with typhus, had his pulse 132, and respiration 36. As he is improving, his pulse has fallen to 72, while his respiration is still 24; the proportion between them being as 3 to 1. When fever patients get very low, their breathing is often more rapid than this; but then other operating causes come in to produce the result, as the congested state of the lungs. In such a case, where at first the pulse was 104, and the respiration 26, the patient sank down, until the respiration became 38; but, at the same time, the pulse receded to 96. During the recovery, a rapid diminution of the numbers of respiration took place, and reached 14, when the pulse had only got to 64, and the patient convalescent. A man, with fever and great cerebral oppres sion, had his pulse for many days 44, while his respiration was 24. woman with fever had a pulse 64, and respiration 32, or the former double the latter. As she progressed, the pulse remained the same for a fortnight, while the respiration gradually came down to the normal standard.

A

In other febrile diseases, I have found the result to be just the same, viz. that the numbers of respirations have always remained high, and out of all natural proportion to the pulse, while the fever lasts. In the exanthemata, as scarlatina, the result is the same as in common fever. As the skin and the lungs have to a certain extent a supplementary action, as regards the evolution of humidity, and even the aeration of the blood, I was anxious to find if the respiration was still high, when the skin was moist; and I found it to be as I before stated, if febrile symptoms existed. In rheumatism, invariably, as in fever, the respirations are increased in number, and this altogether independent of the heart's action. The effect of lemon-juice in lowering the pulse is well known, and exemplified in two of the following cases. The following are the first six in my note-book of acute rheumatism :—In the first case, the pulse was 96, and the respiration 36. In the next, the pulse was 100, and the respiration 30. In the next, the pulse was 88, and the respiration 28. In the fourth case, where was some cough and an old cardiac bruit, the pulse was 132, and the respiration 40. In the next two, lemon-juice was given: no chest symptoms, and profuse perspirations. In the former case, the pulse was 110, and the respiration 40. On the following day, the pulse was 100, and the respiration 32. In three days, the pulse had fallen to 76, while the respiration was still 32. During convalescence, the pulse remained steady, while the respiration gradually subsided to 17. In the last case, where lemon-juice was given, the pulse was at first 120, and the respiration 36. The pulse in three days lowered to 70, while the respiration had only reached 32. After three days more, the pulse was still 70, while the respiration had got down to 24. The pulse was thus seen rapidly to fall under the use of a drug which influenced the heart, while the respiration took its own course slowly to descend.

I have mentioned sufficient cases to draw more particular attention

to the fact, that the respiratory act is exalted in febrile disease, and in proportion to the fever, and is not dependent upon, or proportional to, the action of the heart. As I before said, I do not allude to those cases where any pneumonia, pleuritis, or bronchitis exists, or even that hypostatic congestion in fever, which approaches so nearly to inflammation. In all such inflammatory affections of the chest, the rapid increase of the respiration is well marked, and draws attention to the condition of the lungs, and is a sign, indeed, not to be overlooked, particularly in the course of chronic disease, and where the patient is not likely to make any complaint. The state of breathing, however, to which I have particularly drawn attention, is not so rapid that the medical attendant observes it at all,-it is only by watching the movements of the chest that he becomes aware of their increased frequency.

I will just mention one or two other cases of disease to show the independent action of the heart and lungs, the nervous influence conveyed to one being different from that conveyed to the other, and the two little affecting each other. During the last year, I have constantly seen a man the subject of some obscure cerebral affection, and who occasionally has fits of an epileptiform kind. His pulse is never more than 32, (and the heart's action corresponding); on one occasion it was 26, but the number of his respirations is normal. A young man died of disease of the brain, and his pulse was sometimes as low as 56, though on excitement, it soon rose to 80, and yet his respiration during this time was 28-30. A young child I lately saw with hydrocephalic disease, had its respiration never more than 20, while the pulse was 120.

