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After a cavity has formed, the auscultatory signs are the gurgling rale, cavernous respiration, and pectoriloquy. Besides the gangrenous exudation already referred to, and which continues till the mortifying process is arrested, there is the formation of pus, as soon as the vital powers get the ascendency. Of course, when the cavity is of considerable size especially, the quantity of liquid exuding from the walls is sufficient to give a loud and constant gurgling,-one the extent of which is scarcely equalled in tuberculous disease, as in that cavities are rarely so large and do not give rise to so much liquid.

When the gangrenous matter is expectorated and the cavity is evacuated, cavernous respiration and pectoriloquy appear. The former is generally full and distinct; but the latter, unless the cavity is large and near the surface, has not as clear a resonance as is afforded by the harder walls of a tuberculous cavity. Such, however, may be the size and situation of a cavity, as to give amphoric respiration and full pectoriloquy.

Percussion is resonant in proportion to the size of the cavity over which it is made, and the proximity of the cavity to the surface. If a considerable portion of the lower lobe of the lung is destroyed by the gangrene, the resonance will be very great.

When gangrene of the lungs is being cured and cicatrization is taking place, the signs of a cavity disappear, and are replaced by the sub-crepitant and mucous rales made by the muco-purulent matter in the tubes. Bronchial respiration and bronchophony next appear, and finally give place to sounds nearly normal. The vesicular murmur, however, remains for a long time feeble, and very commonly never fully returns. The normal resonance on percussion, in due time, re-appears.

PROGNOSIS. The prognosis in this disease depends very much on the situation of the patient. In private practice, the patient being properly treated and nursed, recovery is effected in a majority of cases; but, in hospitals and other places in which proper attention is not paid, the chances are on the side of death.

TREATMENT.—In primary pulmonary gangrene, the treatment must be of a supporting character. Hence tonics and stimulants,

in connection with expectorants, are indicated.

As an expectorant, nothing is better than the compound sirup of lobelia and sanguinaria. As tonics and stimulants, peruvian bark, polygala senega, and asarum canadense are good. Even wine, porter, and nutritious food may be freely given.

When gangrene succeeds inflammation of the lungs, or comes on in the course of pneumonitis, more regard must be had to the febrile symptoms. Indeed, the ordinary treatment of pneumonitis must be adopted, with some modifications. The active tonics and stimulants will not, to a great extent, be well borne. The anti-febrile corroborants should be freely employed, such as asclepias tuberosa, corallorhiza odontorhiza, and agents of that class are of great importance.

In this disease anti-septics are valuable, such as charcoal, yeast, &c. A solution of chlorinated soda, unless it proves too laxative, may be given, in doses of ten or twenty drops, every three or four hours. Chloride of lime, too, may be placed in the patient's apartment and near his head. It will add to his comfort, and favor his recovery.

The usual regard should be paid to the secretions generally; and, in some cases, an irritating plaster or other external stimulant is of service. In general, however, but little reliance can be placed on external applications.

CHAPTER X.

PULMONARY EDEMA.

PATHOLOGY. This is generally described as an effusion of serum into the areolar tissue of the lungs. It is doubtless true, however, that a portion of the effusion is into the vesicles and the smallest bronchial tubes. In general, the characteristics of pulmonary œdema are like those of dropsy in the areolar tissue, in any other portion of the system. In fact, the disease is a form of anasarca.

When it exists, it generally affects both lungs nearly equally; and, like anasarca elsewhere, it is first discovered in the most dependent portion of the tissue concerned. This is simply the effect

of gravitation, the meshes of the tissue not forming,perfect cells, but containing interstices communicating with one another.

When a portion of an oedematous lung is examined, it is found to be of a pale gray or yellowish color; it is heavier than healthy lung; it pits on pressure; and it has a peculiar crepitation. When incised, it emits a spurious and transparent liquid which, when fully expressed, leaves the lung in an apparently healthy condition. The texture of the organ is thus proved sound; while its increased density and diminished ability to contain air, are shown to result from the presence of the contained fluid.

