times when inaudible in the jugulars;) the axillary; the superior cava and innominate veins; the veins of the bend of the elbow; certain abdominal veins;* the pulmonary veins; and the supe rior longitudinal sinus, especially at its termination in the torcular Herophili.†

Invariably continuous in rhythm, murmur in a vein may be simply continuous, that is, of equable force constantly; or it may be remittently continuous, undergoing intensification and weakening at regular intervals. The type is humming when the rhythm is thus remittent. Two causes of this remittent character have been suggested: the pulsations of an adjoining artery against the sonorous vessel, which give at regular intervals a momentary impetus to the current in the interior of the vein; and the coexistence of ordinary intermittent blowing murmur in the accompanying artery. The majority of instances are fairly explicable on one or other of these principles; some, which are not so, may, it would appear, be explained by intrinsic inequality of force of current in the veins,—an inequality which, we know, positively exists in cases of venous pulse.

Venous murmur may be accompanied or not with inorganic arterial or cardiac (systolic and basic) murmur.

Venous murmurs are so intimately connected clinically with a spanæmic state of the blood, that they constitute its most positive sign; why that state of the blood should engender them, is a mystery. Physically, the vessels are imperfectly filled, loose and vibratile, the blood is thin, and the friction attending its movement (according to a law of Poisseuille's) thereby proportionally increased,-one element of sonorousness. So, too, external pressure, or muscular action, intensifies the sound by similarly affecting the friction of the current; though, if the condition of the blood be highly favourable, no pressure is required, especially when the arrangement of the vessels is such (e. g. in the torcular Herophili) as to promote forcible collision of currents arriving from different directions at a conflux. M. Andral has attempted to establish the exact relationship between the amount of spanæmic change and the constancy of venous murmur as follows: if the red corpuscles fall below 80 per 1000,

*Case of Sus. Roberts, U. C. H., Oct. 1850. Continuous hum, coupled with arterial intermittent murmur, a little above and to the left of the umbilicus. Here, too, appear cases of continuous hum, audible on deep pressure at the right edge of some enlarged spleens.

† Davis, U. C. H. Females, vol. iv. p. 138. In this case a continuous remittent murmur was also audible at both sides of the mid-dorsal spine.

murmur is constant; if they range between 80 and 100, pretty frequent; if between 100 and 115, occasional; if between 115 and 126, murmur is sometimes heard;-never if they reach the average of health.

There are some facts difficult to reconcile with the ordinary notions in this matter. Thus it is well known that in cases of chlorosis treated with iron, colour returns to the tissues long before venous murmur disappears. On the other hand, Becquerel and Rodier give analyses of the blood of two chlorotic girls, presenting well-marked venous hum, with a mean proportion of 125.1 per 1000 of red corpuscles; certainly an amount falling within the limits of health. It is affirmed, too, by the London Heart Committee, that murmur may be produced in the veins by pressure in a state of robust health; and I have heard it in women of florid complexion, who, as far as I could ascertain, had never been symptomatically anæmic. It is averred by Skoda that hydræmic blood has been drawn from persons perfectly free from venous murmur: it was probably not carefully sought for. There is no proof that mere diminution of the mass of the blood will produce venous hum; such diminution, indeed, never takes place without change in composition. Plethora, especially of that kind in which the proportion of the red disks is raised, is an asserted cause of venous murmur.

In all probability the proportion of white corpuscles may have more to do with the murmur than has been suspected. They are increased in many cases of chlorosis, and (as shown by Remak) augment by the repetition of bleeding; now, their increase must entail great increase of friction and labour in the circulation.

The diagnosis of venous murmurs turns essentially on their continuous character; and is excessively easy, except when accidental circumstances occur to render that character obscure. This happens sometimes about the base of the heart anteriorly, and between the scapulæ in the back. Pulmonary venous murmurs are partially masked by the cardiac sounds. In addition to its peculiar quality, pitch, inconstancy, ready influence by change of posture, as guides to the venous origin of the murmur, its rhythm in respect of the heart's beat will sometimes aid in connecting it with the veins. Thus a diastolic murmur at the base (the signs of organic disease at the cardiac orifices being deficient) must be venous, according to my experience;―at least an inorganic cardiac murmur of that site and rhythm has never fallen under my notice.

PART II.

DISEASES OF THE LUNGS, HEART, AND GREAT

VESSELS.

CHAPTER I.

THE LUNGS AND APPENDAGES.

NEURALGIA OF THE LUNG.

