tory tubes, the nasal cavities, &c., and there will be, in this case, a copious secretion of thick glairy mucus. Persons subject to attacks of erysipelas or psoriasis will sometimes have acute bronchitis developed, in consequence of the tendency of the eruptive diseases to affect the mucous surface of the air-passages much in the same manner as they ordinarily do the cutaneous surface. The same is eminently true of rubeola, variola, &c. A syphilitic taint in the blood will sometimes produce chronic bronchitis, the symptoms of which are very similar to those of phthisis. The discharges from the bronchi are muco-purulent; the system becomes emaciated; and the constitutional disturbance is serious. Indeed, this affection does much to prepare the way for the actual development of phthisis.

In all the forms of bronchitis, the object of nature in the mucous secretion generally is to relieve the congested and inflamed vessels. The discharge is excretory. This object, therefore, whatever may have given rise to the disease, may be aided by artificial means. Equalizing the circulation and promoting the perspiration also tend to the same effect. If this object is not secured, either by nature or by art,-if there is little or no discharge from the bronchial tubes and from the skin, the tendency is for the heart to become congested and the vessels of the lungs to become distended, giving origin to cardiac dilatation and pulmonary emphysema.

Sometimes, however, the secretion continues, without an abatement of the inflammation. In this case, the discharge is a morbid one. The mucous tissue itself seems to be in a morbid condition, so that its secretory follicles act abnormally and do not relieve the blood of those ingredients which keep up a morbidlyrelaxed and over-distended condition of the vessels. These, of course, are the cases in which, particularly, tonics and stimulants are indicated in connection with expectorants, for the purpose of sustaining a healthy action of the mucous follicles.

CHAPTER II.

PERTUSSIS.

PATHOLOGY.I reckon pertussis, or whooping cough, as a thoracic disease, although the affection is not confined exclusively to the bronchi. Superior portions of the air-passages are also involved. The disease is often ranked as a variety of bronchitis; and inflammation of the bronchi does constitute a portion of it, but does not the whole. It involves, also, an affection of the nervous system, producing a spasmodic stricture of the bronchi and the trachea, and especially a spasmodic closure of the glottis. The degree of inflammation and of spasm varies, both may be severe, or both mild; or they may be united in different proportions, the one or the other predominating.

Pertussis is a contagious disease, caused by a specific virus, conveyed from one person to another, by the atmosphere. As the disease is common in every community, and yet is not ordinarily repeated with the same individual, few persons escape it in childhood, and it is confined almost exclusively to that age. It has, however, been said to occur even in advanced age with those who have escaped it in earlier life. As far as the disease consists in inflammation, it is like that of ordinary acute and chronic bronchitis. The spasmodic condition of the tubes, however, commences before the inflammation; and there is a secretion of whitish mucus which accumulates, especially in the smaller bronchi, before any redness or thickening of the mucous membrane appears. But, after the disease has existed for a season, the bronchi become reddened and thickened, and then they are filled first with a yellow mucus, and afterwards with a yellow muco-puru-. lent liquid. The accumulation of the contents of the tubes, particularly in the inferior portions of the lungs, tends gradually to enlarge, and often does enlarge, these tubes. It sometimes results in their permanent dilatation. In some other cases, the obstruction of the smaller tubes leads to the enlargement temporary or permanent of the air-cells. Occasionally it would seem that the inflammation of the tubes induces diphthe

ritis, and, not unfrequently, the inflammation extends to the parenchyma of the lungs, at least to some of their lobules; and then, of course, it is complicated with pneumonitis,—generally of the lobular kind. One other complication is liable to occur. The paroxysms of coughing obstruct the circulation of blood through the lungs, and thereby cougest the brain. The congestion is sometimes so great as to rupture the blood vessels, producing apoplexy, convulsions and death.

DIAGNOSIS. The febrile symptoms in pertussis, unless it becomes complicated with lobular pneumonitis or some other grave disease, are not usually great. There is not great heat of the skin; not much excitement of the pulse. At first, the symptoms are liable to be taken for those of primary acute bronchitis. At this time the cough is not very peculiar. There may be some feeling of constriction in the chest and of weight in the head. Sometimes there is a swelling of the tissues about the eyes; they themselves are inflamed, and there is a propensity to snoring and the discharge of tears. The sputa, at first slight and viscid, become, as the disease advances, more copious and less tenacious.

