the chlorides being placed in the rooms of the patient's house, and the face washed with a weak chlorinated solution.

INFLUENZA.

I. Influenza, or epidemic catarrh, though claiming a place more naturally among bronchitic diseases than any others of the respiratory passages, is evidently, even in its local manifestations, an affection sui generis, and of much more extensive seat (even anatomically speaking) than its classification with bronchitis would seem to signify. Still, in the majority of cases, the most prominent local symptoms are those of bronchitis.

Essentially constituted by catarrh, with nervous and muscular prostration, influenza sets in with lassitude, chill (rarely actual rigors,) and aching pains in the limbs; and more frequently, perhaps, affects the mucous membrane of the throat at the outset than that of the nose or air-passages. So, too, nausea and vomiting may precede all other symptoms, showing that the surface of the alimentary canal early participates in the disease.

Heat and dryness of skin, frontal headache, sometimes excessively severe, small, weak, and frequent pulse, cough of variable severity, expectoration scanty and pituitous, slight dyspnoea, uneasy pain behind the sternum, tenderness under pressure, and sensation of rawness at the epigastrium, white furred tongue, nausea, absolute anorexia, occasionally vomiting, diarrhoea (trifling in amount,) vertigo, tinnitus aurium, pains in the neck, scalp, and over the malar bones (sometimes very acute, and obviously rheumatic,) extreme general uneasiness, contused pains and soreness of the limbs and trunk,-all combined with excessive depression of spirits, and an amount of debility and prostration totally out of proportion with the local ailments (syncope sometimes occurs in the erect posture)—are the symptoms of the established disease in its ordinary and pure form. The physical signs are those of bronchitis, or there are none.

There are exceptional cases (the same poison evidently being at work) where violent headache, flushing of the face, and delirium, with fever, mark its action; others, where the digestive organs alone suffer, and in the upper parts; others marked by diarrhoea or pseudo-dysentery; and yet others where, erethism or actual catarrhal inflammation of the urinary organs is the main phenomenon. In some epidemics especially, the lungsubstance has been very commonly attacked, and pneumonia cut

off multitudes of aged and debilitated persons. Pleurisy is also an occasional complication. Both affections are habitually latent, and to be discovered by their physical signs alone.

Terminating, in ordinary cases, by diaphoresis, sometimes by (or rather with) cutaneous eruptions, at the end of from three or four days to a week, influenza leaves after it, invariably, more or less debility, and, in many cases, chronic bronchitic cough. That the symptoms of phthisis have occasionally first become apparent after an attack of influenza, is unquestionable; and the fair inference is that it accelerated the outbreak of the tuberculous disease. Influenza rarely kills those it attacks, unless, aged and debilitated, they have already one foot in the grave. Among this class of the population, the mortality occasioned by an epidemic has sometimes proved extremely serious.

II. The experience of centuries has established, beyond question, the impropriety of depletory measures in the treatment of influenza. The Czar of Russia was justified, by the mortality clearly traceable, not only in his own dominions, but in various countries of Europe (England, France, Spain, Italy,) to bloodletting, in issuing his Ukase against employment. I doubt if the occurrence of consolidation-signs even warrants the use of the lancet: such signs are observed chiefly in the aged and exhausted; and I know, from experience, that dry-cupping and carbonate of ammonia will remove these signs in such cases; whereas I have never seen any benefit derived from abstraction of blood, either by leeches or cups. Such consolidation is very positively passively congestive in the aged and infirm, and is increased by depressing measures. Should well-marked signs of sthenic pneumonia occur in a young or middle-aged person, leeching or cupping may be advisable; but even then caution is requisite; a dozen leeches have, within my experience, produced successive fainting fits in a previously healthy and robust individual. I have never seen a case (perhaps such may be met with in the provinces) where venesection was advisable. Neither should tartar emetic, active purgatives, nor (I think, in spite of the encomiums of Dr. J. Davies) mercury, with a view to its constitutional action, be employed.

The treatment I have found most successful, is as follows:Keep the patient in bed; open the bowels by some gentle laxative; give some slightly diaphoretic medicine, in combination (if there be rheumatic pains especially) with colchicum and an alkali; procure sleep by extract of lettuce, or of hyoscyamus;

and allow diluents freely. After the first three or four days, if bronchitic rhonchi exist, a blister should be applied between the shoulder-blades or to the sternum, and an expectorant mixture prescribed. This mixture may with advantage be made somewhat stimulant; let the vehicle, for example, be partly ammoniacum mixture, or decoction of senega; lobelia inflata and paregoric should enter into its composition. Tonics, iron, and quinine may be given daily during convalescence, unless the stomach have been implicated to any amount. If there be much exhaustion from the first, sesquicarbonate of ammonia and strong beef-tea should be given without hesitation.

SYPHILITIC BRONCHITIS.

That the virus of syphilis may affect the bronchi, has been made very evident by the inquiries of Drs. Graves, Stokes, and Munk. It appears that a certain time after infection, febrile action and bronchial irritation occur in a variable number of cases, as preludes to cutaneous eruption, disappearing wholly or partly when this is established; and, conversely, if a syphilitic eruption suddenly disappear, spontaneously or through treatment, bronchitis may ensue.

