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that the cause of these conditions is contraction from pleurisy, and further observation confirms the correctness of the suspicion conveyed through the eye. If the heart were displaced by existing effusion, you would, probably, see bulging rather than depression. You put your hand on the flattened portion of the chest as the man speaks, and the vibration of the voice is distinctly perceived; effusion therefore does not exist, for that would interrupt the communication of the vocal thrill. You make percussion, and find dulness greater than the false membrane on the pleura alone would produce, but the dulness lessens as you proceed upwards to the apex of the chest. is displaced, but not extended; extends too much on the left. Accompanying the first sound of the heart, a loud murmur is heard near the apex, but not in the epigastrium, nor to the right of the sternum above the cartilage of the fourth rib.

The cardiac dulness that from the liver

This patient, Thomas C―, a sign painter, aged nineteen years, was admitted on the 23rd of December, 1850; height, five feet, two inches, and three quarters ; weight, seven stones, thirteen pounds; vital capacity by spirometer, 114. He has always lived well till lately, and has usually resided in London; has no hereditary tendency to phthisis; his father died of dropsy at the age of sixty-two, and his mother of jaundice at sixty. He enjoyed good health till three years and a half ago, during a voyage, when he received a severe blow on the right side of the chest, after which he expectorated about four ounces of blood. Six months afterwards he had rheumatic fever, and inflammation of the lungs, and his sputa were streaked with blood.

About eighteen months since he had a recurrence of hæmoptysis, he thinks to the amount of two quarts in a week and since that time his breathing has been oppressed, and some degree of hæmoptysis has occurred whenever he has attempted to resume his occupation. He complains of a sensation of tightness of the chest on the right side, relieved by making pressure on the left; cough slight; expectoration frothy; respirations 32; pulse 88, not strong; digestive organs natural ; enjoys exercise, but sleeps badly, and perspires at night.

In this case the cardiac murmur obviously indicates regurgitation from the left ventricle into the corresponding auricle. This regurgitation, however, is probably not considerable, for the circulation in the radial artery is not disturbed or irregular. There are various circumstances in this man's condition, encouraging us to hope that he will escape phthisis. The disease of the mitral valve is probably due to rheumatism, and such disease is not apt to occur in phthisical subjects. The dulness on percussion is least at the apex of the lungs, where tubercular disease is most common, and greatest at the part corresponding to the blow; which, by inducing inflammation and occasioning consolidation of the pulmonary structure, may have rendered the thrill of the voice more than usually observable. The frequent occurrence of hæmoptysis might excite suspicions of a tubercular tendency, but any such apprehension is qualified by the fact, that this occurrence was preceded and probably induced by a blow. A degree of friction sound at the border of the contracted part of the chest announces that some inflammation of the pleura still

exists.

A blister has been in consequence applied, and the patient is improving under the use of iodide. of potassium.

The next patient, George Sh, you observe, moves the right side of the chest moderately during inspiration, especially at the upper part, but the left side scarcely at all; you may suspect tubercular disease from this fact, and further examination confirms that opinion. Percussion yields a dull sound over the whole of the left side, and in the sub-clavicular region a sound is elicited, which some of you will recognise as amphoric, like that produced by filliping the distended cheek, and doubtless arising from the proximity of a considerable cavity almost full of air. If a smart stroke be given below the clavicle whilst the patient's mouth is open, you hear the sound denominated by the French, bruit de pot félé, resembling, as the designation implies, the noise produced by striking a cracked pipkin. You may imitate the cracked-pipkin sound by doubling the hands together rather loosely, and striking the back of one of them against the knee in such a manner as to allow some escape of air. The production of this particular sound by percussion of the chest is doubtless owing to the proximity of a considerable cavity, having yielding walls, and free communication with one or more large bronchial tubes. If, whilst the patient's mouth is open, you strike smartly over such a cavity, air escapes freely and suddenly from it into the bronchus, and thus the peculiar sound in question is produced. S has no hereditary tendency to phthisis, but for fifteen years has been scarcely free from either syphilis, or gonorrhoea. The free use of mercury, an unsettled life, and

perhaps, an uneasy conscience, may have proved adequate to induce the disease. He began to cough three years since, and a year afterwards to lose flesh; ten months ago he expectorated about four ounces of blood; his sputa, green and viscid, average in quantity ten ounces in the twenty-four hours. Occasionally the cracked-metal sound is suspended, probably in consequence of the plugging of the bronchial tube by the viscid secretion. Pulse 84; respirations 32. There is a chronic ulcer on the leg, which we shall not attempt to heal, for he always feels better when it discharges freely. has fluctuated considerably, but on the whole improved in strength under the use of cod-liver oil. Belladonna pills, and other remedies, have been tried for relief of the cough, but the medicine which benefits him most is the following linctus :-Hydrochlorate of morphia, one grain; diluted hydrochloric acid, five minims; diluted hydrocyanic acid, half a fluid drachm; syrup of squills, one fluid once. Water, one fluid ounce. Mix. One drachm to be taken when the cough is troublesome.

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The last patient I have to introduce to you to-day is Charles B-———. As you watch the movement of his chest, let me remind you that the advance of either of the five upper or " thoracic ribs" in ordinary inspiration should vary from '02 to 07 of an inch, and in an extraordinary effort may extend to about two inches; whilst the four or five inferior ribs, which obey the influence of the diaphragm, move outwards ordinarily from 25 to 30 of an inch, or in an extreme inspiration about an inch and a half. You will observe that the upper part of B's chest moves in correspondence with this rule; but that the lower part, instead of advancing ac

cording to this rule, absolutely recedes. By means of Dr. Sibson's chest-measurer, we may determine the exact amount of this deficiency of movement; or if you have not had sufficient practice for the dexterous management of this instrument, try that of Dr. Quain, in which the sliding joints are dispensed with. Even this instrument, however, excepting to those practised in its use, is not more trustworthy than the eye. In practice, the attentive eye soon detects the difference of form and movement associated with the diseases to which I have referred; but it is doubtless a great advantage to be able to state to others, by the aid of a graduated instrument, the exact amount of difference. If you strike this patient's chest, the sound elicited is clear; and you will have already recognised the characteristic movement of emphysema. The diaphragm in contracting, affords space for the expansion of the lungs, but the pulmonary cells already filled cannot admit more air; atmospheric pressure, therefore, takes effect, and the ribs are forced inwards. This patient is a tailor. He has been subject to colds for ten years, owing, he thinks, to transitions from hot workshops lighted with gas into the cold air. During the last three years these colds have become almost incessant. He has suffered from shortness of breath, and cough, and occasional paroxysms of dyspnoea. For the last ten months he has kept his room; sleeps in the sitting posture, with the body bent forwards; expectoration partly viscid, partly frothy; sonorous and sibilous rhonchi heard all over the chest ; pulse 88; respirations 26. He has no hereditary tendency to phthisis, or to gout, and has never had hæmop* Medico-Chirurgical Transactions, vol. xxxi.

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