,

vessels and air-vessels of the part, and so doubly interfere with the process of re.spiration ; for neither can air enter into

the lungs at this part, nor can the bloodpass with sufficient freedom through theminute branches of the pulmonary artery! and vein in the inflamed part. It’ theinflammation be of small extent, no sen.ous inconvenience may be experienced,’ because there is no material impedimenti to the function of respiration altogether;and the system may not suffer in con-

sequence. But in proportion as the dis,ease is extensive, so must be its import-: ance in regard to the general health ofthe body, and even to life itself.

. When the lungs become generally orextensively inflamed, as is sometimes thecase, the symptoms are of the most alarm.ing and dangerons kind ; for in additionto the common signs and effects of in-

flammation, namely, pain or uneasiness inthe part, with a general febrile state of

system, there is an impediment or inter.

ruption of a function that is imll1edi.telyessential to life, and which cannot beeven partially interfered with, at least inany considerable degree, without greatdistress to the patient, and much injury toa variety of other functions. These, Ishall now proceed to point ont to you.

It is the bronchial artery (that vesselwhich is destined to nourish the lungsand not the pulmonary artery, that il

essentially the seat of the inflammator,the pulmonary artery being passive o0the occasion. No doubt, the coats of thisvessel, as of any other, may participate mthe disease; but this does not appear tobe essential.

Symptoms.—The history I am now to

give you must be considered as applvingonly to the more severe and extensivecases of inflammation of the lungs. Ttt

slighter affections of this sort, not intrr.

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fering materially with the respiratoryfunction. are, of course, marked by feweraud trivial characters. The symptomsthen of violent and dangerous inflamma-don in the lungs are various, and followin a certain order, one arising out of, anddepending upon, another. Now it is of

importance that you should mark theseries and dependence ; as, in practice,onr chief attention should be directed to

the primary symptoms, rather than thesecondary, or still more remote ones ; be-cause the removal of the latter has nonecessary tendency to relieve the essentialpart of the disease, the inflammation, butrather the contrary. Thus it; as is oftendone, yon were to give stimulants in orderto relieve the general prostration ofstrenght that takes place in the advancedstage of the disease, you would be likelyto aggravate the inflammation, and thatwithout a possibility of accomplishing theobject you had in view.

1. Pain in the chest.-Tlie natural in-

sensibility of the lungs renders pain anequivocal symptom, as I have alreadytold yon. When present, it bears in factno necessary proportion to the degree ofthe disease present, the worst cases of

pneumonia being those in which there isthe least pain. Your attention, therefore.Ihoulù be chiefly directed to the state offunctions, in order to form your judgmentof the case.

2. Difficult respiration of a continuedkind.—The breathing is ;.hort and labori-

ous, often with wheezing. This symptomis occasioned by the pressure made bythe swelled portion of lung upon theair cells and minute ramifications of thebronchia, impeding thus the admission ofair into the lungs.3..-/ livid hue of the skin in variens

parts, especialiy of the cheeks, lips, ,.ndnails. This arises from the blood nnt

having undergone the necessary changesin the lungs, ow ing to the imperfect admission of the air in breathing. And as

aoimal heat depends in a great measureapon respiration, this being imperfectlyperformed, coldness of the extremitieshkewise takes place.

4. The same pressure which acts uponthe air-vessels, influences also the blood-vessels of the lungs, namely, the inintitebranches of the pulmonary artery andveins. The blood in consequence i, im-peded in its passage from the right to thelett side of the heart, which is thus de- Iprllell of its due and regular supply ofblood. The pulse in con sequence is ge-nerally small, soft, and feeble, and some-timen irregular.

5. The obstructed state of the pttlmo-nary artery leads to a gorged state of theright side of the heart, which cannot

sufficiently empty itelf’ of its blood. Itbecomes in consequence unable to receivethe venous blood coming from the diffe-’’ rent parts of the system ; and thus a ge-neral stagnation ot circulation takes placein a greater or less degree, and acconntsfor the tumid and bloated state of theface and extremities. The brain from itsproximity to the heart, is likely to sutfermost from the impediment to the returnof blood to the heart; and hence stupor,and not unfrequently detitium ensue.

Something may douhtlecs be attributedhere to the dark or venous character of the

, blood itself, by which it is less fitted to

excite the brain, and other organs of the! body, whence the general torpor and iu-, action observed.

; In severe cases of peripnenmony, thf

tongue assuntes a browu huf, similar tn

’what is observed in low fevfr; aud this: probably from the same cause, the op-’ pressed conditiou of the brain. Thethicker and darker the crust on the tongue

’ is in these cases, the gt eater in general’ is the danger of the disease.

! There is often no cough, because theI mucous membrane is not always or gene-rally affected. When cough does ocear,however, there is not much expectorationat first, and thesputum is often of a brown

or sanious appearance ; sometimes it is

bloody. but the btuod is rather of a darkthan a florid hue.

