Clinical Lectures and Cases in the Medical Wards of the Illinois
General Hospital. By N. S. DAVIS, M. D., Prof. of Princi-
ples and Practice of Medicine in Rush Medical College,
and one of the Physicians to the Hospital. Reported by
B. F. WHITE, Interne.

(Continued.)

CASE 2d. E. B., Irish laborer, aged about 20 years, admit-
ted into the Hospital this day, Jan. 10th. Visited by the at-
tending physician accompanied by his class at 5 o'clock P, M..

You perceive, said the Doctor, that the position of the pa-
tient is dorsal with a slight inclination to the right side; his
face is deeply flushed, but of a purplish or dingy red color,
with something of a bloated aspect; his expression dull and
inactive; his skin dry, harsh, and warmer than natural; his
chest is broad and full, but his breathing short, difficult, and
painful; his cough appears frequent and productive of deep
seated pain, and soreness in the central part of the right
half of the chest, with a pretty copious liquid, and reddish or
bloody expectoration, which you will see by looking in this
vessel, is pretty homogeneous, and not simply streaked with
blood. It is tenacious, however, and of a veinous rather
than arterial redness. His tongue, you perceive, is covered
with a pretty thick yellowish fur, quite dry, and slightly red-

ened along the edges and tip; his pulse is little more than 100 per minute, not full, but easily compressed; thirst moderate; urine scanty and high colored; and his bowels rather tympanitic, with loose watery evacuations. The patient says he was seized with a sense of chillness, pain in his chest, difficult breathing, and cough, while at work four days since, which soon became so severe as to compel him to return home and take his bed. This chillness soon ceased and gave place to a head-ache, thirst, and all of the symptoms which we have just passed in review. He has had no medical attention, but has taken two or three doses of physic, (castor oil and epsom salts), which accounts, in part, at least, for the looseness of his bowels at the present time.

This brief history of the case, with the prominent symptoms which we have passed in review, is sufficient to direct our attention to the thoracic viscera as the special seat of dis

ease.

Indeed, all the general symptoms sufficiently characterize the case, as one which is commonly styled lung fever, or winter fever, in many parts of the country, and which in some sections is exceedingly prevalent and fatal. But to gain rational and accurate indications of treatment, we must ascertain more definitely the location, extent, and stage of the disease. As I lay the chest bare, you observe the left side moves much more freely with each inspiration than the right. Each of you can detect the difference in the resonance, as I compare the one side with the other, by percussion; there being pretty decided dullness over the upper, and the greater share of the middle lobe of the right lung. The dullness seems greatest about two inches above the nipple. By extending the percussion over the abdominal viscera we find no indications of enlargement of the solid viscera, but there is a general tympanitic condition.

Returning to the chest I apply my ear to the left side and hear nothing but an exaggerated or puerile respiration.

Over the infra clavicular region of the right side, the respiration is distinctly bronchial and somewhat intermixed with a coarse mucous rattle or rhonchus, and the voice is decidedly bronchial. Over the upper part of the mammary region and bordering on the axilla, the fine crepitant râle is very distinct. I find no morbid sounds over the remaining part of the chest. The cardiac sounds are normal, the impulse thongh frequent is only of moderate force. Such are the physical signs elicited by percussion and auscultation, and they indicate simply an unnaturally solid condition of the upper, and part at least, of the middle lobes of the right lung. But if taken in connection with the general symptoms, particularly the fever, deep seated pain in the chest, oppressed respiration, cough, and bloody expectoration, there is left no difficulty or doubt in reference to a proper diagnosis. The solidity indicated by the dullness and bronchophony, is simply an early stage of hepatization of the right lung, while the crepitant râle heard at the lower and lateral margin of the dulness, shows that inflammation in its first stage exists, and is probably still extending to other portions of the lung.

Diagnosis. We have then, gentlemen, a case of acute Pneumonia, in the fourth day of its progress, involving the upper and middle lobes of the right lung, in a considerable portion of which the disease has passed into the stage of infiltration, more commonly called hepatization. But this is not all.

For the appearance of the tongue, the tympanitic state of the abdomen, and the loose or watery evacuations, show plainly that the pneumonia is complicated with irritation, if not a low grade of inflammation of the mucous membrane. of the alimentary canal. Before calling your attention to the treatment, however, I wish you to mark well the differences between this case and that of T. Y., discharged a few days since. (See March No. of Journal, Ed.) The principle disease in both was acute pneumonia, and both were admitted at about the same period of advancement. But you will rec

ollect the former case presented us with a bright arterial flush on the face, an active or excited expression of countenance, a very hot skin, and a moderately frequent and full pulse, without any abdominal symptoms. While in the present case you have a darker, more dingy flush, less heat of skin, a quicker but less forcible pulse, and a decidedly dull, indifferent expression, with a constant disposition to drowsiness, and sometimes incoherent talking. You see him falling into a drowsy half-sleeping condition while I am talking by his side. And what does these differences indicate? This is a question of the utmost practical importance. When remarking on the former case, to which I have alluded, it was said that the numerical statistics of M. Louis in regard to the treatment of Pneumonia, were practically not worth a serious examination; simply because they include under the same general head, cases the most diverse in every particular, except the simple existence of pneumonic inflammation. And here you have valid proof of the assertion. Thus in the case of T. Y., we had a strongly marked inflammatory diathesis; or as I should prefer to call it, a high degree of tonicity of the solids, with energy of organic action, which required the abstraction of no less than 30 oz of blood, to make a decided impression on the progress of the disease; while here we have altogether the reverse, viz: diminished tonicity with enfeebled organic action, as indicated by the darker hue of the face, the dull and indifferent expression, the early tendency to mental wandering and somnolency, and above all by the frequent and compressible pulse, unaccompanied by any increase in the force of the heart's action. Now, although both patients were attacked with essentially the same disease, and so far as the lapse of time is concerned, they came under our observation at the same period of their progress, yet from the circumstances already detailed, I venture to predict that this patient will not bear the abstraction of the half of 30 oz. of blood without a dangerous degree of prostration.

And the reasons are to be found in the special condition of the solids and fluids of the system, and the grade of activity of the vital properties, at the time of the supervention of disease. You are all aware that exposure to bad air, unwholesome food, and insufficient clothing, as among the poor of cities, in large Hospitals, Jails, Camps, &c., there is induced such a state of the solids and fluids of the system as to strongly favor the occurrence of Typhus Fever, Erysipelas, and indeed, to give whatever disease may occur, a typhoid tendency. So, too, in highly malarious districts, where Intermitting and Remitting fevers prevail during the Summer and Autumn, the solids and fluids undergo a change which modifies, to a greater or less extent, the organic or vital functions. And although this modification is by no means identical with that which constitutes the foundation of true typhus, yet it is evidently accompanied by an impaired tonicity of the solids, and consequently, diminished energy of the functions of innervation and circulation. And hence any disease, a pneumonic inflammation for instance, occurring in such a system would meet with less of what we may term, vital or organic resistance to its progress; it would pass through its several stages more speedily; the first or congestive stage would be followed by less perfect reaction; the effusion or infiltration in the second stage, would be less plastic and more diffused; and there would be a much earlier failure of innervation, and consequently of capillary circulation. These are the characteristic features of those Lung Fevers, Billious Pneumonias, Thphoid Pneumonias, &c., which are so frequent and fatal in many malarious districts throughout the west, during the winter and spring months. And they are precisely the features which distinguish the case before us from that of T. Y., to whom your attention was directed a few days since. In practice you will find every shade or degree of developement of these features, from the full, healthy degree of tonicity and vital energy exhibited by T. Y., to so great an impairment of these