A treatise on the diseases of the chest : in which they are described according to their anatomical characters, and their diagnosis established on a new principle by means of acoustick instruments ; with plates

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NATIONAL LIBRARY OF MEDICINE
Bethesda, Maryland

Gift of
Worth B. Daniels, Jr., M.D.

In memory of his father
Worth B. Daniels, M.D.

A/

A

TREATISE

DISEASES OF THE CHEST,

IN WHICH THEY ARE DESCRIBED
ACCORDING TO THEIR

ANATOMICAL CHARACTERS,

AND THEIR

ESTABLISHED ON A NEW PRINCIPLE
BY MEANS OF

ACOUSTICK INSTRUMENTS.

iDitfj $ late£.

TRANSLATED FROM THE FRENCH OF

R. T. H. LAENNEC, M. D.

WITH

A PREFACE AND NOTES,

BY JOHN FORBES, M. D.

PHYSICIAN TO THE PENZANCE DISPENSARY, SECRETARY OF THE ROYAL
GEOLOGICAL SOCIETY OF CORNWALL, &C. &C.

FIRST AMERICAN EDITION.

PHILADELPHIA :

JAMES WEBSTER, 24 S. EIGHTH STREET.

William Brawn, Printer.

1823.

hi trip

<®>

TO

MATTHEW BAILLIE, M. D, F. R. S.

PHYSICIAN TO THE KING,

is'c. i^b. ifc.

THIS WORK,

INTENDED TO IMPROVE

PATHOLOGICAL AND PRACTICAL MEDICINE.

IS INSCRIBED,

AS A TRIBUTE DUE TO HIS ACKNOWLEDGED

SUPERIORITY IN BOTH THESE

BRANCHES OF

MEDICAL SCIENCE,

AND IN TESTIMONY OF THE RESPECT

AND GRATITUDE

OF

THE TRANSLATOR

TABLE OF CONTENTS,

Translator's Preface - 1

Author's Preface ----- 25

PART FIRST.— PATHOLOGY.

BOOK FIRST,

OF THE LUNGS.

Chap. I. Phthisis Pulmonalis 33

Sect. I. Anatomical or essential characters - ib.

2. Occasional changes — curability of ) ._

Phthisis \ ^

3. Expectoration in Phthisis-Vomicae - - 55
Chap. H. Peripneumony 59 s

III. Gangrene of the Lungs 64

IV. Haemoptysis, or Pulmonary Apoplexy - - - 69
V. Pulmonary Catarrh, or Bronchitis - - - 74

Sect. 1. Acute ---------- ib.

2. Chronic - - - - 76

Chap. VI. Dilatation of the Bronchia 79

VII Emphysema of the Lungs - 82

VIII. (Edema of the Lungs 92

IX. Accidental Productions in the Lungs - - 99

Sect. 1. Of these in general - ib.

2. Cysts 10©

Vi TABLE OF CONTENTS

Page

Chap. IX. Sect. 3 Hydatids - - 102

4 Osseous Concretions, &c. - - - - 104

5. Melanosis 109

6. Medullary Tumour - - - - - - llT

BOOK SECOND.

OF THE PLEURA

Chap. I. Pleurisy ,""•"'" *^

Sect. 1. Acute Pleurisy ib.

2. Chronic Pleurisy - 129

3. Contraction of the Chest ... - 131

4. Gaugiene of the Pleura ... - 139

5. Circumscribed Pleurisy 140

Chap. II Hydrothorax - - . 151

III. H^emathorax 155

IV. Accidental Productions in the Pleura - - 156
V. Pneumo-thorax ---159

BOOK THIRD.

OF THE HEART AND ITS APPENDAGES.

Chap. I. Diseases of the heart 165

Sect. 1. Hypertrophia ib.

2. Dilatation of the Ventricles - - - - 167

3. Dilatation wi'h Hypertrophia of the ^ .,

Ventricles ------ ^

4. Dilatation of the Auricles - - - 168

5. Partial Dilatation of the Heart - - 170

6. Induration of the Heart 171

7. Softening of the" Heart ib.

8 Atrophy of- the Heart 173

9 : ;itty Degeneration of the Heart - - 174

10. Ossification of the Heart .... - 176

11. Canii-is 177

12 Ossification of the Valves - - - 180

13. Accidental Productions - - - - - 1S2

TABLE OF CONTENTS, Vll

P afire

Chap. I. Sect. 14. Polypus - 183

15. Excrescences on the Valves - - - 185

16. Red colour of internal Membrane - 188

17. Malformation of the Heart - - - 192

18. Displacement of the Heart - - - 193

19. Effects on other Organs - - - - 194

20. Causes 195

Chap. II. Diseases of thk Pericardium 197

Sect. 1. Pericarditis ib.

2. Hydro-pericardium 201

3. Accidental Productions - - - - 202
HI. Aneurism of the Aorta --»---- 204

PART SECOND.— DIAGNOSIS

Introduction ------------- 209

General Remarks on the Diagnosis of Diseases of the Chest ib.
Discovery and nature of Mediate Auscultation - - - -211

Exploration of the Voice 214

Respiration --.--_._ ib,

Circulation 218

Phthisis Pulmonalis --..-. 219

Peripneumony -------______ 227

Gangrene of the Lungs 230

Haemoptysis ---_ 23j

Pulmonary Catarrh -------.-___ 232

Dilatation of the Bronchia ----- 236

Emphysema of the Lungs -- 237

(Edema of the Lungs ------_.__. 238

Accidental Productions in the Lungs - - 239

Pleurisy - - 241

Hydrothorax 246

Haemathorax --- • . . m . ib.

Accidental Productions in the Pleura - - ib.

Pneumo- thorax - 247

Exploration of the heart ----..... 252

riii TABLE OF CONTENTS.

Page

Extent of Pulsation 252

Impulse of Pulsation -- 255

Sound of Pulsation - 256

Rvthm of Pulsation 257

Palpitation - - 260

Irregularity of Pulsation ..-----.--261

Intermission of Pulsation ---------- i&.

Symptoms common to all Diseases of the Heart - -. - - 264
Hyperirophia of ihe left Ventricle ------- 266

right Ventricle 267

Dilatation of the left Ventricle 268

right Ventricle #>•

Dilatation with Hyperirophia of the Ventricles - - - ' - 269
Dilatation of the Auricles ---------- 270

Softening of the Heart -----------271

Carditis #•

Ossification of the Valves - 272

Pericarditis -------------- 273

Hydro-pericardium -- ----- 275

Aneurism of the Aorta 276

Appendix 279

Notes _.-- 301

Explanation of the plates - - - 315

TRANSLATOR'S PREFACE.

Of One of my principal motives for undertaking the labo-
rious task of translating the following work, having been
the hope of rendering its most valuable contents conve-
^ j) niently accessible to the English reader, I must not now
swell either its size or price by a voluminous Preface.
I shall, therefore, confine myself to saying a few words
on the nature of the original treatise, and on my method
of translating it.

M. Laennec has long been known as an ingenious and
industrious man, and as a faithful observer. His oppor-
tunities for studying the class of diseases treated of in
the present work have been, probably, never equalled;
and I think it will be allowed by those acquainted with
his writings, that their value is proportioned to the extent
of his opportunities. He. himself informs us that he
has been engaged in pathological researches for eighteen
years; and when we consider the facilities with which
these can be prosecuted in the French capital, we must
be prepared to expect a work of great value, as the
result of such great advantages. That the present

1

8 TRANSLATOR'S PREFACE.

treatise is well entitled to this character I think no one
who has perused it will deny; as far, at least, as regards
the pathological part of it. Indeed, the facilities for the
prosecution of this department of knowledge in France,
are so very superior to those in England, that we ought
rather to be surprised that our own country has in any
case excelled the former, than that we should be occa-
sionally obliged, as in the present instance, to look to it
for information. In explanation of this remark I shall
here quote the words of a late writer, who has given us
much information respecting the state of medicine and
medical institutions on the Continent. " All the hospi-
tals of Paris are under the direction of a general admi-
nistration; and from the office of this board, where me-
dical men attend during a certain part of the day to
examine them, patients are sent to the different hospitals.
This plan may be attended with some inconveniences
to the patients, but has not a few advantages to the
practice of medicine. Through means of this arrange-
ment the physician of any hospital, whose attention is
turned more particularly to any disease or class of
diseases, by application to the central office may have
such diseases sent to his own hospital. Thus a much
greater number of cases of the disease, which is the
object of his particular inquiry, is brought under his
observation in a given time (an object of no small im-
portance) than could otherwise, or might indeed ever,
have been. To this plan we perhaps owe, in a great

TRANSLATOR'S PREFACE. 3

measure, the excellent works of Corvisart and Bayle,
and that of Dr. Laennec on the diagnosis of the diseases
of the chest. The fatal cases are generally examined
after death. Dr. Fouquier told me, that for twelve years
that he had been physician to La Charite, no patient had
died without being examined ."*

In the original work, the system of arrangement is
founded on the new principles of diagnosis introduced
by the author; consequently the pathology and diagnosis
of the various diseases are blended together, and the
former very generally made subservient to the latter.
As I have thought this method attended by a great many
disadvantages, both in a pathological and practical point
of view, I have taken the liberty, in the translation, of
re-arranging the work throughout, — separating, almost
entirely, the pathology from the diagnosis, and arranging
the various diseases under the head of the affected organ.
Thus, instead of having, as in the original, the diseases
marshalled under four heads according as they are re-
cognised by the exploration of the Voice — the Respira-
tion — the Rattle — and the Circulation, — and the Diag-
nosis of each disease conjoined and mingled with its
description; we have, in the first place, an entire sepa-
ration of the descriptive from the diagnostic parts; and 5
secondly, a subdivision of each of these according to
the respective localities of the diseases, as affecting the

* Dr. Clark's Medical Notes on Climate, &c. pp. 127 and 130,

4 TRANSLATOR'S PREFACE.

Lungs, Pleura, and Heart. By this means, the work,,
in place of appearing, as in its original form, a system
of Diagnosis, with the pathological part subservient to,
and partly concealed by it, is now restored to what I
humbly conceive it ought always to have been, viz. two
independent treatises, — the one on Pathology; the other
on Diagnosis, — mutually adapted to each other, yet each
complete of itself, and not necessarily connected with
the other. In its present condition, therefore, the work
will be found equally available to the practitioner as a
system of pathological anatomy, whether he adopts or
rejects the author's diagnostics; while, in the original
form, these two departments were so interwoven with
each other, that, without a previous study of the one,
the other could not be well understood. In this respect,
then, I consider both the author and the English reader
as obliged to me; — inasmuch as, without in the least
altering either the facts of the pathology or the diagno-
sis, I have rendered them both much more accessible,
and placed them in a clearer, closer, and more connect-
ed point of view.

