pro mulant instead of the nauseating expectorants were inconsiderately prescribed, and often duced injurious consequences. In that variety of asthma, however, which appears to depend on a state approaching to that of paralysis of the system of the par vagum, in which the bronchial cells, being deprived of their nervous energy, do not contract sufficiently to aid the expulsion of the air in expiration, and, instead of aiding, prevent the necessary change of the blood in the pulmonary circulation, the nauseating expectorants prove hurtful, by keep ing up that state of diminished excitability which is the result of the morbid condition of the bronchial nerves. It is in such cases, and in the low stage of pneumonic inflammation, when the febrile symptoms assume a typhoid character and the lungs are loaded with mucus, that the inhalation of the expectorant gases, the internal administration of the balsams, and more especially of ammonia, prove undoubtedly beneficial. Under all circumstances there are three general rules to be kept in view in administering expectorants: 1. The surface of the body should be kept moderately warm, and even in a gentle or breathing perspiration. 2. Whatever determines to the kidneys must be avoided. 3. Purging is not only not to be promoted, but to be most carefully guarded against; for as the action of the secreting vessels of the lungs and those of the intestines are opposed to one another, expectoration is checked when purging occurs. (A. T. Thomson.) EXPECTORATION.-This word (from er and pectus) strictly signifies the act of discharging any matter from the chest, but by a figure of speech it is also commonly applied to the matters discharged from the lungs and airtubes. The act of expectoration is one of the instances of combined movement in the respiratory machine, which, by an admirable and harmonious consent between its numerous muscles, unerringly produces such a variety of actions. The function of respiration is of such vital importance that accumulations or effusions which obstruct it endanger life itself. The structure of the bronchial tree contributes greatly to the easy removal of any superfluous matter in it that might cause such obstruction, for the sum of the area of its branches being considerably greater than that of the trunk, or of the trachea, the air commonly finds easy entrance into the air-cells, and, on its more rapid return in expiration, carries with it the superfluous matter. Thus, ordinary respiration tends to prevent, in spite of gravitation, any accumulation in the air-tubes; but the excretion is more completely effected by coughing, and special efforts of expectoration. consist of a quick and forcible expiration, preceded by a deep inspiration, and accompanied with a constriction of the larynx and trachea, These the effect of which is to bring any superfluous matter into positions from which the air, forcibly expired, drives it through the glottis. It is worthy of remark that expectoration cannot effectually take place without a previous full inspiration, by which air is carried beyond the accumulating matter; hence, when this is prevented, either by weakness of the respiratory powers, or by the impermeability of the bronchial tubes, the excretion is suppressed. The first of these causes of obstructed expectoration is exemplified in adynamic fevers, which may thus prove fatal: the second occurs in pneumonia in the stage of hepatization, and, if extensive, must lead to a fatal obstruction of the respiratory function. They probably occur together towards the fatal termination of bronchitis, phthisis, and other severe diseases of the lungs. Expectoration in its other sense, namely, the matter expectorated, is a subject well worthy of a careful study; for its characters often furnish signs of the greatest value in the diagnosis, prognosis, and treatment of diseases of the chest. It can scarcely be said that the examination of the sputa is entirely neglected in this country; but we have had frequent occasion to observe that opinions are very loosely and vaguely formed from it, and of a nature quite inconsistent with the present state of pathological science. Thus the presence of pus in the expectoration is frequently looked upon as a sure proof that the lungs are "diseased;" whilst the far more pathognomonic sputa of peripneumony and the well marked secretion of acute bronchitis are hardly recognized. The natural secretion of the bronchial mucous membrane is a colourless liquid of somewhat glutinous quality, like a thin solution of gum arabic. It does not greatly differ in chemical composition from the serum of the blood, and it owes its viscidity to an animal substance, which Dr. Pearson, Dr. Bostock,† and Berzelius concur in considering an imperfectly coagulated albumen. This secretion is the basis of most of the varieties of expectoration; but, unhappily, our knowledge of animal chemistry does not enable us to discover the precise nature of the changes in composition which produce these varieties. All that we learn is that albumen, in different forms and proportions, is present; for, whether the expectoration be mucus, serum, pus, tuberculous matter, or coagulated lymph, the chemist can discover in these but scarcely discernible varieties of this same principle. There seems to be a considerable variation in the proportion of saline matter in different kinds of expectoration; and on this depends a distinction, formerly much insisted on, by means of the salt or sweet taste. This criterion certainly fails in distinguishing pus from mucus; but we think that an excess of saline matter may be taken as a sign of inflammatory action in Phil. Trans. 