The peculiarity of the cough, however, appears the most important evidence of the disease. It is found in a series of rapid forced expirations, followed by one long and loud inspiration, the shrill character of which is produced, not so much in the bronchi, or even in the trachea, as in the larynx or glottis. The epiglottis recedes, as if by the relaxation of a spasm, and the exhausted lungs are filled by a single inspiration. Instantly a series of expirations similar to the former commences, and this is followed by an inspiration like the preceding. This process is usually repeated several times, until at length a free expectoration of mucus occurs, and the paroxysm ends. The patient, exhausted and perhaps frightened by its violence, while existing, soon recovers his strength and spirits, and continues as cheerful as be-. fore, until a return of the paroxysm.

As a paroxysm is approaching, generally some warning of it is had in a sense of chilliness on the surface, of tickling in the throat, and of tightness in the larynx and air-tubes. This induces the sufferer to lay hold on something for support, or to fall on the

ground for relief. In severe cases, the sense of suffocation is great, the respiration is much impeded, the features are swollen and livid, the eyes are strained, and tears are copiously shed. The paroxysm is protracted; but, as soon as it closes, the patient is essentially relieved, for that time, though some constitutional symptoms may remain. During the paroxysm, rarely hæmoptysis, but not unfrequently epistaxis occurs. In young children, sometimes, fæcal and urinary discharges will involuntarily occur. Temporary asphyxia is not uncommon, and, in some instances, this has proved fatal. This peculiarity, it should be here remarked, does not show itself until the cough has existed for several days, -often for a week or more. In the onset, the attack seems like one of primary acute bronchitis. The paroxysms of whooping, after they have commenced, are repeated, sometimes at periods of fifteen or twenty minutes, and sometimes much less frequently,— in many cases not returning more than six or eight times in the course of a day. When there is much congestion of the brain, and, of course, a liability to apoplexy, the paroxysms of coughing are attended with a flushed countenance, turgid jugular veins, chemosis, and sometimes epistaxis. In such cases, too, the patient will seem inactive and drowsy, the head will be specially hot, and there may even be a starting in sleep, and a grinding of the teeth.

In this disease, we sometimes have the cantus omnium avium, or the sonorous, the sibilant, the mucous, and the sub-crepitant rales. A copiousness of secretion early takes place, giving rise to the humid rales; and yet portions of the tubes remain in such a state as to continue to produce the dry rales also, especially the sonorous. The manner in which I suppose the last to be made I have previously pointed out. I will here add, that, in this disease, we sometimes get a tone intermediate between these two sounds, as they are heard in their marked forms; and the mucous and the sub-crepitant approach each other. Of course, if the disease leads to other lesions, and becomes complicated with them, the distinctive rales and other indications of those lesions will appear. In general, after a paroxysm of coughing has relieved the bronchi of their contents, the respiration is tolerably free and expansive, till an accumulation has again taken place. This is

After

more particularly true at the earlier period of the disease. inflammation has essentially modified the condition of the tubes, the respiration may be modified and feeble.

Percussion, in pertussis, is usually about normal. In case of some enlargement of the bronchi or the vesicles, the resonance can hardly be perceptibly increased, though, when there is induration of the lungs, to any extent, percussion may become somewhat dull.

The recognition of pertussis is generally easy, by the existence of the whoop, particularly, and by other peculiarities after the lapse of a week or two from the time at which the cough commences. Usually, this whoop characterizes the cough for about one month; at the expiration of which time it essentially ceases; and after about two weeks more, the cough itself is mainly gone. Ordinarily, the whole continuance of the disease is about eight weeks; but it is protracted to twelve weeks or more. An attack of acute bronchitis will prolong its existence, and even return the whoop, after it has ceased, for a week or two to be heard.

The prognosis in the simple form of pertussis is favorable. It is only when some of the complications already referred to occur, that the case becomes one of danger.

TREATMENT.-The indications to be fulfilled, are to eject the matter secreted and accumulated in the air-passages; to allay the spasmodic excitement; and to resolve the inflammation.

To accomplish the first object, remedies will sometimes be found necessary, especially when the accumulation is considerable and the constitutional disturbance is serious. Ordinarily, however, expectorants, freely taken, will accomplish all that it is desirable to do, in this particular. To answer the second object, antispasmodics are required; and, for the third, diaphoretics and relaxants are indicated.

To fulfill all these ends, especially the two former, the compound sirup of lobelia and sanguinaria is admirably adapted. Indeed, in at least four cases out of five, an ordinary dose of this, administered at periods of from two to four hours, will be all the treatment that is essential. If the febrile symptoms should, in any case, be considerable, an ordinary anti-febrile or diaphoretic