The history I have now given, you areto consider as an extreme case of the dis-ease, and a’ it appears in its most simpleand uncombined form. Iii most cases, it

is a much milder disease than I have nowstated, and is most frequently accompa-nied with more or less of inflammationof both tl.e investing membrane (thepleura), and of the mucous membrane, or!that which lines the bronchia. Hencethe pain, and cough, and expectoration,that so commonly are found in combina-tion with the other symptoms.

Progress and Terminations—The pro-

gress of inflammation of the lungs is ac-co:ding to the viutence of the diseaseand the age of the patient. In infants,it often runs ih course, and proves fatalin little more than eight and forty hours ;and the same is the case in very old snb-

jects.I Peripnenmony terminates in variousways; as first, by resolution, as it iacalled ; that is, by simply subsiding, with-out even expectoration or other obviouschange; Second, More frequently it ter-

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minates In coughing and expectoration.The more early this takes place, and themore copious and easy the discharge ofmucus becomes, the more likely is thedisease to terminate favourably.

3. By abscess, commonly though need-lessly termed vomica. The approach ofthis may be suspected from the conti-nuance of the oppressed state of breath-ing, after the pain and febrile symptomshave declined. Occasional shivering fits,also, indicate approaching suppuration.The abscess commonly bursts into thebronchia, when the matter is brought upby coughing. Sometimes, though rarely,it penetrates through the pleura, into thecavity of the chest, and then constituteswhat is called empyema, that is, a collec-tion of purulent fluid in the thorax. Inmany instances, the lungs adhering tothe tibs, the matter makes its way be-tween these, and is discharged at the

skin, often very remote from the openinginto the chest. Patients occasionally re-cover under all these circumstances,thongh slowly, and after a long period.

4. By hœmoptysis.—This occurring earlyin the disease, tends powertully to takeoff the inflammation, though, in itself, itis not unattended with danger.

5. By deposition of blood or serum, orboth, into the cellnlar texture of the lungs,and that to such a degree as to occasionsuffocation. When the disease provesfatal in this way, the lungs, upon beingcut into after death, resemble the liver’in colour; and hence’itave been said to

be hepatized. This is a very unwarrantableuse of language, as it tends to exciteideas that are without foundation. Mo-dern writers have a great deal of this sort ito answer for. ‘.

6. By apoplexy.—The impediment given /’to the return of blood from the head, andwhich is evident in the bloated state ofthe face, the red, and starting, and suf-fused appearance of the eyes, and the i

turgid state of the jugular veins, not onlyinduces stupor, the effect of mere stag-nation, but becomes also, in some cases, ;a cause of irritation to the arteries of the ibrain, urging them to an increase of pro- pulsive action, and consequent rupture ;and extravasation of blood. ;

Prognosis.—The chief danger in perip-neumony, arises from the impeded respi-ration, and the interruption given to the

passage of the blood through the lungs.The unfavourable symptoms are, the-lividhne of the skin, with coldness of the ex-treme parts ; a feeble and irregular pulse;and the occurrence of stupor or delurium.

A thickly coated brown and dry tonpetalso indicates danger.

, Treatment.—The common remedies forinflammation are all that are required to

this case. Bloodletting, commenced at anearly stage of the disease, is particularly

necessary, and that often to a great ex.tent, the patient in many cases requiringto be bled, (once, or oftener, ddily, ac.cording to the severity of the symptons,jfor many days in snccession, till eitherthe disease gives way, or the strengthwill no longer allow of this evacuation.

Of this, you are to judge chiefly by thepulse. In proportion as this decline! in

strength and fulness, you are to be ean.tions in abstracting blood. You must beaware, however, that the pulse in thisdisease is not wholly or exclusively to betrusted to; for, owing to the blood re.

taining its venous character, and therebynot stimulating the heart and arteriessufficiently; and partly, also, to the im

perfect tt admission of the blood throughthe pulmonary artery; the pulse at thewrist may be weak and amall, althoughthe gpneral strength be still unimpaired,In such cases, you must judge. of the ge.neral strength from other circumstances;such as the duration of’ the disease, thequantity of blood already lost, and thestate of the patient immediately previousto the attack.