In respect of the character and value of these two
classes of facts, as contained in the treatise now trans-
lated, I must here be permitted to say a few words. It
will be seen from the author's Preface, an abridgment
of which follows, that, in his description of the diseases,
he has almost exclusively confined himself to'the ana-
tomical character of these. His reasons for so doing

•3

TRANSLATOR'S PREFACE. 5

are stated in the same place, and are principally to be
traced to the nature of his new diagnostic measures,
which, unlike the usual symptomatological distinctions,
are, in most cases, immediately connected with, and
necessarily dependent on the physical alterations which
constitute the disease.

Hitherto, unquestionably, the attention of nosologists
has been too exclusively fixed on mere external symp-
toms, without reference to the internal conditions of
which these were the sign. It is true that there are
many diseases with the pathology of which we are un-
acquainted, and in distinguishing which, we must,
therefore, content ourselves with the external symptoms
merely, without any constant and direct reference of
these to stmie organic lesion as their source. This is
the case at present, I apprehend, with many varieties of
fever, and many of the affections called nervous and
functional. In some of these instances, I presume, our
present inability to trace the morbid derangements to
their source, depends merely on our faulty and imperfect
investigations hitherto, and will, no doubt, be eventually
removed; in others, however, the physical local lesions
are in all probability too minute and evanescent ever to
become the objects of our actual perception, or, if per-
ceptible, too extensive and complicated to permit us to
separate the original and essential derangements from
those which are merely contingent. In a philosophical
point of view, indeed, the primary changes of structure

$ TRANSLATOR'S PREPACE.

which constitute the first link in the chain of all diseases,
must, in all probability, be' considered as placed effec-
tually beyond our finding out; and it may, therefore, be
objected to the pathological nosologist, that his principle
is equally erroneous with that of the mere symptomato-
logist; inasmuch as the former, like the latter, merely
lays hold of one link of the chain, the beginning of
which they are both ignorant of; and the only superiority
of the former being that his link is nearer the primary
one.

In answer to this it may be stated, that this allowed
superiority is a most important one, and almost all that
is contended for. Although it is the object of the pa-
thologist, unquestionably, to trace morbid phenomena to
their very sources; still it is true that this is rarely, if
ever, attainable ; and although, in many diseases, we are
willing and ready to imagine certain changes of func-
tion or structure, anterior to those that are cognisable
by our imperfect senses, in most cases we are obliged to
be content, both theoretically and practically, with the
knowledge of such alterations as can be recognised by
our senses. In the case of a deranged state of the sys-
tem depending on some external local cause, such as an
inflammation or ulcer, we are in most cases satisfied, if
we can trace the general derangement to the local le-
sion, although it is only the obvious physical qualities of
this which we can understand with any degree of cer-
tainty. In like manner, in the study of internal dis~

TRANSLATOR'S PREFACE. 7

eases, we are very well contented if we can ascertain
the condition of the local lesion, that is, the change of
structure that would be obvious to our senses if the part
could be submitted immediately to our inspection.

At all events, we cannot hope, in the present state of
our knowledge, to understand any morbid conditions of
parts better than those which are immediately the ob-
jects of our senses; consequently, our constant aim must
be to endeavour to come as near this knowledge as pos-
sible in such conditions as are not the objects of these;
and the more completely this is effected, the nearer are
we to the attainment of the only sure guide in the treat-
ment of disease. So far, then, I think, it must be ad-
mitted, that a knowledge of their anatomical characters
forms the most essential part of our knowledge of dis-
eases, and the only sure guide in practice; and conse-
quently, that, in such cases (internal diseases) as those
in which this anatomical or essential character is hidden
from our view, the perceptible signs which can certainly
indicate its presence to us, must be considered as of pa-
ramount importance.

It is in this point of view, then, that I consider the pa-
thology* of M, Laennec, and the diagnostic measures
founded on this, as pre-eminently valuable. Almost all
other diagnostic signs are furnished by symptoms, which,
for the most part, have only a remote connexion with
the morbid lesion, and are, indeed, frequently present in
other and very different diseases. M. Laennec's diag-

8 TRANSLATOR'S PREFACE.

nostics, on the contrary, are the immediate and almost
physical result of the individual derangement of' parts;
and if they shall be proved by the experience of others
to be as certain and invariable as he affirms, there can
be no question of his having conferred on Medicine, by
their discovery, one of the greatest benefits with which
it has ever been enriched. Of the uncertainty of the
common signs of internal diseases in general, and espe-
cially of chronic diseases of the chest, every practitioner
must be well aware; and every one who has had much
experience in morbid dissections must have'often endur-
ed the mortification of finding his diagnosis falsified by
the actual condition of the parts after death.

It is hot intended, by the foregoing remarks, that the
study of the general symptoms is useless in the diagnosis
of diseases; but merely that, as these are frequently un-
certain in their indications, more direct and surer signs
are desirable; and, further, that whatever system of di-
agnosis we adopt, we ought always to keep in view the
anatomical character of the disease (where this is known)
as the substance whose presence the symptoms denote,
and without which they are nothing. In this point of
view the descriptions of M. Laennec appear to me to
excel those of e\ery other writer on pathological ana-
tomy, inasmuch as he traces the progress of the organic
lesions from their commencement to their termination;
while almost all other writers on morbid anatomy, how-
ever correct or minute, give us merely detached and

TRANSLATORS PREFACE. 9

isolated descriptions of the parts as they are found on
dissection. And he not only traces the progressive
change of structure in the organ, but connects every
successive step of the change with external signs indi-
cative of its existence. In short, (if his new diagnostics
are as certain as he affirms) he may be said to have re-
alized the wish of the ancient philosopher, and to have
placed a window in the breast through which we can see
the precise state of things within.

But independently of the value of a correct knowledge
of the anatomical character of diseases as leading to a
correct diagnosis, this is no less important as tending to
the improvement of therapeutics. Without knowing
the disease, of course we must be totally incompetent to
treat it. Every one admits this as self-evident; yet how
often does it happen, when we fancy that we do truly
know a disease, at least so far as to name it correctly,
and to discriminate it from others, — that our knowledge
is merely the knowledge of a name; or of phenomena
not essential to the real disease; or, lastly, the belief of
the existence of a condition of parts which is totally dif-
ferent from that which truly does exist! In this case
our nosological knowledge is of very little use; or tends
merely to satisfy our own minds without benefiting our
patient.

In every case where the physical characters of the
morbid lesion are known, these ought invariably to
form the groundwork of every description of disease :

2

|0 TRANSLATOR'S PREFACE.

of these all the external symptoms must be considered
as merely the signs ; and in all our therapeutic mea-
sures, these must be kept constantly in view, and the re-
moval of them considered as the abiding object of all
our labours. These remarks apply only to such affec-
tions as are treated of in the present work, viz. affec-
tions which are usually denominated organic, and which
may more properly be called structural : those whose
anatomical character is as yet unknown, or which consist
in mere disorder of function, or in such minute altera-
tion of the animal fibre as to be imperceptible to our
senses, must be studied differently; and this is not the
place to enter upon the subject.

Although not strictly within the scope of the present
remarks, there is one other point in the diagnosis of in-
ternal diseases which I would beg leave to impress upon
the minds of the younger part of the profession as of the
greatest importance. Of this I have always been con-
vinced; but it is at present more immediately and more
forcibly suggested by the consideration of the measures
of M. Laennec. What 1 allude to is — the examination
of the external parts of the body in the case of internal
disease. How often have I known plain and obvious dis-
eases entirely mistaken and mistreated, for months, —
even years, — merely from the practitioner's neglecting
this simple but necessary measure ! In every case of
disease, whether its seat be in the head, trunk or extre-
mities, we ought to examine the suspected part freed

TRANSLATOR' 3 PREFACE. \\

from covering, or at least from every species of covering
that can impede the necessary examination, — always by
the hand, and often by the eye; and wherever the case
is at all doubtful, we must endeavour to overcome the re-
pugnance of our patients to the measure, however great
this may be, and however natural and proper we may
feel it to be, in certain individuals. In this endeavour,
if properly conducted, I may venture to say that we
shall rarely fail. From the neglect of this precaution I
have known peritonitis and enteritis mistaken for simple
colic; — disease of the heart for disease of the stomach; —
and derangements depending on curvature of the spine
treated for years as a mere nervous affection, and, in
other cases, as organic disease of the heart, lungs, or
diaphragm!