The condition of the heart and lungs must then in disease be considered to a great extent separately; for although the two organs are intimately connected, each has its own independent function and action. In a case of extreme bronchitis, with great pulmonary congestion, and a general venous stagnation, the state of the radial artery is taken as a test of the condition of the circulatory system and of the powers of the patient. Although the veins may be full to bursting, bloodletting is not considered, because the arterial system denotes emptiness and weakness, and the heart feebleness. A stimulant is often given in such cases when the pulse is small, but which only increases the evil. I believe, in such cases, a small bloodletting would often be useful in relieving the circulation, merely by its mechanical effects, and which, I apprehend, to be the principal use of this remedy. The following is a good example of this treatment:-A stout boy, seven years old, who had a chronic cough after pertussis, and who was in a condition commonly called asthmatic, was one winter's day seized with increased difficulty of breathing. The symptoms rapidly became so severe that death was expected. The head was thrown back, the face and body were blue, the eyes protruding, the dyspnoea excessive, the pulse quick and hardly to be felt, and a fatal issue evidently near at hand. The prominent jugular vein stood out tempt

ingly. It was opened, some few ounces of dark blood escaped, the congestion was very soon relieved, the breathing became tranquillized, the boy lay back and was soon in a sound sleep, and the next day was comparatively well. I mention this as an instance exemplifying how useful and often necessary it is to regard the pulmonic circulation more distinctly, and more apart from that of the general circulation. A very rapid respiration is generally indicative of an inflammatory affection of the lungs, unless it arise from a nervous cause, which is usually evident; and a difficult respiration accompanies affections of the air passages, and all causes which hinder a free ingress of air to the lungs. The purport of the present paper is to show more distinctly the increased rapidity of respiration in all febrile disease, and which I take as an evidence of a temporarily increased function. Without, however, laying too much stress upon any of the theoretical statements I may have mentioned, I would at present only draw more particular attention to the fact, that in all febrile diseases, the number of respirations is much increased, and has a certain relation to the fever, and that this symptom is as constant as any alteration in the character of the pulse, skin, urine, &c. A more detailed account of the state of respiration in disease, I shall reserve for another communication.Association Med. Journal, Feb. 17, 1854, p. 145.

35.—ON COUGH IN GENERAL, AND ON HOOPING-COUGH IN PARTICULAR.

By DR. R. B. TODD, F.R.S., Physician to King's College Hospital. [Cough is "a sudden convulsive expiratory effort." Irritation of any kind upon the pulmonary mucous membrane will produce cough;irritation of the nasal mucous membrane will produce sneezing, another expulsive effort. It should be observed, that the nasal branch of the mucous membrane is supplied by sentient branches of the fifth nerve, while the pulmonary surface is supplied by branches of the vagus; and it has been proved that irritation of the vagus, in any part of its course, will produce cough similar to that which occurs in any disease of the respiratory organs.]

A common cause of cough-indeed, a much more common one than is generally supposed-depends on irritation of the pulmonary branches of the vagus, consequent on the pressure exerted on them by enlarged bronchial glands. Tumours, also, of various kinds are capable of exciting cough in a similar way, and the development of tubercles in the lungs may produce the same effect. Aneurisms not unfrequently give rise to a cough, which may baffle us in our endeavours to account for ts production; and, indeed, cough is often a very important symptom in the diagnosis of aneurism, and one from which we frequently derive assistance in localising the disease. An aneurismal tumour may press upon the branches of the vagus distributed to the trachea

and bronchi, and thereby excite the most severe paroxysmal cough. Of this there is an excellent example now in Fisk ward. The patient is a man who was admitted for cough of this character. We carefully examined his chest without being able to discover any indications of disease in the lungs; but at length we obtained evidence of the existence of an aneurismal tumour, which, most probably by pressing upon some branches of the vagus, excited the violent cough, that constituted so prominent a feature in the case.

So, again, inflammatory ulceration of the trachea, whether primary or secondary, resulting from the pressure of an aneurismal tumour, especially about its bifurcation, where there are many branches of the pulmonary nerves, may cause a very distressing cough.