1809. + Elementary System of Physiology, vol. ii. Annals of Philosophy, vol. ii. p. 382. the mucous membrane. It is by its mechanical and visible conditions, however, that expectorated matter is most distinctly characterized; and to examine these fairly, the entire sputa should be collected in one or more convenient vessels of white ware or glass, in which their quantity, colour, and consistence, can be minutely scrutinized. In acute bronchitis there is at first a diminution of the natural quantity of the bronchial mucus, with a sense of roughness and dryness in the larynx and trachea; but soon a saltish liquid is secreted, which increases as the inflammation reaches its height. It is transparent, almost colourless, and moderately viscid, resembling raw white of egg diluted with water. It generally retains a good many airbubbles within it, and if expectorated with much coughing, it is usually covered with a froth. When poured from one vessel into another, it falls in a stringy or ropy stream. Andral considers that its viscidity is in proportion to the intensity of the inflammation; an increased viscidity being always accompanied with an aggravation of the fever, dyspnoea, and other symptoms. When the bronchitis is attended with fever, he remarks that the sputa become more viscid during the febrile exacerbation; insomuch that one inexperienced might be led to suppose that the inflammation had extended to the parenchyma of the lung: after the paroxysm, however, they return to their former state. At the height of the inflammation, and at other times when the cough is violent, they are sometimes streaked with blood: this is produced by the efforts of coughing, and does not tinge the whole mass. These characters are sufficient to distinguish the expectoration of bronchitis in its first stages; and as long as it remains in this state, there is no improvement of the symptoms; but when the sputa become pearly or opake, or of a yellow or greenish-white appearance, we may be pretty confident that the inflammation is on the decline. This opacity is first perceived in the morning expectoration, and in a few points only; and it is uniformly accompanied with an amelioration of the symptoms. The evening exacerbation sometimes brings back the glairy transparency of the secretion; but, unless there be relapse, the opacity returns on the succeeding morning, and gradually extends to all the expectoration, which is then nearly opake, and greenish or yellowish white: the smoke and dust in the respired air sometimes communicate a grey or dirty tinge. This change is often remarkably conspicuous after the successful operation of a sudorific; and, in fact, free perspiration will sometimes partially accomplish it early in the disease. After the expectoration has thus become ripened or concocted, it is coughed up readily, and in loose distinct pellets, which, although glutinous in themselves, do not so readily unite into one mass as before; they gradually diminish in quantity, and in a corresponding degree the cough and other sym VOL. II. * Clinique Médicale, tom. ii. ptoms cease: a relapse is equally marked by a return of the expectoration to its glairy transparent state. Sometimes a cold is prolonged by a series of relapses; and, notwithstanding the length of its duration, the sputa retaining the same character, the affection preserves its chronic form, and does not terminate until the same change has taken place. These successive transitions, which were noticed by Hippocrates and Aretaus, are highly useful to the practitioner in discovering to him the state of the disease, and, taken with the pulse and physical symptoms, will safely guide him in the employment of his remedies. The expectoration in chronic bronchitis is of a very diversified character, and is therefore much less certain in its indications. There is generally in it, opake, yellowish, or greenish-white mucus, like that expectorated at the termination of the acute disease; but it is usually more diffluent, and often floats in a pituitous or serous liquid. The same mucus is sometimes voided in a more inspissated form. Andral describes it as resembling false membranes, and moulded into the shape of the bronchial ramifications; and Dr. Cheyne* and Laennec give accounts of a similar expectoration. In the milder cases the mucus thus modified constitutes the whole expectoration; but in a severer form of the disease purulent matter is added, and the appearance, consistence, and odour of the sputa present very great variety. Many tests have been devised to distinguish pus from mucus; but from what we have before remarked on the close similarity of their chemical composition, it may be judged that they pass by insensible gradations into each other. The utility of minute distinctions of this sort may therefore well be questioned, as they neither enlighten us on the pathology, nor guide us in the practice. Pus is much less viscid than mucus, and not retaining airbubbles, as mucus does, it commonly sinks