Under these circumstances, the diagnosis is easy. But persons, poisoned to the secondary and tertiary degrees by syphilis, may have chronic bronchitis, as a persistent state, they may cough, have sero-purulent and muco-purulent expectoration, nocturnal perspiration, and hectic fever, while they rapidly lose flesh and strength; and no tubercle shall exist in the lungs. Yet here is assuredly enough to create a strong suspicion of its existence, taken in conjunction with the indubitable tendency of syphilis plus mercury to induce the outbreak of phthisis in a person having the requisite constitutional aptitude. How are the cases to be distinguished? By the total want of accordance between the physical signs and the constitutional symptoms: the patient with syphilitic bronchitis has neither consolidation signs, nor, à fortiori, those of excavation. But there is a curious source of difficulty, which sometimes starts up in these cases, and renders doubt imperative: the infra-clavicular ribs and clavicle thicken from periosteitis, and produce dulness under percussion, which cannot with positiveness be distinguished from

that of tubercle within the lung. Here the observer must wait for events to clear up the diagnosis.*

In managing this variety of bronchitis, the whole secret consists in having proper regard to the diathesis inducing it. Ioduretted inhalations are serviceable.

NARROWING OR OBLITERATION OF BRONCHI.

Narrowing and obliteration of the bronchi, a common phenomenon in tubes of very small caliber, becomes rarer and rarer directly as their size; still, obliteration, even of the main trunk, has occasionally been witnessed. The obstruction may depend on intrinsic causes, such as thickening of the mucous membrane, accumulated secretions, especially of the plastic kind (under both these circumstances the condition is of inflammatory origin,) or an accumulation of tubercle or cancer in their interior; or obstruction may be produced by extrinsic pressure, for instance, that of adjacent emphysema, adjacent tuberculous deposit, plastic contractile exudation, infiltrated cancer or chronic solid pleural accumulations: enlarged bronchial glands, aneurisms and mediastinal tumours have sometimes effected the closure of a main trunk by pressure.

If obstruction of a large bronchus, by its own secretions, occur suddenly, or even with notable celerity, dyspnoea proportional to the size of the tube follows; and as this has chiefly occurred in cases of bronchitis, where the efficient breathing surface had already been seriously diminished, risk of fatal asphyxia is incurred, unless the patient retains strength sufficient to enable him to expectorate the accumulation: the relief experienced after such expectoration is almost assimilable to that following tracheotomy for obstructed larynx.

But if the obstruction be on a small scale, or if a large tube suffer only from slow, gradually increasing obstruction, there will be no positive subjective or objective symptoms to indicate. its existence. Such dyspnoea as is really traceable, in part, to

*E. g. Case of Smedley, U. C. H., Females, vol. i. p. 143 (1849.) When admitted in 1846, this woman, in addition to secondary and tertiary syphilis, and cancer of the rectum, had bronchitis and very slight dulness, with harsh respiration under the right clavicle; but as the subjacent bones were obviously thickened, I abstained from giving any positive opinion as to the existence of consolidation of the lung. The chest-symptoms totally disappeared under treatment. I have frequently seen the patient since; consolidation-signs, growing at each interval more marked, had become positive at both apices when I last (winter of 1850,) saw her.

obstruction of the kind, appears explicable by other conditions; and neither cough nor pain in the chest exists.

The physical signs may or may not be satisfactory. Obstruction of the main tube produces collapse of the entire lung, as well shown in one of Dr. Carswell's published drawings;* obstruction of minor tubes, as insisted on by Dr. Stokes, produces local and limited collapse,-the surface of the lung in the affected parts appearing sunken in below the plane of the surrounding pleura. Now, in both these varieties percussion-dulness, proportional to the superficial extent and depth of the collapse, would constantly exist, were it not that, in the local variety, emphysema tends to spring up on the confines of the collapsed spots, and give rise to its own special resonance. The respiratory murmurs are either actually suppressed or weakened considerably, and harsh; and mingled with sonoro-sibilant rhonchi.

The main interest, in the present state of knowledge, of obstruction of a large bronchus, comes of the light it may throw on the diagnosis of thoracic aneurism and tumour.

The treatment of the affection is altogether that of the disease of which it is a sequence or effect.

PLEURISY.

The physical signs of pleurisy, and to a less degree its symptoms, vary with the anatomical conditions of the disease-themselves referrible to four periods: that of hyperemia and dryness; of plastic exudation; of sero-purulent effusion, without or with dilatation of the side; and of absorption, without or with retraction of the side.

Physical Signs.-Dry Period.-The motions of expansion and of elevation, from the consensual avoidance of pain, are diminished to the sight, feel, and measure; their rhythm is slightly jerking. The percussion-sound is not perceptibly duller than natural; I have never known its pitch raised. The respiration is weak, but superficial, and jerking in rhythm. Grazing friction-sound may sometimes be caught, especially about the inframammary and infra-axillary regions.

Plastic Exudation Period.-The state of chest-motion continues as before; rubbing vibration may sometimes be felt with

*Fasc. Atrophy, pl. iv., fig. 3. The lungs are those of a monkey,—the cause of obstruction, extensively tuberculized bronchial glands. Atrophy from inaction would doubtless ensue after a time.