Thus, then, in reviewing the various circumstances under which cough may occur, you may enumerate the following kinds of this affection:-1st. The throat cough, the exciting cause of which may be either in the fauces or in the larynx. 2ndly. The tracheal or bronchial cough, when the trachea or primary bronchi are the irritated parts. 3rdly. The pulmonary cough, when the smaller ramifications of the bronchial tubes or the lungs are the seat of irritation. 4thly. Practical men will admit, I think, the existence of a cough dependent on gastric irritation; and, lastly, in persons of highly nervous temperament, there is the nervous cough, which, in most instances, is no more than a convulsive affection of the throat muscles.

Of these forms of cough, those which most frequently come under our observation are, the throat cough and the pulmonary or lung cough. Both are very prevalent at this time of the year. The former is the common cough of ordinary colds, and may be readily distinguished by the absence of all abnormal phenomena, connected with the breathing sounds, and by the swollen and red condition of the mucous membrane of the fauces, and more or less of hoarseness. In more chronic cases, this membrane is less or not at all swollen, and assumes a dusky red hue and a lax condition. Coughs of this kind are repeatedly mistaken and treated for pulmonary coughs, and the patients condemned to take large quantities of nauseous drugs; whereas many of them are easily curable by local treatment. This kind of cough is often exceedingly violent and distressing, and is not generally accompanied by any other sputa then throat mucus and saliva.

The more common form of lung-cough is that which attends bronchitis. This occurs generally in paroxysms; it is accompanied with expectoration, which is the more abundant in proportion to the extent and severity of the bronchial affection. We find it likewise in connexion with tubercular or other disorganisation of the lung, and the more severe in proportion to the extent of pulmonary destruction and consequent bronchial irritation. Under these circumstances, an expectoration, generally copious and purulent, follows the cough; and, indeed, the presence of this matter in the bronchial tubes very frequently aggravates the cough. Another form of lung-cough is short

and dry, or accompanied by little or no expectoration, and apparently kept up by some permanent irritant in the lung's substance, as crude tubercles scattered among the bronchial ramifications. Such a cough is a common precursor of confirmed phthisis, or, more correctly, an attendant on its early stages.

Such are the ordinary causes and forms of cough.

Hooping-Cough. There is yet one other form so peculiar and characteristic, constituting as it does, not alone a symptom, but in truth a dissease. The hooping-cough, so called from its peculiar final whoop, which is a sign that the patient is again taking breath, is not often brought under our notice in the wards of an hospital. It is much more common among the out-patients of an hospital than among the in-patients.

In the first stage, the symptoms are febrile and catarrhal, and the disease often passes for an ordinary cold. This state continues for ten or twelve days, and is then succeeded by the cough. the peculiar feature of which is, that it occurs in paroxysms, lasting some time, and following each other at variable intervals, and constituting the second stage of the disease; but, during the intervals between the paroxysms, the patient feels quite well, and one would hardly imagine there was anything the matter with him, except in the advanced periods of the complaint. The complete remission, which takes place, in many cases, between the paroxysms, is not the least curious feature of the disease.

[The third stage varies. The patient may recover, or certain changes may take place in the lungs and circulating system, which may lead to a fatal termination. Dr. Todd proceeds:]

Let me direct your attention to these secondary changes, which occur in the lungs and vascular system, after this disease has lasted for some time. At first, the lungs are not at all affected; so that hoopingcough can no more be considered a disease of these organs, than can an aneurismal or other tumour pressing upon the vagus nerve, and in this manner exciting cough, be so regarded. After the cough has continued for a long while, however, changes take place, affecting the lungs and the general appearance of the patient. The countenance becomes full and bloated, and the capillaries distended, especially those of the conjunctivæ, which look watery and swollen; and some of these minute vessels often burst, giving rise to some chemosis. From this state of countenance, a practical eye can generally at once recognise the nature of this malady, under which the patient labours.

Alt these changes result from the circulation in the capillaries being retarded, in consequence of the violence of the cough. At the same time, and for a like reason, the pulmonary circulation becomes similarly affected; the secretion of the bronchial tubes becomes altered; these tubes pour forth more freely than natural a watery mucus; the lungs become congested and oedematous; more or less crepitation is heard in different parts of these organs, according to the amount of fluid in the tubes, or oedema present; and this crepitation is usually most audible towards the lower part, being sometimes more distinct in one lung