in water, whereas mucus generally floats at the surface; and this test gives us as much as is useful in the distinction. When the two are mingled in various proportions, this and all other tests fail in discriminating them. Proceeding from different parts of the bronchial membrane in different degrees of inflammation or morbid affection, some portions of the expectoration are mucous and viscid, whilst others are purulent and diffluent; some greenish-white like pus; others grey, dirtylooking brown, or tinged with blood: generally they are inodorous, but sometimes they exhibit a remarkable fetidity. These characters, however varying, are unquestionably diagnostic signs of chronic inflammation of the bronchial membrane; but their value in the prognosis and in practice is greatly diminished by the circumstance of such chronic inflammation being frequently complicated with other lesions. It almost always, for instance, accompanies the last stage of tubercular dis Pathology of the Membrane of the Larynx and Bronchia, p. 147. Κ ease in the lungs, generally furnishing a great part of the matter expectorated; and its existence is of small importance compared with the phthisical lesion. An inspection of the expectoration alone often fails to distinguish these combined cases from those of simple chronic bronchitis. In general, it may be said that purulent sputa indicate a severe form of disease; but they neither necessarily imply phthisis, nor any other irremediable malady. The chronic bronchitis excited by habitual inhalation of dust or powder, as among needlepointers, leather-dressers, porcelain-makers, &c. is commonly attended early with purulent and bloody expectoration; but if the cases are treated in time, and the patients are removed from the continued application of the exciting cause, they generally recover. So also, severe cases succeeding to measles and scarlatina sometimes present purulent expectoration, yet they are far from being universally incurable. We repeat, therefore, that puriform matter in the expectoration, as a prognostic sign, only indicates an aggravated form of disease. The nature of the expectoration gives the distinctive characters to the diseases termed by Laennec dry and pituitous catarrh. The former is a kind of asthma, attended with no other expectoration than scanty pellets of very tough grey mucus, which lodge in the bifurcations of the bronchi, and sometimes cause severe fits of asthma. It is important to recognize the expectoration of this disease, as it is singularly benefited by the alkaline treatment recommended by Laennec. Pituitous catarrh, or humoral asthma, is remarkable for the profuse watery expectoration which accompanies its paroxysms. This discharge contains albumen, coagulable by heat, and seems to differ but little in nature from the serum of the blood. Its quantity is sometimes enormous, amounting to several pounds in weight. These two forms of secretion sometimes occur at the same time in different portions of the bronchial membrane; and the serous discharge, in smaller quantities, is a common accompaniment of chronic bronchitis. The expectoration of pneumonia is very characteristic. For the first two days there is seldom any expectoration; but, about the third or fourth, a viscid transparent liquid is spit up, uniformly tinged with a rusty or orange hue. At first its viscosity is not so great but that it can be poured from one vessel into another, and it falls in strings or ribands; but in proportion as the inflammation reaches its height, and passes to the stage of hepatization, it becomes so glutinous that the vessel may be inverted, and even shaken without its falling. The red tinge is generally proportionably increased, but this is a less certain test than the viscidity, of the intensity of the inflammation. If the inflammation declines or is mitigated, the sputa become less viscid and rusty, until they present the characters of the expectoration in bronchitis. It is to be regretted that this valuable and truly distinctive sign does not show itself early and constantly in the disease. When it is present, it may confidently be de pended on, but its absence by no means disproves the existence of pneumonia. In some individuals it never occurs; and in children it is difficult to obtain a sight of the expectoration. It is also important to know that many adults, like children, invariably swallow the expectoration. The physical signs are, therefore, alone to be depended on in the diagnosis of negative cases. As a prognostic guide the sputa are highly instructive. The unfavourable import of a late appearance of the sputa was noticed by Aretaus; but M. Andral first pointed out the proportion which their viscidity bears to the intensity of the inflammation. As long as this goes on increasing, or remains undiminished, we may be sure that the inflammation is predominant; but if the expectoration shews a disposition to return to the colourless and less viscid state of simple bronchitis, the disease may be known to be on the decline. In a few cases the expectoration increases in viscidity up to the hour of death, but more generally it is either suppressed or changed, particularly if the inflammation have proceeded to the stage of suppuration. The suppression of the expectoration was considered by the ancients an unfavourable