Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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together to prevent their respiratory motion ; in consequence of which
the spine itself becomes curved, its convexity being directed towards
the sound side.

Palpation merely confirms the superficial breathing, and may yield
the perception of a grating feel ; more, however, towards the end than
at the commencement of the disease, after the exudation has been
absorbed, when, therefore, the surfaces are dryer and the breathing
deeper again, so that the rough surfaces glide more forcibly one upon
the other.

For this same reason, auscultation reveals the friction sound more
decidedly towards the end of the disease.

The third form, with abundant serous-fibrinous exudation, usually
commences with a strong chilly followed by high fever. The chill is
frequently repeated, and the whole affection may look very much like
a tertian intermittent fever. It is also characterized, like the second
form, by violent stitching pjains in the sides of the chest, which, how-
ever, often subside, or at least diminish, before the inflammation and
exudation may have reached their full height. The subsidence of
pain is therefore, in this form, not always a sign of conquered disease.

Generally it is accompanied by dyspnoea as long as the fever lasts,
and in such cases, and where an extensive exudation compresses the
lung, and causes a hypersemic state :and catarrh in the adjoining por-
tions of the lung, there is also cough. Otherwise the cough may be
absent altogether.

The disease generally reaches its height in about six or eight' days,
and commences from that time its gradual decline. Fever, pain, and
cough cease, and absorption of the pleuritic exudation takes place,


diminishing at first much more rapidly than towards the last, so that
sometimes, even after weeks, still some fluid can be detected.

In some cases this form comes on quite stealthily, without either
prominent fever, pain, or cough. The patient feels only a gradual
loss of strength, some difficulty of breathing ; he grows pale, and
loses flesh, and thinks that the source of all his troubles lies in his
abdomen, especially when, by exudation on the right side, the liver
has become dislocated downwards. Even the physician may be
astonished when he, by closer examination, finds the whole pleural
sac filled with fluid, amounting even from ten to fifteen pounds.
Such an enormous quantity, of course, can be absorbed at best only
very slowly, being alternately augmented and decreased in the mean
time. It terminates finally, in a great number of cases, in tuber-

Physical Signs.

Inspeetion discovers an enlargement of the thorax in breadth and
depth on the diseased side if the exudation is sufficiently large. The
intercostal spaces are wider, and are on a level with the ribs, or even
bulging out between them. The respiratory motion is much less, or
ceases altogether on the diseased side.

Palpation reveals the absence of the vocal fremitus, which is the
necessary consequence of the intervening fluid between the thoracic
walls and the lung; it reveals the dislocation of the heart or the liver,
and also sometimes the friction of the roughened pleural surfaces
above the exudation.

Percussion yields a somewhat duller sound, in case the exudation be
moderate, so as not to compress the lung tissue to such a degree as to
drive all air out of it ; it yields a tympanitic sound if the pressure
upon the lung be just sufiicieut to deprive it of its natural tension
and elasticity ; it yields a dull, fleshy sound if the secretion augments
to such a degree as to deprive the lung of all the air ; above this dull
sound we hear again the tymp)anitic sound, for here the lung, although
compressed, is not entirely without air. Variation in position does
not change the result of percussion, because, as we have seen, the ex-
udation is always enclosed and bordered by adhesions.

Auscultation reveals an absence of the respiratory murmur over the
whole part that is covered by exudation. In other cases, however,
we hear all over the thorax a loud bronchial breathing, especially in
case of dyspnoea ; no matter how much fluid intervenes between the



thoracic walls and the lungs, or how much the lungs may be com-
pressed. The auscultatory signs are therefore not very characteristic.

The fourth form, with jyurulent exudation^ the empyema or pyo-
thorax^ differs from the latter only by the abundance of its pus-
globules, and is frequently found in consequence of infectious dis-
eases and a general pyemic condition. Its physical signs are all the
same as above stated.

When empyema is going to discharge through the thoracic tvalls we
observe in the region of the fourth or fifth rib an oedematous swell-
ing, which soon changes into a hard, tense swelling protruding from
between the ribs ; by-and-by it becomes fluctuating, and lastly it bursts
and discharges an immense quantity of pus. This opening sometimes
remains for years, forming a thoracic fistula, and discharges every now
and then larger or smaller quantities of pus.

