EMPHYSEMA OF THE LUNG. 123 



lime, and if, from time to time, upon aggravation of the bronchial ca- 

 tarrh, oedema and cyanosis set in, the symptoms subside as the catarrh 

 improves, a proof that the circulatory disturbance depends upon the 

 transitory aggravation of the catarrh. The same causes operate in re- 

 tarding derangement of the aortic system in emphysema, which often 

 so long avert the appearance of cyanosis and dropsy in valvular disease 

 of the mitraJL In proportion as the circulation becomes embarrassed, a 

 complication develops in the right side of the heart, which has the oppo- 

 site effect, which counterpoises and compensates for the circulatory im- 

 pediment namely, hypertrophy of the right ventricle of the heart. 

 The addition of symptoms of venous derangement about the vena cavae 

 does not take place in emphysema until this compensation begins to fail 

 through a gradual degeneration of the thickened heart-wall by fatty 

 metamorphosis of its muscular fibre. Then the jugular veins swell up 

 and throb, with every ventricular impulse, as the vibration, into which 

 fche valves of the tricuspid are thrown during the systole of the right 

 ventricle, is shared by the column of blood which rests upon it. (See 

 chap., mitral insufficience.) The face becomes cyanotic, the lips swell 

 up and become blue, the cheeks and alas nasi have a varicose appear- 

 ance. The obstructed evacuation of the cerebral veins makes the patient 

 complain of dizziness and headache. All the signs attain their highest 

 pitch when the patient coughs. Symptoms of engorgement in the 

 course of the ascending vena cava also set in. The liver swells because its 

 outflow of blood is impeded, and the engorgement extends through the 

 portal system to the gastric and intestinal veins, giving rise to gastric 

 and intestinal catarrh. In the same manner, the veins of the rectum 

 often enlarge into varices (blind piles). The latter circumstance is 

 almost always greeted with joy by the patient. They believe that they 

 have now found the centre, the main root of all their trouble, and are 

 all-hopeful for a cure from the critical haemorrhoidal flow, just as they 

 are misled by the gastric catarrh, and the loss of appetite which attends 

 it, to regard the stomach as the source of their troubles, and to call their 

 cough a " stomach-cough." 



In the latter stages of emphysema the cyanosis often becomes ex- 

 tremely intense. The cheeks, ears, lips, and tongue of the patient are 

 literally blue. In no other disease does the cyanosis attain such severity, 

 excepting in cases of disorder of the orifices of the right heart, which 

 are mostly congenital, and it is never met with in valvular disease of 

 the left ventricle. True, in the latter, the patients generally grow blue 

 about the lips and cheeks, but the general color of the countenance 

 remains pale, and the blueness is never so pronounced as in emphysem- 

 atous persons, or in such as have congenital heart-disease of the right 

 side. This fact, which hitherto has received too little attention, is easj? 