omen; modern pathology discovers that it is so, either because it proves the inability of the patient to expel it, or because the secretion has ceased, and the inflammation passed to the hepatized and suppurated stages. In the former case suffocation must soon ensue from the accumulation in the bronchi: in the latter the rusty expectoration is often replaced by other kinds. Sometimes it consists of brownish dirty-looking opaque mucus; sometimes whitish specks, as of pus, are seen in it, and, rarely, it is entirely purulent. M. Andral describes another kind of expectoration which he considers generally to indicate the stage of suppuration. This is a deep reddish-brown and slightly viscid liquid, like the juice of preserved prunes or liquorice water. In six out of nine cases in which this was observed, the lung was found, on dissection, in the state of purulent infiltration; in two it was hepatized; the remaining case was a slight one, and recovered. Laennec does not attach any importance to this kind of expectoration, considering it only as the sign of a cachectic or scorbutic habit. It certainly cannot be considered distinctive, but it may be taken presumptively, and must generally be looked upon as an unfavourable sign. The tinge of the characteristic peripneumonic sputa, which is, in different instances, greenishyellow, orange, rust-coloured, and bright-red, obviously proceeds from the colouring matter of the blood, intimately mixed with it in various proportions. If the inflammation terminates in resolution, this tinge diminishes and disappears, and the sputa exhibit the characters, and go through the changes of the expectoration in bronchitis. In pure pleurisy there is either no expectoration, or one simply of a catarrhal nature. The fluid secreted in chronic pleurisy has been sometimes known to make its way into the bronchi, and to be evacuated by expectoration; but other signs must rather be depended on for discovering the nature of such a case; as a similar expectoration is sometimes derived from a pulmonary abscess, and even from sudden and copious secretion from the bronchial lining only. The character of the sputa has been more consulted in the diagnosis of consumptive diseases than in any other; but the advances which have of late been made in developing the true nature of tubercular phthisis, have proved that all the distinctions and tests proposed are more or less fallacious. Thus it was long held that the presence of pus in the expectoration was a pathognomonic sign of pulmonary consumption;. and all efforts were directed to find out a sure method of detecting it and of distinguishing it from mucus. We have already remarked that purulent expectoration is not an uncommon consequence of simple bronchitis, and this disease presents all the phases formerly ascribed to phthisis. Something of the prognosis may, we believe, be learnt by consulting the expectoration, but its distinctive characters are to be depended on only after repeated examinations, and in combination with other signs, particularly those of auscultation. In the first stage of phthisis, that of miliary tubercles, there is either no expectoration, and the cough is dry, or it is of a simple bronchitic nature. When the lungs are thickly studded with miliary tubercles, there is not unfrequently an abundant serous secretion like that of pituitous catarrh, which is accompanied with a constant and general mucous rhonchus in the lungs. Whenever these present themselves for any length of time in an individual of tuberculous diathesis, and especially if there be any irregularity of resonance on percussion about the clavicles, we consider the fate of the patient almost certain, and the disease will probably run a very rapid course. Except in this case, and in that of hæmoptysis, which is treated elsewhere, (see PULMONARY APOPLEXY and HEMOPTYSIS,) the expectoration does not assist us in the first stage of phthisis. The characters of the sputa in the second stage, or during the softening and evacuation of the tubercles, would be much more distinctive were they not almost always mixed up with the mucous and muco-purulent secretion of a chronic bronchitis, which always more or less prevails at this period. Hence the signs, as relating to the tubercular disease, must be considered in a corresponding degree ambiguous. Attentive examination will often discover in the mucus expectorated fine whitish streaks, which consist of the softened tubercle; more rarely there are little yellowish white masses like grains of boiled rice, which are portions of crude tubercle. As the softening proceeds and the cavities are enlarged, the sputa become less frothy, sink in water, and are principally composed of greenish white masses of irregular shape and outline, sometimes tinged n parts of a dirty red or brownish colour. These flatten at the bottom of the vessel like on. * Transl. of Laennec, 3d edit. accurate diagnosis, which, if confirmed by the general and physical signs, will leave no shadow of doubt. As our design in this article has been rather to direct the attention of the practitioner to the importance of expectoration as an aid in diagnosis and prognosis than to give a complete account of the subject, we refer for further descriptions to the articles in which the diseases of the chest are particularly treated