■ When the empyema is going to discharge through the hronchial tubes
there may appear at first symptoms of pneumonia, or the bursting
takes place suddenly, when, with violent fits of coughing, the patient
throws up large quantities of pus. Even here recovery is possible,
though it may happen that the patient sufibcates or sinks under the
influence of pyemic poisoning of the blood. The empyema may also
discharge doivnioards through the diaphragm into the abdominal cavity,
where it occasions a violent j^eritonitis.

Differential Diagnosis between Pleurisy and Pneumonia.

Eepeated chills.
Catarrhal sputa.
Stitching pain.

Enlargement of the thorax.
Absence of vocal fremitus.
Dislocation of heart, liver,

Friction sound.



One chill.

Eust-colored sputa.

No pain or dull when the bron-
chial tubes, and stitch-like when
the pleura, is involved.


Increased vocal fremitus. .


Crej^itant sound.

Therapeutic Hints,

Aeon., chill; fever; great thirst; quick pulse; dry skin; anxious
restlessness ; agonizing tossing about ; stitching pain in chest ; in-
ability to lie on the right side ; dry hacking cough.


Arnica, after mechanical injuries; constant changing of position on
account of feeling as though the bed were too hard.

Bryon., stitching pain in chest, worse from slightest motion ; tongue
white ; great thirst.

Kali c, when the violent stitching pain does not yield to Bryon. ;
especially on the left side with violent palpitation of the heart ; cough
is dry, and worse towards three o'clock a. m.

Mercur., stitching pain through to the back when coughing or
sneezing ; especially on the right side.

Nitp. ac, in old people, when the pain leaves and the pulse in-
creases ; great weakness and diarrhoea.

Phos., in complications with bronchial affections ; tightness across
the chest; dry, tight cough, which is worse from evening until

Rhus t., after exposure to wet, or from straining, lifting, wrestling,
&c. ; tip of tongue red ; fever-blisters around the mouth and nose ;
very restless disposition, notwithstanding the pain.

Squiila, stitching pain in left side ; short, rattling congh, disturbing
sleep; inability to lie on the left side; grating of teeth; twitching of
the lips, which are covered with thick yellow crusts, more on left
side ; worse in all respects in the morning.

Sulphur, when the pain is in the left side, lower region, going
through to the shoulder-blade, and of a more steady nature ; lips
bright red; follows well after Bryonia or Ehus t.

Tart, em., in pleuro-pneumonia at the commencement ; according to
Kafka, specific.

With these means we need scarcely ever fail in recent cases. The
morbid process being nipped in the bud, it cannot bring forth large
exudations. In neglected or badly-treated cases, where the exudation
is abundant, or in cases developed in cachectic constitutions, with a
pyemic tendency, we shall have to compare Arsen., Calc. c, Cam ph.,
Carbo veg., China, Ferr., Hepar, Jod., Lach., Lye, Sepia, Senega,
Silic, and others.

In pyothorax, when the pns is about to discharge itself externally,
I would decidedly object to opening the abscess by the lancet, be-
cause it is apt to let in air, thus giving rise to pneumothorax, which
has almost always proved fatal. If the abscess be let alone, it will
take care of itself, break at the right time and at the right place, and
let in no air.

Paracentesis has very seldom proved beneficial.



This consists of a collection of air or gas within the pleural sac.
As air alone, however, is rarely found in this locality, but mostly in
combination with pus, hlood, or serum, it is called, according to the
nature of the coexisting fluid, either pyo, or hsemo^ or hydro-pneumo-

Pneumothorax, whether it be in combination with fluids or not, is
always characterized by an enormous extension of the thoracic wall
of the affected side, the intercostal spaces of which bulge out. When
on the left side, it pushes the heart towards the right; if on the right,
it presses the liver down into the abdominal cavity. The lung itself
is compressed to a small volume, containing little or no air, and lying
close to the spine.

The gas, which is collected within the pleural sac, consists mostly
of carbonic acid gas and nitrogen, with very little oxygen ; and in
cases where decomposition has taken place, of sulphuretted hydrogen.
These gaseous substances may be diffused, and fill the whole pleural
cavity of one side, or they may, in rare cases, be limited therein to a
certain portion, in consequence of previous pleuritic adhesions.

