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Show DISEASES 0F TIIE ORGANS OF RESPIRATION. [SncTon III. TABLE XII. attack exacerbation. and taken with sever? acute gastritis; FIGs. I. 2. 3. >f.-(.'//r0771'c cuiarrlml inflammation of Hm fli/‘_l/)l.1', {rue/IHI, um] bronchi. on both sides of the pharynx. Respiration a little easier. The following night, delirious. Sixth (lay, decided typhoid symptoms; very dry skin; hot, dry tongue. Pulse very dyspnoca set in. Fig. I. shows the anterior wall of the trachea which is opened posteriorly. the thyroid body (( ‘. T.) enormously en- larged. surrounding and compressing the whole anterior and lateral portions of the trachea, only the membranous part being free; the internal surface. of the larynx and t 'achea in a state of hyperplastie inflamn'iation. Neoplastic deposits are lodged upon the mucous membrane, partly in patches (1'. 5.), partly in spheroid nodules, forming a somewhat coherent membrane (1'. S. T.), which extends down the bronchus and into some of its primary divisions. To the On the fifth day purulent spots found frequent and feeble. the eighth day. Stertorous biwitlliiig; coma. Died Past JIor/cm.--Brain anaemic. Serum in a ‘achnoid cavity. lleart and lungs nearly normal. 7N othiug remarkable about the bronchi. The epiglottis (Fig. 1) very red and much swollen. and raised high up in the pharynx above the level of the tongue. All the soft parts between the epiglottis, the root of the tongue, and upper edge of the larvnx enormously swollen. The epiglottal edges rolled in iind right, the carotid artery (A. (‘.) and the J ugular vein (V. 1.). formed a groove (a) l lading to the vocal orifice. the latter containing purulent coagula, 'ause complete obliteration of the circulation. Fig. 2 shows the nodular deposits extending into the dilated bronchi, one of which terminates in a cavity of a behind and on each side of the glottis were two very thickly swollen and very red sacs pressing upon it and nearly closing it up. They extended from the external and posterior portion of the pharynx to two inches below the upper part tubercular lung (1'. 1).). of the (esophagus. The base of the right arytenoid sartilage is exposed by insertion of a hook, and shows loss ofsubstanee produced by ulceration. Fig. 3 shows bronchial bifurcation, each division being alike affected by inflammation. (P. 1'.) enlarged papillze. Figs. 4, 5. Acutepitaryngo-Zm‘g/ngitis and cpiglottitis. Caste-L. "7., a man 28 y Ears old. [history and Nymph)man-Affected with a light form of angina of the fauces and larynx. Second day after the Situated ()n opening, the sacs were found to contain blood and pus. The folds of the mucous mem- brane were infiltrated with serum. Fig at shows the fauces and the visible portions of the pharynx very red and swol- len; the epiglottis high up in the cavity. Fig. 5, a long- itudinal section of the glottal cavity. (.\.) tongue. (15.) epiglottis. ((7.) crieoid 'artilage divided. (1).) epiglottal folds. (E.) inner surface of the anterior wall of the larynx. (F.) inner surface of same "avity below the vocal cords. be closed by all sorts of solid substances coming from without or A very important part of diagnosis forms the exact tracing of secreted internally. Compression of the bronchi often produces similar sound-pllenomena. 3. Closed bronchi will show on inspection that they do not par- the pulmonic boundaries, for they may deviate in several ways from the normal; first, by irregularity on both sides; second, take in the respi 'atory process, by retraction of the thoracic wall \Vhen the larger bronchi are occluded, or, during inspiration. when very many smaller ones are so, there will be cymmsfs of the skin, and dyspmea will indicate the obstacle to respiration. \70cal fremitus will be absolutely wanting in the region of the occluded bronchi; as long as the air-cells contain air there will be no dullness on percussion. )thn the obturation lasts for a considerable time the sound will be tympanitic, due to absorption of portions of the stagnant air behind the obstructed portion. 4. There is no respiratory murmur in the diseased region audible by auscultation, because the respiratory murmur cannot be continued beyond the obstructed portion. Nor will there be any bronchophony. Very copious mucous rales will point. to great accumulations in the 'avity. Foreign bodies, if they penetrate and obstruct the bronchi, will have to be ascertained. If fibrous coagula are. the cause, a portion of fibrin is al\ 'ays found in the expectorate. Compressions have to be ascertained by careful examination of the heart. vessels. etc. 5. Between perfect closure of the bronchi and their entire freedom stands the constriction or stenosis of the bronchial cavity. The more constricted the more will the symptoms be like those of occlusion. \thn the constriction is not very great it will be manifested by increased strength of the respi ‘atory murmur. Occasionally the expi ‘atory act is longer than usual and is accomlamied by snoring, sibilating crepitation. In progressive stricture vo ~al fremitus and l)ronchophony grow feebler, the respiratory movement and the respiratory murmur lose their force, whilst the inspiratory act will be cha 'acterizcd by retraction. 