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medy acts more efficiently when allowed to dissolve in the mouth than when taken in mixture. The following prescription is appropriate for this purpose. Take of powdered gum arabic, and of white sugar, each three drachms; powdered tragacanth, a drachmi and a half ; alum, two drachms; catechu, three drachms; rose-water, as much as sufficient for a mass to be formed into sixty lozenges.
The most powerful of direct astringents in the treatment of urgent cases, is acetate of lead. You may give two grains for a dose in a mixture, with half a drachm of distilled vinegar; or, if you prescribe it in a pill, give acetic acid immediately afterwards, in order to counteract the tendency to the formation of carbonate of lead, which is apt to produce colic. Gallic acid is not so prompt and effectual as acetate of lead, but suits some cases remarkably well. Turpentine is probably one of the most certain and suitable remedies in a majority of instances. Two drachms of oil of turpentine, two ounces of mixture of gum arabic, and four ounces of infusion of matico, or of cinnamon water, with thirty minims of tincture of capsicum, form an appropriate mixture, of which an ounce may be given at intervals. In slight cases the infusion of matico alone is often sufficient.
When the hæmoptysis is associated with suppressed catamenia and hysterical symptoms, lytta is of great value ; but let me repeat the opinion, that in a majority of instances of phthisis moderate expectoration of blood is useful, and that whilst you allay the apprehensions of the patient you may leave the symptom to its own course.
Expectoration as a means of diagnosis—Its varieties in different
conditions and periods of Consumption : 1st, salivary; 2nd, mucous ; 3rd, flocculent; 4th, purulent-Proportion of saline matter—Changes indicative of amelioration-Bronchial polypi
-Expectoration of conferva—Vegetable parasites in animal structures.
ONE of the circumstances to which your attention will be continually invited by patients suffering from pectoral complaints, is the “expectoration," a term which we use in its popular acceptation as applied to the material eliminated from the chest. I take an early opportunity of introducing this subject, as it constitutes one of the symptoms sometimes inadequately regarded by those whose minds are engrossed by the study of auscultation. It may be acknowledged that conclusions were formerly drawn from the appearance of the expectoration with unwarrantable confidence ; great importance was attached, for example, to means by which pus could be distinguished from mucus, on the assumption that the presence of pus in the expectoration was a diagnostic mark of the existence of phthisis. We now know that this opinion is inaccurate, and that purulent expectoration may attend bronchitis and other affections, and be absent in consumption. At the present time, however, it may be more seasonable to warn you against the opposite error, and to show you how much valuable information may be derived from examining the expectoration.
There are certain general rules worthy of regard in connexion with this subject. Thus, if a person with some severe chest complaint coughs frequently, and expectorates only frothy, salivary-looking fluid, you suspect pleurisy. If another patient expectorates a glairy fluid, resembling white of egg, you suspect bronchitis ; if the expectoration have a rusty tinge, and resemble thick gum-water coloured with blood, you are not likely to err in recording pneumonia ; if you are told of a sudden expectoration of a gush of pus in considerable quantity, especially if it be fetid, you would expect to find that matter accumulated in the cavity of the pleura had found its way into the bronchial tubes.
We have said that purulent expectoration may occur both in bronchitis, and in phthisis. When, however, long-continued purulent expectoration is unaccompanied with any distinct rhonchus, you may be tolerably certain that the source is a vomica, and not the bronchial tubes. Let us consider to what extent we may derive aid in our diagnosis of the existence and stage of phthisis, from an examination of the sputa. We must not expect conclusive evidence from this, or indeed from any other single symptom, in phthisis ; since the disease may proceed to an advanced period unaccompanied with expectoration, or the expectoration may be for a time suspended, espe
cially under the successful employment of medical treatment.
In S. A. M., for example, a patient whom you formerly examined, you have unquestionable proof of vomica in the cracked-metal sound, which you readily detect by making smart percussion in the second left intercostal space, but there is scarcely any cough, and that cough is dry. Still there are certain common circumstances regarding phthisical sputa, which may be briefly detailed. A member of a consumptive family feels a little out of health, and has a dry morning cough ; after a time the cough is attended with slight expectoration, at first salivary, after a short period becoming viscous, but transparent and homogeneous, subsequently dotted, and then streaked with blood, the striæ becoming by degrees more abundant. After a longer or shorter time, whitish opaque spots appear, of the size of a pin's head, rounded or flattened, giving a pearly aspect to the expectoration. These multiply and enlarge, and ultimately form masses of an opaque white or dark grey colour, varying in size from that of a lentil to that of a florin, irregularly rounded and chequered at the side, sometimes streaked with blood, and floating in a viscous transparent fluid. At a more advanced period of the disease, the expectoration is purulent, spreads out into a porraceous mass, and shortly before death is often surrounded by a pinkish halo.
The changes thus described do not necessarily occur in so uniform a manner; but the most characteristic appearances attending the series of changes of the expectoration in the different stages of the disease may be conveniently described under four divisions ; namely.
First, the salivary, or frothy.
The first is what you would expect from irritation, the result either of pulmonary congestion, or of slight tubercular deposit.
The second would indicate a more confirmed affection of the bronchial tubes.
The third is peculiarly characteristic of secretion from a vomica, modified by the absorption of its thinner constituents.
The fourth is indicative of phthisis far advanced, and (if unmixed with froth) usually involving both lungs.
Let us see how far such a representation is in harmony with the facts at present accessible in the hospital. I show you some examples of simple frothy expectoration. The first is coughed up, in the quantity of four ounces in the twenty-four hours, by the patient I now introduce. W. G., aged forty-two, a postilion, admitted into the hospital Nov. 18, 1850, says he has been for eight years subject to asthmatical cough ; fourteen months since he observed some streaks of blood in his expectoration, and during the last fourteen months has been losing flesh; the pulse is 84; respirations, 28 in a minute ; height, five feet two inches and a half; vital capacity, 140. These circumstances are sufficient to make you suspect the nature of the disease; at the same time, the local signs are so slight, being almost confined to the existence of a little dul