The entrance of air into this cavity almost always causes in a short
time a pleuritis with either sero-fibrinous or purulent exudation ; and
is occasioned either by a perforation of the 'pleura pulmonum, in which
case the air enters from the air-cells of the lungs ; or by a perforation
of the thoracic wall, when the air enters from without*, or gaseous sub-
stances may be formed by means of decomfosition in a pyothorax.

In cases in which the air fills the pleural sac through the lungs, it
takes place almost always quite suddenly, and the patient has a feeling
as though something had burst in the chest; which is in fact the case.
At the same time he experiences great difi&culty in breathing ; he is
obliged to sit erect, and can lie only on the diseased side, and for an
obvious reason, — to keep the sound lung free from any pressure.
The worst cases are those which exist in consequence of tuberculosis,
gangrene, or carcinomatous degenerations of the lungs. Those in
consequence of emphysema or external perforations are not so violent.

Physical Signs.

Inspection. Enormous enlargement of the diseased side of the tho-
rax; its intercostal spaces bulge out; perfect want of respiratory

Palpation, Total absence of vocal fremitus; liver or spleen dis-


placed downwards ; heart towards the middle or the right side of the

Percussion. Tympanitic sound, unless greatly distended, when it
becomes non-tympanitic, or full lung sound. Dull sound in the upper
posterior region, where the compressed lung lies, and in the lower
regions of the thorax, when effusion exists; changing locality with
the patient's change of position.

Auscultation. Absence of respiratory murmur by full resonant
percussion sound ; metallic tinkling when the patient talks, coughs, or
inhales deeply. Bronchial breathing and bronchophony, where the
compressed lung lies.

In cases where air and fluids co-exist we hear a splashing sound
whenever the patient moves quickly, just like water in a half- filled
bottle, if it be shaken.

Likewise do we sometimes hear a falling of drops with a metallic
tinkling sound, when the patient rises from a recumbent position.

Differential Diagnosis.

Pneumothorax differs from emphysema by its dyspnoea coming on
suddenly and growing worse steadily; by its one-sided distention of
the thorax, the intercostal spaces of which bulge out ; by its want of
vocal fremitus, the absence of the vesicular murmur, and the presence
of the metallic tinkling sound.

It differs from large superficial cavities, by the distention of the
thorax and the displacement of heart, liver, or spleen, and the absence
of vocal fremitus.

Therapeutic Hints,

For the sudden dyspnoea, Arsen.

When caused by external injury, Aeon., Arn., Staphys.

When in connection with tuberculosis, compare the remedies men-
tioned there.

For the subsequent inflammation of the pleura, compare Pleuritis
and Pneumonia.

Hydrothorax, Dropsy of the Chest.

This is a collection of serum in the pleural sac, without any inflam-
matory process in that locality. It is mostly found on both sides of the
chest at the same time, although one side may contain more fluid than
the other. The serum is clear, yellowish or greenish ; sometimes red-
dish, when mixed with blood ; it never contains fibrinous substances,


as an exudation of pleurisy always does, but in place of it a great
deal of albumen. The pleura itself looks pale and dull, without any
sign of inflammation ; the lung is pressed towards the spine whenever
a large amount of such fluid exists, and generally appears oedematous.

Hydrothorax originates mostly in consequence of lung and heart
diseases, which cause obstruction to the venous circulation within the
lungs ; or in consequence of such morbid states of the body as cause
the blood to become thin and watery, as is the case in Bright's dis-
ease, in certain spleen and liver affections, in ansemia, in intermittent
cachexia. It is, therefore, almost always attended by other dropsical

From this it is apparent that its symptoms must vary greatly. Its
most prominent feature, however, is dyspnoea^ which is always ivorse
in a lying^ and hetter in a sitting position, and this for obvious reasons :
>vhen sitting the fluid settles to the lower part of the thoracic cavity
and leaves the upper part of the lungs free for respiratory action ;
whilst in a horizontal position the whole lung becomes overflown and
compressed by the fluid. Where there is a great deal of serous
effusion the patient seems to suffocate whenever he turns in bed. Nie-
meyer explains this important sign in the following manner : as the
fluid is not limited to a certain place, as is the case of pleuritic
effusions, it changes its position freely whenever the patient changes
his position, following the law of gravitation. Wherever it locates,
there it naturally compresses the lungs, makes them unfit for respir-
ation, whilst the uncompressed portion fulfils this office undis-
turbed. A turn of the body reverses at once the location of the fluid ;
it now compresses those portions of the lungs which were breathing,
and sets others free that were compressed. Ere these can be per-
vaded by air the patient has no breath. This explains fully those
suffocating fits which such patients experience when turning in bed.