' vestis adempta est;

Qua posita, nudo patuit cum corpore crimen.

As another branch of the same mode of investigating
diseases, I may here notice the necessity of our strictly
examining all discharges from the natural passages of
the body, more especially if we have reason to sus-
pect disease in these, or the parts immediately connected
with them. In such cases we must never trust to the
reports of patients themselves or their attendants, as we
are almost always sure of being misled by their prejudice
or ignorance, both as to the quality and quantity of the
excreted matters, i would further add the interna)

\2 TRANSLATOR'S PREFACE.

examination of some of these passages, by the hand or
instruments, in every case attended by the slightest un-
certainty. How often are diseases of the uterus, rec-
tum and bladder, mistaken, from the omission of this
very simple precaution, and how much misunderstood
are often the disorders of the alimentary canal, and
even of the lungs, for want of attention to the character
of their secretions! In short, the more closely we can
trace the symptomatic derangements to their source, in
every part of the body, the more likely are we to un-
derstand the real nature of these, and the less liable are
we to be misled by the numerous sympathies, which, in
almost every disease, constitute a prominent part among
the more obvious phenomena.

As to the individual descriptions of disease contained
in the present work — I doubt not that the most learned
English reader will find in them many things that are
new to him. At the same time he will find several an-
nounced as such, and their discovery claimed for France,
which have been long familiar to the British pathologist.
Indeed, I am sorry to be obliged to remark, that, like
most of his countrymen, the present author is too much
disposed to overlook the advances made in science by
other nations, and to claim for French literature false
and surreptitious honours, which that country's un-
doubted titles to desert ought to teach her to despise.

In respect of the general merits of mediate ausculta-
tion as a means of diagnosis, I am disposed to coincide

TRANSLATOR'S PREFACE, 13

in the high opinion of the author; due allowance being
made for the natural partiality of a discoverer. My own
experience, of course, has been, comparatively with that
of the author, quite insignificant; and has, in every case,
but one, wanted the only sure seal of merit — morbid
dissection: although, therefore, it would have been both
unphilosophical and indecorous to have allowed the few
results obtained by me, had they been opposed to those
of M. Laennec, to weigh in any respect against the im-
mense experience of that gentleman, — it must be satis-
factory, at least, to know, that they have, as far as they
go, coincided with his in every respect. I am sorry to
say that it is only within the last few months that I have
given the new methods of diagnosis a fair and continu-
ous trial; and I am the more sorry, as I am daily more
and more convinced of their extreme value. It is in
chronic cases, more especially, that the method of M.
Laennec will be found of the greatest advantage; and,
exclusive of the unimpeached testimony of the author, I
have no doubt whatever from my own experience of its
value, that it will be acknowledged to be one of the
greatest discoveries in medicine by all those who are of
a temper, and in circumstances, that will enable them
to give it a fair trial. That it will ever come into gene-
ral use, notwithstanding its value, I am extremely
doubtful; because its beneficial application requires
much time, and gives a good deal of trouble both to
the patient and the practitioner; and because its whole

U THAKSLATOK'S PREFACE.

hue and character is foreign, and opposed to all our
habits and associations. It must be confessed that there
is something even ludicrous in the picture of a grave
physician formally listening through a long tube applied
to the patient's thorax, as if the disease within were a
living being that could communicate its condition to the
sense without. Besides, there is in this method a sort
of bold claim and pretension to certainty and precision
of diagnosis, which cannot, at first sight, but be some-
what startling to a mind deeply versed in the knowledge
and uncertainties of our art, and to the calm and cau-
tious habits of philosophizing to which the English
Physician is accustomed* On all these accounts, and
others that might be mentioned, I conclude, that the
new method will only in a few cases be speedily adopt-
ed, and never generally. In all hospitals, however, both
civil and military, and in the public services of the army
and navy, — in all of which situations the above-men-
tioned obstacles to its employment scarcely exist, — I
should hope that its adoption will be less tardy and par-
tial. It is to them, especially, that it is adapted; it is
in them that its merits can be put to the test; and it is
to be hoped that if its value is once acknowledged in
them, no minor objections of mere inconvenience or
formality will be permitted to effect its exclusion from
general practice.

Notwithstanding that M. Laennec's invention has
been before the public nearly two years, I fear it has

TRANSLATOR'S PREFACE. 15

received but few, and these unsatisfactory, trials in this
country.

Among all my medical friends, Dr. Duncan,- Jun.
Professor of Materia Medica in Edinburgh, and Dr.
James Clark, now of Rome,* are the only ones who
appear to have given the practice a fair trial. Dr.
Duncan's report of its merits is most satisfactory; and,
as his experience has been considerable, and in a field
favourable to correct observation, and affording frequent
opportunities of proving by morbid dissections the cor-
rectness of opinions, — it is to be hoped that the inven-
tion will shortly receive from such high authority a new
title to the consideration of the public. In a letter
which I have just received from Dr. Duncan, he in-
forms me that he has made great use of the stethoscope,
and is satisfied that it greatly facilitates the diagnosis of
diseases of the chest. As might have been expected,
the novelty of the measure excited much scepticism,
and some ridicule at first, but the accuracy of the diag-
nosis obtained by it, soon compensated for and removed
these. Speaking of the stethoscope, Dr. Duncan says,

* It is but justice to state, that it wasat the suggestion and ear-
nest request of Dr. Clark that I undertook the present work. He
■was the first to make the practice of M. Laennec known in Eng-
land, in his excellent and very amusing work on Climate, &c. ;
and it was the high opinion of its value, as confirmed to me by so
judicious and experienced a physician, that induced me to make
trial of it in my own practice.

l(j TRANSLATOR'S PREFACE.

" Its use indeed requires tact, or rather experience, to
enable one to understand the signs it furnishes. The
information afforded by it is often obscure and uncer-
tain; so is the touch of the pulse, and all other applica-
tions of our senses in the investigation of diseases. I
had often heard pectoriloquism before I recognised it."
— I understand that Dr. Duncan has gained many
proselytes to the practice among the students; and I
need scarcely observe, that the adoption of it by a prac-
titioner of such experience and deserved celebrity is a
convincing proof of its value and importance.

In corroboration of Dr. Duncan's statement I may
also observe, that my first trials of the instrument were
very unsatisfactory, from the doubtfulness and uncer-
tainty of the results obtained. This however arose
entirely from inexperience, and from not attending pro-
perly to the directions given for using the instrument.
All the uncertainty and apparent difficulty was soon re-
moved by a little practice; and I speedily became con-
vinced that the results obtained were of that distinct
and precise character to justify every expectation of
advantage from their being attended to in the diagnosis
of disease.

In exploring the Respiration, more particularly, we
must be most careful to keep the funnel-shaped ex-
tremity of the instrument very exactly applied to the
chest, by its whole circular edge, which can only be
done by attending to the author's direction of holding

TRANSLATOR'S PREFACE. 17

it as we do a pen, and keeping the hand quite close to
the patient's chest. We must never attempt to alter the
perpendicularity of the instrument, so as to bring its
extremity to suit the convenience of the ear, but must
bring the ear to it; and we must be careful not to press
with any considerable degree of force upon the instru-
ment, yet, at the same time, apply the ear quite close to
it, and with the meatus directly opposed to its canal.
All these precautions are necessary on account of the
moderate degree of the respiratory murmur, which, al-
though in general extremely distinct, is often very low,
and never, except in certain cases of disease, such as to
be called loud, unless comparatively with its own ha-
bitual condition. From the same circumstance, the
injunction of the author respecting the absence of all
other noises in the chamber of the patient, is never to
be forgotten; as talking, even in a whisper, in the room,
or any noise in the street from wheels, &c. will often
effectually mask all perception of the sound we are at-
tending to.

In studying the action of the he#rt, also, I would
suggest one caution respecting the statements of the au-
thor as to the extreme distinctness of the sounds. These,
doubtless, are very distinct; but the quickness with
which they succeed each other requires considerable
care, and also experience, to obtain the necessary pre-
cision in recognising them. This caution is, perhaps,
the more necessary, as we are apt to forget the natural

3

t

13 TRANSLATOR'S PREFACE,

briefness of the heart's pulsations, while perusing the
graduated and formal description of them given by the
author. In respect of Pectoriloquism, I would request
attention to the varieties of it called uncertain, lest the
non-perception of it in its very decided character, in
cases where the conditions said to be productive of it
may be presumed to exist,— should produce scepticism
respecting its occurrence at all.

In all cases I must caution the young explorer not to
be over hasty in condemning the practice. Let him
recollect that the discoverer of the method has declared
that it is only in hospital practice, — or in a practice af-
fording similar facilities of reiterated examination both
before and after death, — that it can be properly studied.
Let him call to mind how many things in his various
studies, which seemed impracticable and false at'first,
further experience taught him to believe both easy and
useful. Above all let him never forget, that the object
proposed to be obtained, by the new method, is the im-
provement of the diagnosis of a numerous class of most
formidable diseases; an object, which, as it involves every
thing that can be most valuable to a medical man, has a
right to claim the most zealous and patient attention of
every one who has at heart either his own professional
success, or the welfare of his patients.

