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ness on percussion at the apex of the right lung, and rather strongly pronounced breathing under the left clavicle,—that we may reasonably form the conclusion, in harmony with the appearance of the expectoration, that the disease is in the first stage, and not at present considerable. The second variety of expectoration is mucous, viscid, transparent. Two very good examples are before you. This patient, W. D., expectorates half an ounce daily of this kind of fluid ; he is a gardener, has no hereditary liability to phthisis, and attributes his complaint to bad diet. He began to cough last August, and at that time expectorated about half a pint of salivary frothy fluid in twenty-four hours. This patient's pulse is 78; height, five feet four inches; vital capacity, 155. The upper part of the left chest expands less than the right during inspiration, and is rather dull on percussion. The expiratory murmur is prolonged, being equal to the inspiratory at the apex of each lung. There has never been hæmoptysis. The disease is evidently rather more advanced than in the patient previously introduced to you ; but as yet there is no softening of tubercle, and the expectoration depends on bronchial irritation. W. D.'s expectoration contains a little blackish matter, resembling what is often supposed to owe its origin to carbonaceous matter abounding in the London atmosphere ; but the colour fades on the addition of nitric acid. It cannot, therefore, be carbon; it is rather the black matter of pigment cells, known to be formed under slight, but not under severe forms of bronchial inflammation. On applying a little heat, and examining this expectoration with the microscope, crystals, apparently of triple phosphate, may be seen. By the politeness of Dr. Garrod, I am able to show you another microscopical preparation of triple phosphate expectorated. It is from a patient concerning whom a strong impression had been entertained of the existence of phthisis. Dr. Garrod, however, ventured to pronounce the affection bronchial, and not intense. The progress of the case has established the correctness of his diagnosis, and serves to confirm an opinion which I am inclined to entertain, that the proportion of salts in the expectoration attending bronchitis appears to be in an inverse ratio to the degree of inflammation present. Such an opinion is at least in harmony with the interesting observations recorded by Mr. Brett.* As an approximation to the proportion of saline matter in the solids expectorated, we may mention from twenty to thirty per cent. in catarrh, from fifteen to twenty in the more opaque mucus of chronic bronchitis, and rather less than ten in the puriform expectoration of advanced phthisis.
Dr. Babington found that the addition of common salt converted pus after a time into a viscid mass like mucus. Dr. Golding Bird perfected the analogy by adding soda to pus, and then transmitting through it a current of carbonic acid. + Chemically speaking then, the watery frothy-looking secretion of our first division is chiefly serum ; the second, or mucous, is albumen mixed with saline material; the fourth, or purulent, the blood-globules devoid of their colouring matter, combined with coagulable albumen ; and the
* Transactions of the British Association for the Advancement of Science. 1837.
† Guy's Hospital Reports, No. 6.
third, or flocculent, has the mixed character, varying according as the principal proportion of material is supplied by the vomica, or by the bronchial tubes.
In the next patient, the boy W. J., if you listen attentively under the right clavicle, you will perceive as he speaks, especially in a whisper, a sound resembling pectoriloquy. It is transmitted to the ear like bronchophony, but still it seems to me to be formed within a small and limited space. This is a case illustrating the difficulty of distinguishing between bronchophony and pectoriloquy. My own impression is that a little cavity is forming in this situation, and the appearance of the expectoration is favourable to this opinion. You will observe that, although it is chiefly composed of transparent gelatinouslooking material, like that of W. D., yet its surface is striated here and there with little streaks of pus. I examined this sputum microscopically, not without the expectation of finding saline crystals. In this I was disappointed, but observed a peculiar conferva, of which I show you a drawing, resembling that described by Dr. Hughes Bennett,* not unlike the Penicillium Glaucum of Link, having jointed tubes dichotomously branched, and giving off at the extremity little spores arranged in bead-like rows. · It is the third variety of expectoration, however, to which I am specially anxious to direct your attention, because with scarcely any qualification you may regard
* Transactions of the Royal Society of Edinburgh, 1841, Part II.
it as pathognomonic of phthisis. Several specimens of this variety are on the table. When spat into water, you observe it assuming the form of globular masses, like little balls of wool or cotton. Some of these masses have subsided, some are suspended at different depths, others float on the surface, sustained by bubbles of air entangled in the surrounding mucus. Similar expectoration spat upon the plate has taken the form called by the French nummular, being in flattened, rounded, separate masses, and assuming a shape not unlike that of pieces of money.
Some of the patients from whom these specimens were obtained are before you. Examine J. E.; you hear in the right subclavicular region two or three distinct clicks accompanying inspiration and expiration. This is humid crepitation, and so good an example of the clicking variety as to give appropriateness to the term of “ clicking rhonchus,” employed by my colleague Dr. Cotton, as applicable to this conclusive sign of softened tubercle.
E. P. has distinct indications of vomica, and the cavernous gurgling attending her cough, heard under the left clavicle, accords with the information supplied by the ragged flocculent masses floating in her expectoration.
Having given examples of progressive changes for the worse, let me now indicate the reverse alterations characteristic of amelioration. When the process of contraction is going on in a vomica, a diminished quantity of expectoration is a common and a favourable symptom.
C. V. a month since expectorated four ounces
daily ;—now the expectoration has ceased. This result may partly be attributed to improvement of health under the use of appropriate regimen, and the administration of cod-liver oil; but has probably been promoted by the inhalation of turpentine.
Profuse secretion into a phthisical cavity is probably a cause as well as an indication of deteriorated blood; and measures which are consistent with a judicious regard to the accompanying conditions, may be advantageously employed in order to lessen its quantity. When the bronchial tubes contribute much to the supply, the skin being moist, and the appetite defective, pyroligneous spirit may sometimes be useful, but, generally speaking, tannic acid will probably be found a more appropriate medicine.
Under suitable treatment, the daily expectoration in L. D. is reduced from ten ounces to a few drachms, and instead of being, as formerly, purulent, has become serous and frothy. The physical signs correspond ; pectoriloquy, although still existing, is less extensively heard than formerly, and the chest over the affected part is contracting.
You find in many of these spittoons a combination of purulent and frothy expectoration. In others, there is no froth. What is the import of this difference ? Does the frothy intermixture result from the comparative immunity of one of the lungs from disease ? The list before you furnishes some facts favourable to such an opinion. This table gives a few particulars regarding the expectoration of twenty-nine patients, at present under my observation. Such tables, even when they may not present any special novelty, are