Physical Signs.

Inspection. Enlargement of the thorax.

Palpation. Absence of vocal fremitus and displacement of heart,
liver, spleen.

Percussion. Dull sound as far as the fluid reaches, changing local-
ity in different positions of the patient.

Auscultation. Absence of vesicular breathing where the fluid covers
the lungs, but bronchial breathing about the spine, where the lungs
are compressed.


TJierapeutic Mints,

Apis., great oppression ; inability to lie down ; absence of thirst ;
urine dark like coffee ; after taking cold during desquamation in
scarlet fever.

Apocynum cannabinum, inability to speak; catching of the breath;
irritability of stomach so great that even a draught of cold water is
rejected ; suppression of urine.

Asclepias syriaca, recommended especially after scarlet fever.

Arsen., dyspnoea, worse from any exertion ; when lying down at
night, if ever so carefully, the patient experiences a sense of suffoca-
tion; also when turning in bed* with great anxiety; palpitation of
the heart, and great dryness ; drinking constantly but little at a time.

Asparagus, old people with heart diseases.

Bryon., pain in the side; cough, with contraction of the diaphragm;
vomiting and splitting pain in the head, excited by any motion;
retarded stool and frequent desire to pass water, but only a few drops

Colchic, asthma ; oedematous swelling of hands and feet ; constant
urging to pass water, as from spasm of the bladder, but only little is
voided and that with great pain; heart disease in consequence of
acute rheumatism.

Digit., intermitting pulse ; pale face ; cold skin ; flabby, oedema-
tous swelling all over ; difficult urination ; cyanotic symptoms, with

Helleb., slow comprehension; slow in answering questions; pale
face ; griping pain in the bowels, with diarrhoea of a jelly-like slime.

Kali c, whizzing breathing; oppression worse about three o'clock
in the morning ; oedematous swelling between the eyebrows and lids,
looking like a little bag ; insuflS.ciency of the mitral valves ; great
dryness of the skin.

Lachesis, suffocating fits, waking from sleep, with throwing the arms
about ; cyanotic symptoms ; swelling of the liver ; black urine ; offen-
sive smell of feces.

Lycop., dyspnoea worse when lying on the back ; constipation ;
rumbling in the left iliac region ; red urine ; exceedingly cross after
getting awake.

Merc, after scarlatina; oedematous swelling all over; sweating
without improvement; dry, hard cough; inflammation of the genital

Squilla, strong urging to urinate, with scanty and dark urine ; con-



tinuous cough, witTi mucous expectoration; oedematous swelling of
the body.

Senega, loose, faint, hacking cough, with expectoration of a little

Spigelia, dyspnoea during motion in bed ; can lie only on the right
side and with the trunk raised ; danger of suffocation when making
the least motion or raising the arms, with anxiety and palpitation of
the heart.

Sulphur, sudden arrest of breathing at night in bed when turning
to the other side ; going off" when sitting ; constipation, or diarrhoea in
the morning ; liver complaint ; red lips.

Tart, em., much coarse rattling in the chest ; expectoration not
equivalent to the secretion within ; drowsiness ; cyanotic symptoms.


Is a collection of blood within the pleural cavity, which is brought on
either by external injuries of the chest, as wounds from stabbing,
gunshot wounds, fracture of the ribs, contusions, or from internal rup-
tures of blood-vessels, carcinoma and tubercles.

The patient complains of sudden dyspnoea, with or without cough ;
his face grows pale ; he faints, has ringing in the ears; darkness comes
before his eyes, and the skin is cold.

Physical signs the same as in Hydrothorax.

Thej^apetitic Mints. — When from external causes, compare
Aeon., Arn., Calendula, Erigeron, Hamamelis, Ehus t., and the like.
When from internal causes, they must be considered in each individ-
ual case, and reference should be taken to those remedies which are
indicated in hemorrhages from the lungs. Great loss of blood indi-
cates China, and a nourishing diet.