As much and frequent reference is made in the fol-
lowing treatise to the Percussion of the Chest, and as
this practice is but little known in England, it may be

TRANSLATOR'S PREFACE. 19

useful to say a few words respecting it in this place. In
France, and some other parts of the continent, it is in
habitual use; and was reckoned, even before the disco-
veries of M. Laennec, of very great importance in the
diagnosis of diseases. Dr. Clark informs us that " a
patient brought into any of the hospitals of Paris with
any affection of the chest, is as regularly submitted to
this process as the English Physician would ascertain
the state of the pulse."

I am informed by Dr. Baillie and Dr. Duncan. Jun.
that they have both used this method in many cases,
and with considerable advantage. The latter states it
to be of easy application and of great use. For a de-
tailed account of this method I must refer to the origi-
nal work of Avenbrugger,* or rather to the translation
of it by Corvisart.f At present I shall merely quote a
brief notice of it by the latter in his work on the heart,
and for this purpose avail myself of the translation of
Mr. Hebb. " This method, recommended by ^en-
brugger, under the name of percussion, consists in strik-
ing the chest with the ends of the fingers united; in
which case, if the lungs are sound, full of air, and if no
foreign body, either solid or fluid, occupy the interior of
the thoracic cavity, the sound produced by the percus

* De Percussione thoracis. Vienna, 1763.
t Nouvelle methode pour reconnoitre les maladies internes, fee-
Paris, 1808. .

20 TRANSLATOR'S PREFACE.

sion has been compared (an exaggerated comparison)
to that proceeding from an empty barrel when struck.
Where, on the contrary, a solid or fluid body fills one
of the cavities of the thorax, or both, the parietes give,
to the extent so occupied, a sound which has been
characterized by the term (mat) dull, and which is said
to resemble that excited by striking the thigh in the
same manner, or with the flat of the hand. The sound
produced by percussion in some diseases of the heart,
is but little less than in a natural state, and is then the
index of a less decidedly morbid state of the viscera
within. The knowledge of the degree of sound which
denotes the perfect healthy state of all the organs of the
chest can only be acquired by practice; and it is that
alone also which enables one, in rfome sort, to judge of
the solidity of the body which prevents the chest from
sounding at all; but in forming a judgment, every allow-
ance must be made for the natural thickness of the inte-
guments, and for the very frequent anasarcous state of
those parts, which have, in many cases, led to the belief
that the chest sounded badly, when it was entirely owing
to these circumstances." (Page 327).

Before terminating these prefatory observations, it
will be expected that I should say something respecting
the share which, as translator, I must claim in the pre-
sent character of the treatise. I have already stated the
changes which I have made in the arrangement of the
original articles. The only other alteration of any mo-

TRANSLATOR'S PREFACE. 21

ment, consists in my having very considerably abridged
the cases, and, also, in a lesser degree, some part of the
diagnostic details. The pathological parts are, for the
most part, fairly translated, only in many places very
considerably condensed, by the omission of redundant
expressions and repetitions, and by the exclusion of cer-
tain paragraphs which had no necessary connexion with
the main object of the work. By these means, the work
is reduced to one half its original dimensions; and I am
inclined to believe that its intrinsic value has by no
means suffered in the ratio of its diminution. The
truth, probably, is, that medical and other scientific
writings, whose value is altogether independent of style,
may, unlike the productions in elegant literature, be ra-
ther improved than deteriorated in the hands of a judi-
cious translator; inasmuch as he will act as a severe re-
viser of the style, without any of the prejudices and par-
tialities which so easily beset an original writer. With
the translator, no favourite expression, or well turned
period, or pretty interloping remark, or elaborated and
long-concocted yet stupid notion, will find mercy, unless
redeemed by some other more useful qualities; yet we
must all allow that these and a thousand other things of
no greater moment, often plead irresistibly with our-
selves during revision, and to the manifest deterioration
of our writings. From this cause, then, a work, in be-
ing translated, may be greatly condensed, and yet not
abridged. The former epithet, I presume, is applicable

22 TRANSLATOR'S PREFACE.

to the greater part of the present translation; and the
latter only to the cases. In respect of these, indeed, I
think I have committed an error in this particular; and
if I had the work to do over again, I would make some
considerable alteration in the manner of detailing them.
The truth is— that when I began my translation I was
too little impressed with the importance of the diagnos-
tic measures recommended in the work; and my object
was rather directed to improve the pathology at the ex-
pense of the diagnosis. In consequence of this, I must
admit that several of the cases (in the beginning of the
work more especially) are too much abridged; and that
some valuable diagnostic details are thereby excluded.
With the view of making all the amends in my power, I
have given several of the more important cases thus
abridged, more at length in the Appendix; and have
added several others not translated in the body of the
work. Indeed I am now disposed to believe that the
work would have been improved if I had entirely ex-
cluded the Cases from both Parts of it, and had given
them in one body, and in considerable detail, at the end;
and should the translation (unlike translations) ever
reach a second edition, I shall do so still. As it is, how-
ever, I still think the present arrangement very supe-
rior to the original.

In respect of the mere literary execution of my hum-
ble yet laborious task, — I, of course, could have no
higher aim than that of giving a faithful delineation of

TRANSLATOR'S PREFACE. 23

my original. In this, I trust, I have succeeded; and if
I shall be considered to have done so, without much vio-
lation of the idiom of our language, — I shall obtain the
only additional title to credit of which I am desirous,
and to which a translator of a merely scientific work
can aspire. At all events, even should this claim be re-
fused, I fear the present state of medical literature in
England furnishes too many examples of bad writing,
even in original composition, to render the imputation
of a failure very oppressive, where the permanent dis-
torting influence of a foreign idiom can be adduced in
excuse.

In the few Notes which I have added to the work, I
have noticed some of the principal English writers who
have treated on the diseases therein described, and have
put down a very few obvious practical inferences and
suggestions. — My anxiety to keep the volume within a
tolerable size has prevented me from enlarging on this
head ; and I fear in the few remarks made, the meager-
ness of a private and provincial library, and the too limit-
ed acquaintance of the writer with the literature of his
profession, will be sufficiently conspicuous.

AUTHOR'S PREFACE.^

I began, three years since, the researches of which 1
now publish the results. Although these have not reach-
ed the degree of perfection which longer experience
would have conferred on them, I have thought it ad-
visable, for many reasons, to communicate them to the
public. Among those reasons I may mention — the in-
correct accounts of my discoveries that have found their
way into the journals of the day; the favourable report
of the Academy of Sciences;* and the hope and con-

* Extract from the Report of the Academy of Sciences' (drawn
\ip by M. Percy, and signed by him, and MM. Portal and Pelle-
tan, 29th June, 1 8 1 8,) on a Memoir of M. Laennec respecting the
use of Auscultation, more particularly in Phthisis Pulmonalis.

" The Cylinder, applied to the chest of a healthy person who
sings or speaks, produces a sort of vibration, which is more
distinct in some places than others. But when there exists an
ulcer in the lungs, the patient's voice then, instead of being heard
in the usual manner by the exposed ear, reaches the other entirely
through the tube of the instrument. We have ourselves verified
this fact on several consumptive patients; it appeared to us
striking, and well fitted for furnishing a certain and easy sign of

4'

26 AUTHOR'S PREFACE.

viction that the mode of exploration detailed in this
work will be confirmed and extended* by other ob-
servers. Kl J

It will be found that of the facts narrated in my
treatise, I have given some as certain, others as doubtful,
and a few merely as problematical. Of the first class,
if future experience should invalidate any, I may ven-
ture to believe that the number will be few; and I am
even convinced that the greater part of those which I
have stated as doubtful, will be found by further obser-
vation to be constant and certain.

In respect of the pathological details, which consti-
tute so large a portion of the work, I think it necessary
to make a few observations. The great attention that
has been paid to morbid anatomy, since the commence-
ment of the present century, throughout Europe, and
more especially in Paris, has been productive of many
improvements and discoveries which are but imperfectly

certain morbid conditions of the lung, which, in the present state
of medicine, can only be suspected to exist. * * *

We have also examined, by means of the cylinder, the respira-
tion in different parts of the chest of a healthy person, and found
it very distinctly audible in every point of this cavity which cor-
responded with the lungs. We have also found that the motions
of the heart were equally perceptible ; and it has, consequently,
appeared to us, that the assertions of the author, of the possibility
of obtaining, through these two kinds of auscultation, certain
signs of the several diseases of the heart and lungs, were, at
least, extremely probable,"

AUTHOR'S PREFACE. 27

known; and, indeed, many of which have not at all
been communicated to the public, at least by their dis-
coverers. On this account, the present state of our
written knowledge is obviously behind our actual know-
ledge ; and if, in the present work, I had contented my-
self with merely describing the signs of the organic
lesions, without describing the lesions themselves, I
should have often run the risk of being not understood
at all, or (what is worse) of being misunderstood. I
have, therefore, felt that the only means left of escaping
this danger, was to give an anatomical description of all
the diseases of which I have noticed the symptoms In
fulfilling this task I have endeavoured to render my de-
scriptions concise, yet, at the same time, sufficiently
exact and complete to characterise the objects.

Another motive has contributed to strengthen this
resolution: — viz. the conviction of the practical utility
of my mode of diagnosis, and the belief that the surest
way of procuring its more general adoption was to asso-
ciate the exposition of its principles with a description
of the diseases which it indicates, more exact than any
that yet exists.