of. In conclusion, we would strongly recommend our readers to consult the second and third volumes of Andral's Clinique Médicale, and Dr. Forbes's translation of Laennec's Auscultation Médiate, where they will find instructive and convincing proof of the assistance which the expectoration gives, especially if taken in conjunction with the physical signs, in the distinction and treatment of diseases of the chest. (C. J. B. Williams.) FAVUS. The pustules termed favi are so named from the character of the crusts by which they are succeeded; these being cellular, and fancifully compared to an irregular honeycomb. The term favus, however, was differently employed by the ancients: Galen applied it to ulcers which exude, through small orifices, a matter resembling honey in consistence: Celsus regarded it as synonymous with miliary. Favi, in the modern acceptation of the word, are small, yellow, irregularly circular pustules, nearly flat, at least not acuminated; and, according to Biett, always depressed in the centre. Their base is slightly inflamed; they generally appear in circular patches or clusters; are attended with itching, and frequently with glandular swellings from absorption of the matter. These pustules are succeeded, after some days, by a thick yellow, nearly semi-pellucid, somewhat cellular, augmenting crust or scab; at which time they frequently exhale a very offensive, nauseating odour, not unlike that of the urine of a cat. As the crusts dry, they become white, and easily detached. The seat of favi is most commonly the scalp, in the epidermal layer which covers the papillæ of the true skin. As they most commonly occur on parts covered with hairs, Dr. Duncan advanced an opinion that the disease is in the bulb of the hairs, which are indeed easily detached, and display a swelling at the base. Biett accords with this opinion; but Rayer dissents from it, and supports the view which we have adopted. Favi generally occur during childhood; they seldom affect the general health, although, when they appear during the period of dentition, they seem to be in a great degree connected with the disordered state of the digestive organs which more or less attends that period, and the increased irritability of the habit. They occasionally, however, appear in adults, on the neck, ears, and occiput: in these cases they are always preceded by some degree of constitutional derangement; headach, an uneasy state of stomach, loss of appe tite, irregular bowels, and fever: the inflammation surrounding the pustules is more extensive, and the crusts are thicker and harder than in childhood. Alibert affirms that cooks are very liable to eruptions of favi. They are chiefly known as the distinctive feature of one species of porrigo,-P. favosa; under the head of which we shall have again to direct the attention of our readers to their characters. Biett supposes that the minute pustules of porrigo scutulata, which appear in circular patches, are favi, differing only in their arrangement and some little variation in the state of the crusts; but as far as we are enabled to form an opinion by the appearances which they present, when viewed with a powerful magnifier, the opinion of Bateman, who regards them as achores, is correct. Rayer considers both the pustules and crusts intrinsically different from those of porrigo favosa. As we shall have again to detail the treatment of favi under the article porrigo favosa, we have only to mention, at this time, that it consists in correcting the irritable state of the stomach, and in not permitting crude undigested matters to remain in the alimentary canal. This is best effected by moderate doses of hydrargyrum cum creta, combined with antimonials, administered at bed-time; and alkaline salts, particularly subcarbonate of soda, in combination with calumba, or cascarilla, or cinchona bark in powder, given twice or three times a day. It was the opinion of Etius and other old writers, that danger attended the repulsion of favi: modern practitioners, regardless of this, employ a variety of external applications; but these are general mild stimulants, intended rather to restore the healthy action of the skin, after the crusts have been removed by poultices, than to repel. They consist of ointments composed with the oxides of zinc, acetate of lead, and tar with sulphur; and the ointment of nitrated mercury largely diluted with simple cerate. When there is much itching or pain, the writer of this article has seen great benefit derived from the following lotion, applied in a tepid state, in the form of a poultice. R. Liquoris plumbi subacetatis, f 3i fs. Aquæ distillatæ, fvi. M. Fiat lotio. Cleanliness, exercise in the open air, and the stimulus of soap and hot water, are great aids to every method of treatment. Much depends on diet, which should be apportioned both in quantity and quality to the powers of the stomach and the general strength of the patient. If the patient is weak, which is generally the case, the food should be nutritive, but not stimulant: we have found nothing answer better than milk, with a moderate allowance of plainly cooked mutton or poultry Abrégé pratique des Alaladies de la Peau, par MM. Cazemene et Schedel, p. 231. + Synopsis, edit. 7th, p. 138. Traité théorique et pratique des Maladies de la Peau, par P. Rayer, vol. i. p. 520. |