THE parenchyma of the lung is, not only, under ordinary circumstances, endowed with but slight sensibility, but even in the state of inflammation is very rarely the seat of pain, at least of pain demonstrably referrible to itself. Still, pain has occasionally been noticed in central pneumonia, where the pleura had wholly escaped; and various anomalous, and more or less painful, sensations felt by phthisical patients, deeply within the chest, apparently originate within the pulmonary texture. Certain morbid processes in the parenchyma appear then to irritate the branches of the pulmonary nerves.

The only physical condition I have ever succeeded in connecting with these painful sensations (and this only in cases of phthisis,) is jerking rhythm of the respiration. The quality of the murmurs may also probably be roughened by their existence.

These sensations are either greatly relieved or altogether removed by counter-irritation, and emollient and anodyne inhalation. They are not so directly, as might be expected, modified by anodynes taken internally.

PLEURODYNIA.

Rheumatism of the intercostal muscles, accompanied, as it is, with more or less acute pain, generally most marked in the infra-axillary and infra-mammary regions, increased by pressure, by deep inspiration, by coughing, movements of the side, and decumbency upon it, simulates pleurisy in its earliest or dry stage. The physical signs, even, are not dissimilar; the movements of expansion and of elevation are diminished in freedom, and their rhythm becomes jerking; the respiratory murmurs are of intermittent weak type, and jerking rhythm; the percussionsound is not perceptibly altered. Friction-sound is of little use in the distinction of the two affections,-for the grazing variety, that appertains to dry pleurisy, is often wanting in that disease, and the jerking rhythm of pleurodynic respiration may so closely simulate it, as to leave a cautious observer in doubt. If with pleurodynia there be a chance co-existence of febrile action, cough and slight bronchitis, a positive diagnosis should be refrained from, until a certain number of hours having elapsed, the rubbing friction-sound of plastic exudation, if the case be one of pleurisy, will have established the fact beyond the possibility of doubt.

True rheumatic pleurodynia yields rapidly to cupping, dry cupping, anodyne and stimulant liniments, and the internal use of colchicum and an alkali.

INTERCOSTAL NEURALGIA.

The intercostal nerves, especially on the left side, and from the sixth to the ninth, are not unfrequently the seat of neuralgia, which, in respect of diseases of the lung, derives its interest from the possibility of its being confounded with pleuritic pain, and from its being pretty frequently associated with phthisis. The pain is severe, occurs paroxysmally, follows the course of the affected nerve, and, if there be co-existent palpitation, may (especially if combined with brachio-cephalic neuralgia) simulate, in its paroxysm, an attack of angina pectoris. Generally speaking, three tender points (as was first, I believe, shown by M. Valleix) may be detected by pressure in the course of the nerve,-one in the vertebral groove, another about the axillary

region, a third in front towards the terminal ramusculi. In the female, intercostal neuralgia is often associated with that of the mammary gland, and with spinal irritation.

The physical signs are those of pleurodynia; impaired chestmotion, with weak jerking respiration, the percussion signs being negative. The three painful points in the course of the nerve, point to the true nature of the affection, distinguishing it from periosteitis, and all pains of intra-thoracic origin.

If the tenderness be extreme at any one of the three points, a few leeches are requisite; subsequently flying blisters will, as concerns local measures, often complete the cure. The endermic use of morphia, and inunction with belladonna or aconitina ointments, combined with purgatives, and iron and quinine internally, will triumph, generally, over the most obsti

nate case.

BRONCHITIS.

Inflammation of the mucous membrane of the bronchial tubes, or bronchitis, perhaps the most common of pulmonary diseases, occurs in the acute and chronic forms.

ACUTE BRONCHITIS.

I. Simple primary acute bronchitis of the larger tubes, in the adult, is commonly ushered in by coryza, sore throat, and slight hoarseness, chilliness (scarcely amounting to rigors,) with lassitude and continued pains in the limbs, and frequent pulse. The occurrence of coryza is significant of the primary character of the disease, tuberculous bronchitis very rarely originates with this symptom.

The disease being established, more or less discomfort and pain are felt behind the sternum,-a sensation of heat, soreness, or rawness of the bronchial surfaces, increased, perhaps, to acute pain by coughing, and attended with a sensation of oppressed breathing. The respiration is increased in frequency, slightly out of proportion with the pulse,-in severe cases, notably so. The cough, an essential feature of the disease, at first short and dry or nearly so, occasionally paroxysmal, and severest after sleep, loud, hoarse, and ringing, is attended, after the lapse of one or two days (when it becomes loose,) with expectoration of frothy mucus, watery in the main, ropy in some measure, of saline taste, faintly yellowish, yellowish green, or grayish yellow