Many reasons have induced me to prefer the anatomi-
cal to the mere symptomatical description of diseases.
The former method has the advantage of brevity, per-
spicuity and certainty. It is, for example, much easier
to describe tubercles and detail the signs of these, than
to define the disease by the external symptoms only.

28 AUTHOR'S PREFACE.

and to arrange its varieties according to their causes.
Emphysema of the lungs consists in an alteration of
parts which can be described in a few words, and of
which the signs can be easily recognised; while in stu-
dying asthma, according to the method of Sauvages, we
shall require to write a volume on generalities before we
can arrive at any thing positive.

It will, perhaps, be objected that the anatomical me-
thod has the disadvantage of founding its species on
distinctions, the chief characters of which can only be
obtained after death: but this objection scarcely merits
refutation. We might as well say that it is useless for
surgeons to make any distinction between dislocation of
the femur, and fracture of its neck; or that it is useless
to separate bronchitis from peripneumony.

The morbid alteration in the affected organ is, un-
questionably, the least variable and most positive of the
phenomena of local disease; it is on the nature an(J
extent of this alteration that the danger and curability
of diseases always depend; and it is this, consequently,
that ought to be considered as characterizing them.
On the contrary, the derangement of functions which
accompanies these alterations is extremely variable: it
is often the same under circumstances entirely different;
consequently, it can rarely serve to discriminate differ-
ent diseases.

Besides, it is a mistake to consider the recognition of
nosological species, founded on the data of morbid ana-

AUTHOR'S PREFACE. 29

tomy, as impracticable before death: on the contrary,
(hey are often more readily recognised during life, and
certainly present to the mind something much clearer
ancj more positive, than any nosological distinction
founded on the symptoms merely. Peritonitis, for ex-
ample, is assuredly a disease easily distinguished during
life; and out of twenty medical men acquainted with
morbid anatomy called to see a case of it, not one will
make a mistake concerning its nature or name. But
will this be the case with those who are accustomed to
see in diseases nothing but symptoms? Of the twenty
shall we not find one considering the affection as ileus,
another as hepatic colic, a third as puerperal fever, and
so on? The same thing may be said of peripneumony.
nephritis, hepatitis, &c. ; and I hope that the work now
submitted to the public will enable us to say the same
thing of most of the diseases of the lungs, pleura and
heart.

Morbid anatomy must, then, I think, be considered
as the surest guide of the physician, as well to the di-
agnosis as to the cure of diseases. But it must not
be forgotten that it has also its obscure points. It is 3
no doubt, an easy matter to distinguish striking changes
of structure; but there are many slighter alterations,
among which it is difficult to ascertain what is healthy
and what diseased; what cause and what effect; and,
lastly, whether the appearances are truly the effect of
disease, or merely an accident of assimilation, or circu-

5(j AUTHOR'S PREFACE.

lation, that has taken place in articulo mortis, or even
after death. In these cases we must content ourselves
with what is clear and distinct; never forgetting in prac-
tice the principle of Hoffman — Nunquam aliquid magni
facias ex mera conjectura aut hypothesi; and sedulously
guarding against the error of believing that the mere
knowledge of the seat and nature of the disease can
justify our neglecting its individual character, as in-
fluenced by external circumstances or personal idiosyn-
crasy.

From the foregoing observations it will be seen that
this work is not, like that of Avenbrugger, a simple ex-
position of new means of diagnosis. Neither can it be
considered as a monography of the diseases of the
chest, — since I have taken little notice of the ordinary
and more general symptoms of the -diseases, and have
not at all touched upon their treatment.

In the construction of my treatise I have quoted but
two authors. The chief object of my researches was,
in a great measure, new; and for the facts already
known respecting the diseases of the lungs and heart, I
have thought it unnecessary to go beyond the works of
M. Corvisart and Bayle* If I have occasionally dif-

* Essai sur les maladies et Ies lesions organiques du coeur, &c.
par J. N. Corvisart. Translated by Hebb. London, Underwood,
'.813.

Novelle methode pour reconnoitre les maladies internes de la
poitrine par la percussion de cette cavite, par Avenbrugger, ouy-

AUTHOR'S PREFACE. 31

fered from these distinguished authors, I trust no one
will misinterpret my motives. No one can be more
sensible of their merits, both as men and Physicians,
than myself. At the very time I question their opinions,
I most willingly confess my great obligations to them.
It is much easier to improve a field already cultivated,
than to reclaim a wild and barren soil. In respect of
the works of M. Corvisart, more particularly, it is to be
regretted that those of them published by others, are far
from giving a just idea of the author's merits. The
uncertainty of the signs of diseases, and the vagueness
of description in these, appear peculiarly- striking to
those who, like myself, were his pupils, and habitual
witnesses of the boldness and precision of his diagnos-
tics. This defect, no doubt, partly depends on the in-
communicable tact of the physician, which forms so
great a part of the art, and which M. Corvisart possessed
in the highest degree.

I have hopes that the advantages of my method ofdi-
agnos j may be extended, in some degree, to veterinary
medicine. Many reasons, however, exist, why this art
must derive inferior benefit from it. Among these I may-
mention the absence of the voice;— the comparative in-
accessibility of the region of the heart; and lastly, the

rage traduit clu latin et commente, par J. N. Corvisart. Paris.
1808.

Recherches sur la Phthisie pulmonaire, par G. L. Bayle,
Paris, 1810. Translated by Barrow. 18 i 5

32 AUTHOR'S PREFACE.

great indistinctness of respiration in the horse, and pro-
bably all herbivorous animals. In cases of disease,
however, the respiration will be more audible in the
sound portions of the lungs; as I/ound in a case of perip-
neumony in a cow, which I recognised during the ani-
mal's life, as easily as in the human subject. In the
dog, and cat, and probably in all carnivorous animals,
the sound of respiration is as distinct as in man. Not-
withstanding these difficulties, I have no doubt that fur-
ther experience will prove the utility of mediate auscul-
tation in the disease of animals, especially if combined
with percussion of the chest.*

* The author further suggests the probable utility of the ste-
thoscope in the instruction of the deaf and dumb, by applying one
end of it to the trachea of the speaker and the other to the ear of
the pupil : — but surely this must be fanciful, — or at least of infe-
rior value to other means. — Trans.

ANATOMICAL ACCOUNT

DISEASES OF THE CHEST.

BOOK FIRST.

OF THE LUNGS

CHAP. I.

OF PHTHISIS PULMONALIS, OR TUBERCULAR
DISEASE OF THE LUNGS.

SECTION FIRST.

Of the essential, or anatomical, character of Tubercles oj
the Lungs.

1 he existence, in the lungs, of those peculiar productions to
which the name of Tubercles has been restricted by modern ana-
tomists, is the cause, and constitutes the true anatomical character,
of Consumption.

These bodies, when first observable in the substance of the
lungs, have the appearance of small semitransparent grains,
greyish or colourless, and varying from the size of a millet-seed
to that of a hemp-seed : in this, their first state, they may be
called Miliary Tubercles. These gradually increase in size, and
become yellowish and opaque, at first m the centre and succes-
sively throughout their whole substance. In their progressive and

5

34 DISEASES OF THE LUNGS.

mutual increase, several unite together so as to form larger masse*
of the same kind, which, like the individual ones, are of a pale
yellow, opaque, and of t he consistence of very firm cheese: in
this stage they may be named crude or immature Tubercles.

It is in this stage of their progress that the substance of the
lungs, which had been hitherto healthy, begins to grow hard, grey-
ish, and semitransparent around the tubercles, by means of a fresh
production and seeming infiltration of tuberculous matter, in its
first or transparent stage, into the pulmonary tissue. It also some-
times happens that considerable portions of the pulmonary tissue
put on this character without any previous development, of indi-
vidual tubercles. Parts so affected are dense, humid, quite im-
permeable to air, and exhibit, when cut in'o, a smooth and polish-
ed surface. Gradually there are developed in these comparatively
solid and pellucid masses, an infinity of very minute yellow opaque
points, which, increasing in size and number, ai length convert the
whole diseased space into a tuberculous mass of the kind named
crude or immature.

In whatever mode the tubercles have first shown themselves,
they at length, after a very uncertain period, become, first, soften-
ed, and finally liquefied This change of consistence commences
in the centre, and progressively approaches the circumference.

In this stage the tuberculous matter is of two different kinds in
appearance: — the one resembling thick pus, but without smell,
and yellower than the immature tubercle; the other, a mixed fluid,
one portion of it being very liquid, more or less transparent, and
colourless (unless tinged with blood), and the other portion opaque,
of a caseous consistence, soft and friable In this last condition,
which is chiefly observable in strumous subjects, the fluid perfectly
resembles whey having small portions of curd floating in it.

When the softening of the tuberculous mass is completed, this
finds its way into some of the neighbouring bronchial tubes; and
as the opening is smaller than the diseased cavity, both it and the
latter remain, of necessity, fistulous, even after the complete evacu->
ation of the tuberculous matter. It is extremely rare to find only
one such excavation in a tuberculous lung. Most commonly the
cavity is surrounded by tubercles in different stages of their pro-
gress, which, as they successively soften, discharge their contents
into it, and thus gradually form those irregular and continuous ex-
cavations so frequently observable, and which sometimes extend
from one extremity of the lungs to the other.