6. Dilatation of the bronchi can only be diagnosed when it takes place in spots and is widely diffused. Only very copious expector- ation will indicate such a condition. Uircumscribed brom'hiectases are manifested by nearly the same Differential diagnosis between physical symptoms as cavities. excessive broncho-ectases and cavities the sputa alone can determine, as mentioned above. Examination of thcexpectorate for shreds of pulmonic tissues has to be carried on for some time; for in the primary conditions of lung cavities those shreds are. often wanting. The history of the case will often throw light upon the subject and help to make out a diagnosis. Tympanitic sound by percussion on the thorax in bronchial dis- eases is only then produced when the bronchi are partly closed up and leading to softening of the lung-tissue; or when they are very nuieh dilated and situated very superficially. \Vhen they are surrounded by portions of the lung having a thickness of at least five centimetres no tympanitie soundiwill be heard. It is especially necessary to percuss over the bronchi more forcibly than over other portions of the thorax, in order to elicit the bronchial sound through the lungtissuc. lironehi situated in a. depth of at least five centimeters, even if they be very muchdilated, will not yield any tympanitie sound. As dilated bronchi usually contain much secretion it often happens that the sound becomes masked when they are filled, and reappears when they are. emptied by expectoration or otherwise. As a rule bronchiectasis exists in the posterior and lower portions of the lungs. ()nly superficially situated portions of the hing are accessible to diagnosis by auscultation and percussion. (‘entrally located diseased parts can only be recognized by the expectorates: thus do rusty-colored sputa indicate tibrinous pneumonia. (‘cntrally located gangrene and abscess are diagimsed by dark or greenish- colored cxpcctorates. ' both borders passing their limits; third, by displacement downward. A.-- (far/11ml position, is rgffrncxz‘, found of {/m apfcrs (f f/zc [UM/.9 in, Utt' course of chronic [mlmwtion 0r shrinking of fire (issues, and forms a rcry (important symptom, [a .sloz/‘lj/ drrrlopiar/ pulmonary [flit/Lists. 3._snmom/,1 f/zc Nari/ml boundaries by any (any, [a any direction, [8 may sriz/nfficrou‘ 'ff (1. com/foo); of alrcolm' (vaplo/srnm. Such a condition may exist in one or in both lungs. If in the right lung alone. it is best recognized by [is luzrcr [Ion/('1' passing its normal limits. If in the left lung, its increased volume will not, only make it, pass the normal downward, but its rower/or victim/i [mm/rr will uppreach the lift slrrlml /)()}'([(‘I', and the lung will cover the pericardium, anteriorly, far more than usual, so that the region of cardiac dull sound will be diminished in size, or will altogether disappear. A greatly enlarged volume of the lung must necessarily depress the diaphragm, the apex-beat will then appear lower, say in about the sixth intercostal space, and the locality below the heart, which is characterized by tympanitie sound, will proportionately lose in extent. Increase of volume of a lung, if existing for some time, often changes the configuration of parts of, or of the whole chest. C.--I11 very severe derangements of the lungs vocal fremitus and bronchial resonances lose very much of their force, the same also with the respiratory murmur; the w *akness is due to much loss of force of the respiratory movement. Decrease of volume of the lungs may take place under two circumstances. (Inc, by compression. from below upward, by any distension of the abdominal contents, from whatever cause. Two, by shrinking and atrophy of the parenchyma itself; also by compression by liquid or solid foreign substances in the thorax. Atrophy of the lungs is manitcsted by the following physical symptoms: Inspection and percussion of the thorax will show a feeble circumv ference of the chest ~avity, narrow intercostal spaces, feeble respir- atory movement, scoliotic curvatures of the spine. I'ercussion will show the lower borders of the lung to stand higher than usual, whilst the healthy lung will, in the same ratio, reach much lower down. Accordingly, when the left lung is atrophied the apex-beat will be found in the fourth intercostal space, whilst the sub *ardiac region will be marked anteriorly by a wider tympanitic-sound region. \Vhen the median border of the left lung is drawn outward the origiu of the pulmonary artery becomes more exposed, and its systolic filling readily visible and palpable in the second left intercostal space. Auscultation of such a. lung will show the same characteristic sound as that of an indurated lung. There will also be increased vocal fremitus, bronchophony and bronchial respiration. During each inspiration the lung normally increases in volume, especially when deep breathing is carried on, and the complementary spaces of the thorax are filled out. )thn inflammatory pro- cesses have produced zulhesion, and the complenn-ntary spaces are thus obliterated. the respiratory displacement of the borders of the lungs will be either very limited or cease altogether. The liver will retain its position in both phases of the respiratory act, and the cardiac dull-sound region and sub "ardiac tympanitic region will remain normal. I).-I.iqnids collected in the alveoli of the lungs manifest phys- ical symptoms different when they contain air-bubbles than when they contain none. In the first case-which is really the most frequent-auscultation will discover cola/«tiny I'((]('.\'. Percussion will usually produce tymrespanitic decp resonance, whilst inspection will show disturbed piratory motion. The quality of the liquid (whether 1tvbe blood, serum, pus. etc.) must be ascertained by the sputum. V cry often the historv of the course of the case throws light upon the subject, and the nature of the, liquid surmised. Unc fact must not be |