In the advanced stape of the disease,when the skin is livid, the extremitict

cold, pulse feeble and irregular, and thetongue ot a dark brown colour, bloodlet-

ting is hardly admissible, although wemay be convinced the inflammation is stillgoing on. Bleeding then, to any amount,will but hasten the fatal event. In thee

cases, it is usual to give stimnlants, as

ammonia, the seneka, and wine; as if,because bloodletting was no longer ad-

missihte, an opposite treatment were

required. It is difficult, however, to reoconcile this with either reason or expe. rience. The reason commonly assignedfor employing stimulants on such occa. sions, namely, " to support the strength."is quite fallacious; for no medicine hasany such power. All that slimiliantlcan do, is to excite vascnlar action; butthis effect is of short duration, and notfavottrable, one would suppose, to thereal disease, the inflammation. Whenthe unfavourable symptoms I have justdescribed, have made their appearana,little, probably, can be done by art or

their relief. The insufficiency of catmeans, under such circnmstances, shouldmake us doubly attentive to the diseasein the beginning, when it is modywithin our power.

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I hardly need observe, that, besides)ttoad!rtting, counter-irritation of differentkinds is to be used ; or to remind you,!that mercury. as on other occasions, and iafter a proper use of bloodletting, is cal-colated to assist materially in the cure.As to what are commonly termed e.rpee-torants, these are probably of little mo-ment. It is no doubt desirable to see

expectoration taking place freely; hutthis j, rather to be looked upon as a sign,than as a cause, of returning health. NorI. it much in our power to promote thisevent, unless by the use of nauseatingmedicines ; and these, in all probability,arcomplish the object, rather by checkingthe inflammation, than by any direct ex.pectorant Dower.A mild and chrorcic kind of pulmonary

inflammation is a far more common oc-currence, than the acute form I have justdescribed to you, and, upon the whole, ismuch more fatal in its result. It takesplace mostly at the approach of winter,commonly in the form of catarrh, andhpreafis gradually to the lungs themselves, Band often their investing membrane;giving rise to a complication of symptoms,easy to be conceived. If neglected, as

among the poorer classes generally is thecase, it continues till perhaps the returnof spring, and is renewed the succeedingwinter, becoming worse upon each return,and gradllally laying a foundation forvarious incut able states ot’disease in thoseorgans. The mucous membrane becomes

permanently thickened, and otherwisediseased in its strncture, and acquires ahabit of secreting mucus largely, and of avitiated quality ; thus occasioning a cou-tinued difficulty of breathing, with con-ttant cough, vulgarly termed asthma, andthat fluctuates in point of severity withseason and weather. The affection of thepleura, in its turn, gives rise to adhesionand serous accumulation in the cavitv ofthe chest. While the continued or fre-quently-repeated attacks of inflamma-tion (however slight) in the lungs them-selves, gradually induce an alteration ofstructure in these parts, which, by slowdegrees, degenerates into pulmonary con-sumption, a disease which we shall soonhave to notice.Nor is this the whole of the mischief

that results from slight and neglectedinHammation in the pulmonary organs.The resistance the heart encounters in itsendeavours to propel the blood through%e lungs in the diseased state of thoseorgans, becomes a source of irritation tothe heart, that at length terminates inartllal disease, such as morbid enlarge-ment or other change of structure, eitherin the heart itserf or the large vessels con-

nected with it, attended of n.ct’!lsity withdisordered action, discoverable in thepulse, and which is productive of thegreatest possible distress to the patient,and not unfrequently a sudden and fataltermination. A great proportion of the

chronic diseases of the heart originate inthis way, namely, in diseased lungs.General anasarca, firt noticfd ahont

the ancles, is also frequer.tly induced bythe same canse, inflammation of the p.irtswithin the chest, impeding, by pres,ure,or by the extension ot inflammation to the

great trunks of the absorbing sBstem, thefree discharge of lymph into the veins.Many of these cases of dropsy, if earlyattended to, and treated by moderate andrepeated bloodletting, and other antiphlo-

gistic measures, admit of cure, by the

removal of the cause ; whereas, if treatedin a different way, by stimulants and thelike, they soon terminate fatally.

FOREIGN DEPARTMENT.

PATHOLOGY.

Curious Case of Paralysis.—(Hufeland’sJournal, d. p. h. Feb. 1826.)

C. S., twenty-five years of age, of a

sanguineo-melancholic temperametit, forfour years laboured under a peculiar kiudof weakness. The commencement uf thisweakness is attributed to a leap whichthe patient made from a stair, in FebruaryL822; in consequence of which, the jointot the right root was sprained. The samejoint on the left side bpcdme also a little

injured, from being used to assist the oneth-it had bet’n fint hurt. Several reme-dies were employed for these accidentswithout removing the comptaints. In the

spring of 1822, the patient’s state becameworse, insomuch, that when he came outof the country, he could not place his footon the plain field. When he sat with thesolz resting on the ground, very disa-ureeabte sensations were felt, and itwas only when the leg was pruperly sup-ported with suitable contrivance.., thathe was able to ride in a carriage. This,as already rematked, was the fir st sign ofthe commeucement of the disease. Itmust be noticed, however, that he hadanffered from a weakness in the ri;;htpectoral muscle some years previous,which prevented the use of the right armfur any length of time, even in writing.