Bands, composed of the natural tissue of the organ, condensed,
as it were, and charged with the tuberculous degeneration, fre-

PHTHISIS PULMONALIS. 35

quently cross these cavities, in a manner something resembling
the columns carnece of the ventricles: these are of less dimen-
sions in their middle than at their extremities. These cross bands
have often been mistaken for vessels; and M Bavle himself seems
to have fallen occasionally into this error, since, hp says, that ves-
sels frequently traverse such cavities; whereas this is, in my opi-
nion, a very rare circumstance. Nay more, I have never even
found a vessel of any consequence included within the substance
of these bands. Neither is there any example of this in M.
Bayle's work; and 1 only remember to have heard him mention
one case where this took place, viz. in a fatal haemoptysis, where
the ruptured vessel was found crossing a very large cavity. In the
few cases where I have found blood-vessels in such bands, they
constituted only a small portion of their mass, and were, for the
most part, obliterated. Generally, indeed, they can only be traced
for a small space into these columns, being soon undistinguishable
from the pulmonary tissue injected with the tuberculous substance.
It would appear that the tubercles, during their increase, press on
one side and separate the blood : vessels, as we find these sometimes
of considerable size, lining the internal surface of the cavities, and
forming a part of them These vessels are generally flattened,
but rarely obliterated: their smaller ramifications, however which
stretch towards the tuberculous excavations, or towards unevacu-
ated tubercles, are evidently so, as is proved by our abortive
attempts to inject them. Baillie and Starck bad already made the
same observation. The ramifications of the bronchia, on the con-
trary, seem rather enveloped than pressed aside by the tuberculous
matter; and it would appear that the pressure soon obliterates theip
canal, as they are hardly ever to be detected in the morbid sub-
stance. That they must, nevertheless, have originally traversed
the spaces now occupied by the tubercles, seems proved by the
fact, that in every excavation, even the smallest, we find one or
more bronchial tubes opening into it These tubes scarcely ever
open sideways, but are cut directly across, on a line with the in-
ternal surface of the excavation; and their direction is such as
shows them to have originally crossed this space

In proportion as an excavation discharges its contents, its walls
become covered with a species of morbid or false membrane, thin,
smooth', white, nearly quite opaque, of a very soft consistence,
and almost friable, so that it can readily be scraped off by the
scalpel. This membrane is generally quite perfect, covering the
whole internal surface of the cavity. Sometimes, in place of that
just described, we find a membranaceous exudation, thinner, more

36 DISEASES OF THE LUNGS.

transparent, less friable, more intimately connected with the walls
of the cavity, and, for the most part, lining these only in part.
When completely investing (he cavity, it presents, in different parts
of its surface, points here and there of greater prominence, as if
the exudation had begun in these different spots at the same time.
Frequently we find this second membrane beneath the first, which
last is then quite loose and lacerated in several places. Occasion-
ally, also, both these membranes are entirely wanting, and the walls
of i he. cavity are directly formed by the natural tissue of the lungs,
which, in this case, is commonly condensed, red, and charged with
tuberculous degeneration in different stages of its development.

From these facts it appears to me that the second species of
false membrane just mentioned is only the first stage of the first
species; and that when this is fully formed it is apt to be detached
and discharged in a greater or less degree, — forming- one portion
of the sputa expectorated by the consumptive.

Bayle thinks that this false membrane secretes the pus expectora-
ted in this disease; — an opinion which is founded on the analogy
existing between it and tha*t which forms on the surface of blisters
and ulcers. It seems certain, however, to me at least, thai the
greater part of the matter expectorated is the product of the bron-
chial secretion, augmented as this is by the irritated condition of
the lungs. 1 do not assert thai pus is not formed in these tubercu-
lous excavations at all, but I certainly have observed that when
these are lined by the soft membrane described above, they are
often entirely empty, and that, when they do contain any puriform
matter,- this bears by no means so great a resmblance to the sputa
as that does which is contained in the bronchia.

If the disease remains long stationary, there are at length deve-
loped, indifferent points under this false membrane, patches of
a greyish white colour, semitransparent, of a texture like that of
cartilage, but somewhat softer, and adhering closely to the pulmo-
nary tissue. These patches coalesce as they grow in size, so as
eventually to form a complete lining to the ulcerous excavation, and
this lining seems to form one continuous surface with the internal
coat of the bronchial tubes which open into it.

When this cartilaginous membrane is completely formed, it is
commonly white or of a pearl grey; or it has a slight reddish or
violet lint, which latter colour is derived from the colour*ofthe
subjacent tissue being seen through it Sometimes, however, even
when the membrane is of considerable thickness, its internal sur-
face is of a rose or red colour, which does no; yield to washing, and
which is therefore probably occasioned by the vascularity of the

PHTHISIS PULMONALIS. 37

part, although, in such cases, we are unable to detect any distinct
vessel.

In some very rare instances we find tubercles entirely, or al-
most entirely, softened, in a portion of lung in other respects
quite healthy and crepitous; and, in such cases, (two or three
of which only I have met with in eighteen years,) the walls of the
cavity are smooth, and seem to be formed merely by the pulmo-
nary tissue somewhat condensed, there being no accidental mem-
branous production whatever.

Sometimes, but very rarely, the semi-cartilaginous membrane
is perceptible before the softening of the tubercles, and, indeed,
seems to be of the same date as themselves. This is the encyst-
ed tubercle of Bayle. The texture of these cysts is entirely
cartilaginous, only a little less solid than cartilage, and they
belong, therefore, to the class of imperfect cartilages, of which
I have given an account in another place* They adhere firmly,
by their exterior surface, to the parts which surround them, so as
only to be separable by the knife, or by forcible detraction. The
tuberculous matter contained in these adheres strongly to their
sides, which, when it is removed, are seen to be smooth and po-
lished, though more or less uneven or rugged. These encysted
tubercles are more frequent in the bronchial glands then in the
substance of the lungs.

The above is the ordinary manner in which tubercles are de-
veloped; but there are two other modes, which, although proba-
bly mere varieties of the former, are yet deserving notice. The
one is where, in a lung containing tubercles in different stages,
we find small portions of the pulmonary tissue seemingly infil-
trated by a gelatinous-looking matter of a consistence intermediate
between liquid and solid, transparent, and of a light greyish or
sanguineous hue. In these diseased portions the cellular struc-
ture of the lung is quite destroyed; but we can perceive in them
a multitude of* very small points of a yellowish white colour and
opaque, and which are evidently portions of the tuberculous
matter which has reached the second stage of its progress, with-
out there being any surrounding portion of the greyish substance
which denotes the first stage.

The second mode of anomalous development of tubercles ap-
pears likewise to lake place without any previous formation of
grey matter : at least, if there be such, the transition from it to
the second stage is so rapid that I have never been able to detect

* Diet, des Scienc. Med.

38 DISEASES OF THE LUNGS.

its presence. In this variety we find here and there in the lung
tuberculous masses of a yellowish white colour, much paler, less
clear, and differing less from the substance of the lung than the
ordinary immature tubercle. These masses are irregular, angular,
and have scarcely ever the rounded form of ordinary tubercles. They
seem, like the variety described in the preceding paragraph, and
like the diffused grey matter noticed before, to be an infiltration
of tuberculous matter into the pulmonary tissue, while the proper,
or rounded, tubercles are foreign bodies which separate or press
it aside, rather than penetrate it. These masses may, therefore,
properly enough be named tubercular infiltration of the lungs.
They occupy sometimes a considerable portion of one lobe.
When they reach the surface they occasion no prominence, on
the part, nor in any degree alter its form. As they increase they
assume the yellow colour of other tubercles, and terminate by
softening in the same manner.

These three varieties of tuberculous degeneration are often
found in the same lung. Sometimes I have found the last variety
alone, in lungs affected wish peripneumony, and this even in
the hegatised portions. In these cases, the small number and ex-
tent of the diseased masses, and their deep pale colour, showed
their formation to be recent We must not, however, conclude
that the tuberculous degenerations were here (he effect of the in-
flammation, sines' — setting aside .heir inftcqiiency compared
with the frequency of this disease of the lungs — I have often had
occasion to observe this variety of tubercle, and to the same ex-
tent, in subjects whose lungs were, in every respect, quite sound.
Besides, M. Bayie has completely proved that tubercles cannot
be regarded either as a termination, or consequence, of inflamma-
tion.

It cannot, indeed, be denied that peripneumony, both acute
and chronic, sometimes cq- exists with tubercles; it is even pro-
bable that this disease may, at one time, be the cause of their
devolopment in subjects predisposed to them, and at another, may
itself be excited by the irritation, produced by a numerous crop
of these. Any person at all accustomed to the examination of
bodies after death must admit these positions ; yet it is, never-
theless, satisfactorily proved by a multitude of facts, 'hat the
growth of tubercles in the lungs most commonly takes place
without any previous inflammation, and that, when inflammation
is found contemporaneous with these, it is generally posterior in
its origin.

