LECTURE VIII.

Early signs of consumption-Prolonged expiratory murmurMode of determining its degree-Causes-Relation to phthisis -Illustrative cases-Irritability of muscle-Cough-Fistula in ano as affecting the course of consumption-DiarrhoeaCauses and treatment-Charcoal-Sulphate of copper-Acetate of lead-Nitrate of silver-Bismuth, &c.

CONSIDERABLE evidence has been brought before you, gentlemen, that cases of consumption, which would formerly have been regarded as hopeless, may be ameliorated by treatment, and even issue in apparent recovery. But it must not be concealed that, with the aid of all our improved appliances, confirmed phthisis must still be regarded as a most destructive disease, and one in which, at every stage of its progress, the hope of beneficial treatment lessens in a remarkable degree.

It becomes, therefore, a most important object to detect the disease at its commencement, and with this view let me invite your particular attention to one of the earliest signs which can be traced by auscultationnamely, a modification of the expiratory murmur, consisting in an apparent prolongation, usually accompanied with an increase of coarseness. On examining healthy individuals, you will find that, ordinarily, the expiratory murmur is very slight, and very little more distinct in

any one part of the chest than in another. In some individuals, indeed, it is inaudible except during hurried breathing.

The natural elasticity of the lungs is essential to soft and uniform expiration. When considerable consolidation is produced in their texture, by tubercular or pneumonic deposit, bronchial expiration is produced; but, between the healthy state and decided consolidation, there are various intermediate conditions. When the pulmonary cells, as seen under the microscope, are only slightly thickened, and the glairy, greyish deposit, studded with little bright cells, characteristic of phthisical disease at an early period, is beginning to permeate the structure, bronchial expiration is not induced, but the diminished contractility of the cells, interrupted passage of air, and increased power of conducting sound, are sufficient to render the expiratory murmur more durable, coarse, and audible. In pursuing this investigation, be careful not to confound the inspiratory and expiratory movements with the inspiratory and expiratory murmurs. The duration of the two movements is nearly, if not exactly equal. In the natural state the inspiratory murmur occupies the whole time of inspiration, but the expiratory murmur, at least to ordinary ears, only a fourth of the time of inspiration, the remaining part of the expiratory movement being accomplished in silence. I believe the expiratory murmur follows the inspiratory immediately without a pause. With the progress of phthisis, the duration of the inspiratory murmur usually lessens materially, though not necessarily in proportion to the prolongation of the expiratory; and some practice is necessary in order to

acquire an aptitude in determining how much of the alteration depends on diminution of the duration of the inspiratory murmur, and how much on extension of the expiratory. You will find much assistance in estimating the relative duration of these sounds, by adopting a plan suggested to me by Dr. Sibson-namely, that of counting the number of strokes which can be given, by beating time with the finger, during the presence of each murmur respectively. The expiratory murmur, as disease advances, may gradually increase, until, instead of occupying, as in the natural state, a fourth of the period of healthy inspiration, it may even come to exceed in duration the inspiratory murmur.

You will occasionally find it stated, even in writings of some authority, that prolonged expiratory murmur is a sign of doubtful value, and not to be relied on; but when reasons are given for this assertion, you will find them unsatisfactory. If no symptom of disease were to be regarded which did not require to be accepted with some qualification, and interpreted with discrimination, the science of diagnosis would dwindle into childishness. What, then, are the cautions to be observed in attempting to deduce conclusions from the sign under consideration? You will best learn them by examples. In the man, B. H., now before us, you find the expiratory murmur equal in duration to the inspiratory, over nearly the whole chest ; but the sound on percussion is for the most part clearer than natural, and the diaphragmatic ribs rather recede than advance during inspiration. This patient has not an aspect nor a pulse characteristic of phthisis. His countenance is slightly livid, as though from imperfectly oxygenated blood; he

has never had hæmoptysis. You see the pulsation of his heart in the epigastrium. Such a case you would never mistake for one of phthisis. You readily recognise it as one of extensive emphysema, and the prolonged expiratory murmur thence derives a ready explanation.

Take another patient, in whom prolonged expiratory murmur is heard extensively, and indifferently at the lower and upper parts of the chest, but associated with sonorous and sibilant rhonchi. This is a case of chronic bronchitis. There is no circumstance to lead you to apprehend consumption. Again, you are probably aware that consolidation of lung in any part, from pneumonic or other deposit, may produce bronchial breathing, and the same cause, existing in a slighter degree, may induce prolonged expiratory murmur; but you will almost always find, in the constitutional circumstances, the history, the expectoration, and the other physical signs, enough to guide you to the correct interpretation. Let me contrast such conditions with those in which the expiratory murmur is modified by tubercular disease. In the patient whom I now introduce, P. D., you may ascertain, adopting the means formerly described, that the expiratory murmur, at the apex of the left lung, is equal to the inspiratory, each murmur occupying the time required for five beats with the finger, and that the interval of silence is equal to two. Under the right clavicle the duration of the expiratory murmur might be represented by three. In other parts of the chest, expiration is not attended by any audible sound. There is no bronchial rhonchus, and the situation and degree of the phenomenon lead you to suspect phthisis. The

movement of the chest is natural, and there has been no decided hæmoptysis; but I think you will be able to distinguish a slight degree of dulness, when you strike the left clavicle, as compared with the right, and you will observe an irritable or quivering action of the intercostal muscles, produced by a smart blow, a fact which is worthy of notice as by no means uncommon in phthisical individuals. This patient has had a cough for six months; his expectoration is mucous, but, under the microscope, a few blood-globules may be detected. His height is five feet four inches; vital capacity by spirometer, 155 cubic inches, not quite a fourth less than the average for his height, and he weighs ten stone six pounds, having never, he says, exceeded eleven stone when in good health. These particulars, while they strengthen the conclusion to which you are led by the degree and place of the prolonged expiratory murmur, also serve to impress the value of the sign, by showing that the disease is at a somewhat early period.

In the next patient, W. U., the sign being only on the right side, were it not considerable, would be inconclusive, on account of the greater audibleness of the respiration on this side in the natural state; but it is so much prolonged, in this patient, as to exceed the inspiratory in length, the proportions being, four for the inspiratory murmur, five for the expiratory, and three for the interval of quiet. Furthermore, there is a little dry crepitation (crackling) at the apex of the right lung. This patient has had occasional hæmoptysis, has declined in weight fifteen pounds during the last two years, and has almost lost his voice. The aphonia depending probably on a relaxed condition of the laryngeal