For the subsequent pleuritis, compare the corresponding chapter.



First step ; To know how the heart works.

The heart consists of four apartments ; two antechambers (auricles)
and two chambers, (or ventricles,) which are respectively named from
their position, right and left.


Into the rigJit auricle the veiise cavse empty all the blood which has
been used in the body for its sustenance. From this antechamber a
large aperture leads into the right ventricle, which is called the aurie-
ulo -ventricular opening, and which is guarded by a kind of gate, con-
sisting of three triangular folds, (the tricuspid valves,) opening inward.
In the right ventricle we observe another opening, which leads into
an artery called the pulmonary artery, because it brings the deoxy-
genized blood into the lungs. This opening is likewise guarded by
a set of valves, which, from their half-moon shape, are called semi-
lunar valves, and which open outward.

This arrangement we find repeated in the left auricle and ventricle.
Into the left auricle the pulmonary veins empty all the blood which
has been oxygenized in the lungs. From this cavity a like aperture
leads into the left ventricle, which is likewise guarded by valves,
consisting, however, of only two segments, {the bicuspid or mitral
valves) opening inward.

In the left ventricle we observe also an opening, which leads into
an artery called the aorta, and which distributes the blood all over the
body. This opening is likewise guarded by a set of valves of semi-
lunar variety, which open outward.

Now let us see how this apparatus works. The ventricles being
fully distended, they immediately and simultaneously begin to con-
tract. On account of the relation of the several valves to these two
cavities, the action of the blood under the great pressure from this
contraction forcibly shuts the tricuspid and mitral valves, thus closing
the auriculo-ventricular openings, and the same action opens both sets
of semi-lunar valves for the escape of the blood. Through the pul-
monary artery the dark blood is propelled to the lungs, whence it is
returned through the pulmonary veins to the left auricle, thus making
the lesser, circuit — the pulmo7iic circu lation. Through the aortic valves
and artery the red blood is propelled through the whole body, whence
it is returned through the vense cavse to the right auricle, thus making
the greater circuit — the systemic circulation. As the two ventricles
contract, the two auricles dilate, and vice versa. The contraction of
the ventricles and simultaneous dilatation of the auricles is called the
' heart's systole, and by causing a forcible closure of the auriculo-ven-
tricular valves produce the first sound of the heart. The dilatation of
the ventricles and simultaneous contraction of the auricles is called
the heart's diastole, and by forcibly closing the two sets of semi-lunar
valves produce the second sound of the heart. This explanation of



the two sounds of the heart suffices for my purpose, and may be'
demonstrated to the eye by the following diagram :

This first step we must make securely, if we want to get along at
all towards reaching the goal of diagnosticating heart diseases : the
first sound is caused by the shutting of the tricuspid and mitral valves.
The second sound is the consequence of the shutting of the semi-lunar

Second step: How to find the exact situation of these
different valves in the living subject.

In order to find out the position of the heart, and its parts, we must
first ascertain lohere it strikes against the thoracic loall.

It does it with its ajjex, and in a majority of cases between the
fifth and sixth ribs, about one inch on the right of a line drawn verti-
cally through the left nipple, the person being in an upright position.
In persons of a short stature, we find the heart's impulse between the
fourth and fifth ribs ; and in persons with a long thorax, it may be
felt still lower. So also different positions of the body change the
place of impulse. In a person lying upon the back, it is observed
nearer to the medium line ; while lying upon the left side causes it to
tilt over more towards the nipple line. This point of impulse we
must take as a fixed point for determining the position of the left
ventricle, which it never fails to represent. The other parts have a
constant relation to this.



The lase of the heart, and consequently the aortic and pulmonary
valves, are almost invariably situated behind the 'middle of the sternum.

The ascending aorta lies somewhat to the right of the vertebral
column, and consequently its sounds and murmurs must always be
souo-ht for over the middle and somewhat to the right of the sternum.

The mitral valves are situated nearly one inch below those of the
aorta, and on the left side of the sternum.

The tricuspid valves are to the right of and anterior to the mitral, and
they are for the most part covered by the sternum.

The position of the right ventricle is variable, and cannot be deter-
mined, unless that of the left ventricle and aorta has been previously

Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 21 of 65)