To convince us of the truth of this observation, we have only

PHTHISIS PULMONALIS. 39

to attend to the progress of tubercles in scrophulous glands, which
we frequently find to remain swollen for a very long time, with-
out the least redness, not only of the surrounding skin, but even
of <he gland itself. It is often not till after several years that in-
flammation tomes on, which then seems to accelerate the aoften-
ing of the tuberculous matter. Sometimes, however, this takes
pJace, and the matter is even evacuated, without the supervention
of what can properly be called inflammation. When this does
occur it has evidently its seat in the tissues surrounding the
scrophulous gland, and not in the gland itself

Anoiher proof, equally strong, of what has just been advanced,
is afforded by the simultaneous existence of tubercles in different
organs of the same subject. In consumptive patients it is very
uncommon to find the tubercles confined to the lungs : almost
always they occupy the intestinal coats, at the same time, and
are the cause of the ulceration and consequent diarrhoea so gene-
ral in the disease. There is perhaps no organ free from the
attack of tubercles, and wherein we do not, occasionally, disco-
ver them in our examination of phthisical subjects. The follow-
ing are the parts in which I have met with these degenerations,
and I enumerate them in the order of their frequency : the
bronchial, the mediastinal, the cervical, and the mesenteric
glands ; the other glands throughout the body ; the liver — in
which they attain a large size, but come rarely to maturation;
the prostate— in which they are often found completely softened,
and leave, after their evacuation by the urethra, cavities of dif-
ferent sizes; the surface of the peritonaeum and pleura, in which
situations they are found small and very numerous, usually in their
first stage, and occasion death by dropsy, before they can reach
the period of maturation ; the epididymis, the vasa deferentia,
the testicle, spleen, heart, uterus, the brain and cerebellum, the
bodies of the cranial bones, the substance of the vertebrae or the
point of union between these and the ligaments, the ribs, and,
lastly, tumours of the kind usually denominated schirrus or can-
cer, in which the tuberculous matter is either intimately combin-
ed with, or separated in distinct patches from, the other kinds of
morbid degeneration existing in these.

Tubercles are found more rarely in the muscles of voluntary
motion than in any other part. The most remarkable case of
this sort I have met with, was that of a consumptive patient who
had tubercles in almost every situation mentioned above, and who
had, besides, the ureters so much dilated as to receive the thumb.
and their internal coat converted into an adhesive layer of tuber-

40 DISEASES OF THE LUNGS.

culous matter. In this person the lower extremity of one of the
sterno-mastoid museles was converted into tuberculous matter, firm
and consistent. In this case the muscular structure was still preserv-
ed in the parts most altered. In the parts least altered, and
which passed by insensible gradation into the sound portion, the
tuberculous matter was in its early stage, grey and semi-transpa-
rent. 1 had particularly attended to this man's case ; he never
complained of pain in the neck, but merely some difficulty in
moving it. At the same time the cervical lymphatic glands were
full of tubercles and much enlarged.

Almost all the cases given in M. Bayle's treatise, afford ex-
amples of the simultaneous development of tubercles in different
parts of the body, without there being discoverable in the affect-
ed parts either pain or any symptom of inflammation. The same
is true of the tubercles of the lungs, which scarcely ever occasion
any disorder until they have become numerous and large.

From all this it follows, that we must either admit that tuber-
cles are not a termination or a product of inflammation, or agree
to receive this word in a sense as general and vague as that of
irritation, or even to consider it as synonymous with cause : — a
mode of proceeding which seems to possess no advantage what-
ever. There is sufficient obscurity already in the etiology of dis-
ease without augmenting this by forced relations. The above re-
marks respecting inflammation are equally applicable, as has been
well shown by M. Baylf, to several other diseases, both general
and local, which have been assigned as causes of consumption; —
such, for instance, as Syphilis, Hooping-Cough, Eruptions, Hae-
moptoe and Catarrh. These affections may accelerate the de-
velopment of tubercles already existing; they may even some-
times be the occasion of their development, but this can only be
in subjects primarily predisposed to them. The real cause, like
that of all other diseases, is probably beyond our reach.

M. Bayle does not seem to have been well acquainted with the
different modes of development of tubercles, as above described.
This appears to be owing to his not having paid sufficient atten-
tion to the grey semitransparent character of them in their early
stage, and the true relation between these and the yellow opaque
tubercles.

On the other hand, he has been, perhaps, too much struck with
one variety of these tubercles, those, namely, which he has de-
scribed under the name of miliary granulations. These are, no
doubt, very remarkable by their want of colour, transparency, dis-
tinct round or oval shape, smooth and shining surface, great hard-

PHTHISIS PULMONALIS. 4j

ness uniformity of size, and infinite number spread through the
whole lungs, (healthy in other respecls,) or a great part of them,
without their being ever found united or grouped together. They
look as if they had all been produced on the very same day, not
one of them being more advanced than another.

M. Bayle has however evidently been deceived in considering
these granulations as different from tubercles; still more so in
classing them with morbid cartilaginous bodies (cart, accidentels)
If this opinion were correct, we should see them occasionally con-
verted into bone, which is never the case. But, indeed, an atten-
tive examination shows them to be tubercles. In the centre of
those least transparent we can discover a yellow opaque point
which is obviously the commencement of the passage to the se-
cond or mature stage. M. Bayle himself cites a strong example
of this (case 4). r

Besides, in some cases, we find the lungs completely filled with
very small, equal-sized tubercles, but opaque, yellow, and occa-
sionally in a well-marked state of maturation. M. Bayle "ives
also an example of this kind, (case 16), although he pretends to
distinguish this variety from that of his miliary granulations,
Hie only ditierence, in my opinion, between them, is the differ-
ence that exists between the green and ripe fruit. Besides these
miliary granulations are never found but in lungs which contain
other and larger tubercles, whose advanced stage incontestiblv
proves their character. J

The progress of tubercles in different organs affords a sufficient
number of facts, to prove, that in their first and earliest stage
these foreign bodies are always diaphanous or semitransparent'
colourless, or at most slightly greyish. This is often the case
with the tubercles observed on the surface of the pleura and peri-
tonaeum. On the contrary, these have sometimes an opaque yel-
low spot in the centre, and, on other occasions, they are convert-
ed into tuberculous matter more or less soft. All these varieties
are observed on the same membrane. The same varieties of
miliary tubercles are found in the bottom of the intestinal ulcers
of consumptive patients. Lymphatic glands containing tubercles
have often a slight degree of semilransparencv and pearl colour
in the tissue surrounding these,— a proof and sign of the ulterior
degeneration of the whole gland. Bayle has found the spleen
filled with small greyish bodies, which he himself considers as
tubercles.

Besides the effect of the various degrees of development, other
accidental causes may affect the colour of tubercles. Icterus rer> -

42 DISEASES OF THE LUNGS.

tiers them yellow, especially at the surface, and this is chiefly in
the liver. Gangrene in their vicinity, and also the black pulmo-
nary matter, blackens them in a greater or less degree. More
especially those found in the bronchial glands are often tinged
with a deep black, which is seen gradually fading into the natural
colour of the tubercle. Most miliary tubercles, whether semi-
transparent, or yellow and opaque, have a small dark spot in their
centre, which disappears as they enlarge. This condition must
not be confounded with melanosis, as will be shown more particu-
larly hereafter.

When there exists a great number of tubercles, even very
small ones, in the lungs, death will sometimes take place before
any of them have arrived at the stage of maturation; and conse-
quently before these can have formed any ulcerous excavation.

When, on the contrary, there is only a small number of tuber-
cles, we sometimes find them all evacuated and hollow on exami-
nation after death. In the majority of cases, however, the de-
velopment of tubercles is evidently successive, so that, on exami-
nation, we generally find these bodies in the different stages we
have described, viz : 1. granular, grey or colourless, and semi-
transparent ; 2. grey, but larger, and yellow and opaque in the
centre ; 3. yellow and opaque throughout, but still hard ; 4. soft,
especially towards the centre ; and, lastly, cavities more qr less
completely empty.

SECTION SECOND.

Of some ulterior changes in certain cases of the Tubercular Disease;
and on the curability of Phthisis.

To many practical physicians, who are not anatomists, the pos-
sibility of a cure taking place after the formation of an ulcerous
excavation in the lungs, may seem quite admissible. This opi-
nion, however, will, in all likelihood, appear quite absurd to those
who have paid much attention to morbid dissection.

Previously to the knowledge of the true character and mode of
development of tubercles, and while consumption was considered
simply as a consequence of the chronic inflammation and slow
suppuration of the pulmonary tissue, medical men did not question
(any more than the vulgar now do) the possibility of curing this
disease by a suitable mode of treatment, especially if taken in time.

PHTHISIS PULMONALIS. 4j

and during the first stage of it. It is now, however, the general
opinion of all those who are acquainted with the actual state of
our knowledge respecting the pathology of diseases, that the tu-
bercular affection, like cancer, is absolutely incurable, inasmuch
as nature's efforts towards effecting a cure are injurious, and those
of art are useless. Bavle, in particular, advocates the incurability
of this disease: he, however, admits the possibility of its bein*
almost indefinitely prolonged.

The observations contained in the treatise of M. Bayle,as well as
the remarks made in the preceding section, on the development of
tubercles, sufficiently prove the idea of the cure of consumption in
its early stage to be perfectly illusive. Tubercles tend essentially
to increase in size and to become soft. Nature and art mav retard
or even arrest their progress, but neither can reverse it. But while
I admit the incurability of consumption in the early stages, 1 am
convinced, from a great number of facts, that, in some rare cases
the disease is curable in the latter stages, that is, after the sof-
tening of the tubercles and the formation of an ulcerous excava-
tion.

Occasionally, while examining the lungs of subjects that had
suffered from chronic catarrh we find irregular caviiies lined by a
semi-cartilaginous membrane, in all respects similar to that describ-
ed above, and these cavities accord perfectly with the tuberculous
exulcerations, except that they are empty. In carefully investi-
gating ihe history of such subjects, we find that they all referred
the origin of their catarrh to a violent anterior disease vyhich borq
ihe character of consumption, so strongly as to make their case at
the time, be considered desperate.