Pulmonary edema is a lesion not very unfrequent with the aged, though it is often to be regarded only as a part of general dropsy. It sometimes, however, appears,-not, perhaps, as an idiopathic disease,—but as the principal manifestation of a dropsical tendency. It has sometimes proved the immediate cause of death at the termination of a fever which has been badly treated and in which the blood has become watery and deprived of its vital properties.

DIAGNOSIS.-Dyspnoea is a general symptom of this disease; and the evidence from this of existing pulmonary edema is strengthened, if there is anarsaca or evident dropsy of other parts of the system. Generally, the expectoration is not great. What is raised is chiefly aqueous fluid, a little foamy, and containing some floating mucus. Sometimes, however, a very considerable amount of liquid is coughed up and otherwise expectorated. In one marked case of the disease, ending fatally, I saw the patient a little before and after death, which was sudden. There was general dropsy; and, after death, a good deal of watery fluid was pressed from the lungs out of the mouth.

The prominent physical sign is a coarse crepitant rale, heard at the base of the lungs, or, if the disease is extensive, over a considerable portion of them. The bubbles of this rale are somewhat coarser than those heard in pneumonitis; but they break even more rapidly, and do not extend in long trains, from one point to another.

Percussion is but little altered. With the liquid, there is sufficient air in the lungs to give nearly the ordinary resonance,

At

any rate, as both sides are alike affected, we have not the advantage of comparing a diseased with a healthy lung, and cannot, therefore, as well judge what is the normal sound.

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PROGNOSIS. The prognosis in this disease is generally unfavorable. If the lungs are extensively affected, as shown specially by the peculiar crepitant rale, there is but little room to hope for essential improvement.

TREATMENT.-Like other dropsies, pulmonary edema generally arises from disease of the heart, or obstruction of some large bloodvessels. The immediate cause, therefore, must be sought out, and, if possible, removed. As palliative, rather than curative' means, diuretic and diaphoretic medicines may be administered :— also, if the debility of the patient does not contra-indicate, hydragogue cathartics. Of course, his strength must be sustained by

vegetable bitter tonics, so far as they are well borne.

CHAPTER XI.

PLEURITIS.

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The term pleuritis, synonymous with the more common word pleurisy, signifies inflammation of the pleura; and pleura, in Greek, supa, signifies the serous membrane which lines the internal surface of the thorax and covers the viscera. monitis, pleuritis never takes on a form so distinctly chronic, as that which bronchitis sometimes assumes. It sometimes, however, becomes an asthenic and latent disease, and sometimes comes

on as the sequela of some other affection. In its usual form, it may be regarded as a primary or idiopathic, and a sthenic disease. As such, it is properly called primary sthenic pleuritis.

SECTION I.

PRIMARY STHENIC PLEURITIS.

As the simple term pleuritis, without any qualifying epithet, is generally employed in this sense, I shall, for brevity's sake, so use it; and only use qualifying words to express other modifications of the disease.

PATHOLOGY. Pleuritis, in the sense of a primary and sthenic disease, is divided into two stages. The first is the stage of inflammation. When it commences, the small blood-vessels beneath the pleura, are distinctly visible through that transparent membrane, being interwoven in various directions, and forming a thick net-work of a bright red color. When this membrane is detached, it is found to be but slightly changed in appearance,the development of the inflammation being really, in the main, in the sub-serous areolar tissue, rather than in the serous itself. The truth is, serous tissues generally differ from mucous, in being thinner, more delicate, and supplied only with the very smallest bloodvessels, such as do not transmit the red globules of the blood; whereas some of the branchings of the arteries of such size as to convey the red globules, and be easily traced, pass into mucous tissues. As in all cases of inflammation, effusion or extravasation is liable to occur; so in pleuritis, bright red spots of blood, effused or extravasated from the vessels, are sometimes quite numerously seen.

In pleuritis, we cannot trace the gradual progress of the inflammation and the consequent change of the symptoms, as in bronchitis. The delicacy of the parts concerned, and their connection with the nervo-vital fluid, cause the inflammation rapidly to reach its height; and then the reparative process, mostly in the granulating form, is soon established.

The second stage, which is that of effusion, commences at this point. If my readers have made themselves familiar with my views of the reparative process, and its connection with inflammation, as illustrated in the first Division of the first Part of this work, they will see how beautifully the pathology there given is

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