( )n the other hand, in subjects dead of consumption, whose disease
had lasted very long, several years for instance, we very commonly
find similar excavations entirely lined by semi-cartilaginous mem-
brane, and free, or almost free, from tuberculous matter. In the same
lung we shall also find excavations having the cartilaginous mem-
brane much softer and less complete, and still containing a consi-
derable quantity of tuberculous matter; while other excavations
are observed almost filled with the puriform tuberculous fluid, and
with scarcely any of the cartilaginous lining In conjunction
with all these we almost always find tubercles in various degrees
of maturation, and even in their miliary and semiiransparent
stage. This reunion of tubercles in all theirvarious degrees of
development, considered in conjunction with the slow progress of
the disease, decidedly proves, in my opinion, that the tubercles
have been developed at different periods; and that the oldest

44 DISEASES OF THE LUNGS.

those, namely, which have given rise to the empty ulcerous cavities
lined by the cartilaginous membrane — have originated, in many
cases, several years before the others.

The formation of this semi-cartilaginous membrane on the sur-
face of tuberculous excavations, must be considered, in my opi-
nion, as a curative effort of nature. When completely formed it
constitutes a sort of internal cicatrix analogous to a fistula, and is,
in many cases, not more injurious to health than this species of
morbid affection All the persons whose cases I noticed above
died of diseases not referrible to the pulmonary organs. They had
all lived a greater or less number of years in a very supportable
state of health, being merely subject to a chronic catarrh Some
indeed had more or less of dyspnoea, but without any fever or ema-
ciation.

I have at present under my care several patients affected with
chronic catarrh, and who afford distinctly the sign of pcctorilo-
quism* although they have in no other respect any symptom of con-
sumption. I have met with several other cases, wherein this phe-
nomenon was observable along with a slight habitual cough, very
little expectoration, and scarcely any marked alteration in the
general health. In a lady formerly a patient of M Bayle eight
years since, and whose case was decidedly consumption (as appears
from M. Bayle's notes in her possession), the sign of pectoriloquism
is most distinct This lady recovered beyond all expectation; she
is now stout, and the only symptom she has at all referrible to
the lungs, is a slight cough. I have no doubt that the cartilagi-
nous excavations above described exist in this person's lungs.

In proof and explanation of what we have advanced in this sec-
tion, I shall here give a brief notice of five cases that have come
within my own observation.

Case 1. A woman, aged 68, laboured under an affection of the
chest for many years, chiefly marked by copious expectoration and
dyspnoea, and called by her asthma. Along with other morbid ap-
pearances, there were found two large ulcers or excavations in
the lungs, perfectly lined by the cartilaginous membrane as above
described.

Case 2. A man aged 32, brought to the hospital for a maniacal
affection, died a few days after, comatose. On examining the body
sufficient cause of death was detected in the brain, and the follow-

* For an account of this particular sign, which the author considers quite
pathognomonic of that stage of Phthisis when the tubercles are evacuated.
<?ee Part Second. — Trans.

PHTHISIS PULMONALIS, 45

ing appearances were found in the lungs. The left lung much less
than the right, and containing a few tubercles in the first siage.
The right lung containing in like manner tubercles in different
stages, and also an excavation large enough to contain an egg.
This was filled by a clot of blood, and was completely lined by
the cartilaginous membrane above described.

Case 3. A woman aged 42, long subject to cough, difficult
breathing, and expectoration, died of an aggravation of the symp-
toms. The left lung contained a few tubercles past the first stage,
and a small excavation, of the size of a filbert, lined by a soft
white membrane, and filled by tuberculous maiter, partly of the
consistence of cheese and partly puriform. The right lung con-
tained a cavity of the size of a walnut completely lined by the
semi cartilaginous membrane, communicating with the air cells
by one bronchial tube of the size of a crow-quill, which was
partly obstructed by a calcareous concretion The lung contained
a few more similar concretions, but was not in other parts much
diseased.

Case 4. A lady aged 48, was subject for several years to severe
attacks of pulmonary catarrh, which usually became chronic, and
reduced the patient considerably. Latterly she had been much
better. In July 1818, she seemed to have all the symptoms of in-
cipient tubercular phthisis. In February 1819, a great expecto-
ration supervened and continued a month, after which time she
began gradually to amend, and finally recovered completely. Af-
ter the period of the expectoration the symptom of pectoriloquism
was observable, and still continues very distinct. She has little
cough and less expectoration.

From considering the foregoing observations, the shape of the
pulmonary fistula?, the smooth and polished surface of their lining
membrane, and the analogy of fistulae in other parts of the body,
we might naturally be led to suppose that the formation of the semi-
cartilaginous membrane is the last effort of nature towards a cure,
after the formation of an ulcerous excavation in the substance of
the lungs, and that it is impossible for the walls of a cavity lined
by such a membrane to unite and cicatrize. The following case,
however, leads me to the contrary conclusion.

Case 5. A patient, admitted into the hospital for a diarrhoea,
and who was observed during the time he remained there to have
also a cough and expectoration, died suddenly of an apoplexy, the
cause of which was found in the brain. Both lungs contained
tubercles, and in the left lobe was found a cavity sufficient to hold
an almond in its shell, into which several bronchial tubes opened,

46 DISEASES OF THE LUNGS.

lined exactly as those already described by the semi-cartilaginou£
membrane. In the other lobe there was found, on its superior
part, a deep hollow on the external surface > which, on further ex-
amination, was found to be connected with an internal cicatriza-
tion. From the centre of the depression a cartilaginous band, half
a line in thickness, passed inwards, and, after the space of half an
inch, divided into two portions so as to form a cavity or cyst capa-
ble of containing an almond, and then these two reunited and
formed one band as at the opposite extremity. This cavity was
half filled by tuberculous matter, of a yellowish white colour,
opaque, friable, and much drier than usual. (See fig. 2. plate II.)

The foregoing condition of parts appears to me evidently pro-
duced by the imperfect union of the membrane lining two sides of
an ulcerous excavation, and which has been rendered imperfect by
the portion of tuberculous matter still remaining in it at the period
of union. This must be regarded as a very rare occurrence. It
is the only one of the kind I have met with. It is, however, not at
all uncommon to find in different parts of the lungs, especially in
the upper part of the superior lobes (in which situation tubercles
are well known to be of most frequent occurrence), bands com-
posed of a condensed cellular substance, intermixed sometimes
with fibrous, or fibro-cartilaginous portions, which by their white-
ness form a striking contrast with the natural tissue of the lungs.
These bands have every resemblance to cicatrices in the pulmo-
nary substance. Sometimes, in place of these bands, we observe
masses, of various size, of condensed cellular or fibro-cartilaginous
substance. Commonly, the substance of the lungs in the vicinity
of these accidental productions is much more impregnated with
the black pulmonary matter than elsewhere; so much so, that, it
would seem as if the formation of such foreign bodies were neces-
sarily accompanied by an extraordinary secretion of this peculiar
matter, which ought not to be considered as a morbid production.
The parts most deeply impregnated with this matter are commonly
more flabby and less crepitous than natural, and have intermixed
with them fibro-cartilaginous bands. It is not uncommon to find
in such lungs concretions of a bony or earthy nature.

I had often observed the above state of things without knowing
to what to attribute it, and without attaching much importance to
the appearance; but after I was convinced of the possibility of
cure in the case of ulcerations of the lungs, I began to fancy that
nature might have more ways than one of accomplishing this end,
and that, in certain cases, the excavations, after the discharge of
their contents, by expectoration or absorption, might cicatrize in

PHTHISIS PULMQNALIS. 47

the same manner as solutions of continuity in other organs, with-
out the. previous formation of the semi-cartilaginous membrane.
In consequence of this idea I examined these productions more
closely , and came o the conclusion, that, in every case, they might
be onsidered as cicatrices, and that, in many "cases, they could
hardly be conceived to be any thing else.

In all such cases of supposed cicatrization, I found on the su-
perficies of the lung, at the point nearest to such cicatrice, a de-
pression of greater or less extent, with a hard and irregular sur-
face, furrowed by linear marks, which sometimes exhibited an
irregular net-work or embroidery, and sometimes resembled the
mouth of a purse by their common union in one centrical point.
In the same point there are usually found adhesions between the
pleura of the ribs and lungs.

These depressions are found most frequently on the posterior or
exterior side of the upper lobes. When they are very deep, it
sometimes happens that the anterior part of the lobe, drawn up-
wards and backwards by the apparent loss of substance and conse-
quent falling in of the part, overlaps the depressed portion like the
crest of a helmet. The posterior portion of the lung has some-
times the same appearance, but in a manner much less strongly
marked. (See fig. 1 and 2, plate III.)

Whatever resemblance these depressions may have to cicatrices ,
I do not consider them as really such, but rather as analogous to
those depressions met with in schirrous mammae, which are, in
like manner, occasioned by the diseased action going on in the sub-
stance within. In the one case the surface of the lungs, in the
other the skin, is retracted by the shrinking of the subjacent parts.

In carefully examining such lungs as showed similar depressions
on their surface, I have invariably found, at the depth of half a
line, a line, or two lines at farthest, a cellular, fibrous or fibro-car-
tilaginous mass similar to those described above. The pulmonary
tissue comprehended within this (depressed) space is almost always
flabby, and not crepitous, even in cases where there is no sign of
congestion nor of impregnation with the black pulmonary matter.
Every where else, however, in the vicinity of these productions,
the lung is generally quite sound.

In tracing the bronchial tubes near these masses I have observ-
ed that such as held a direction towards them were commonly
dilated. In some cases 1 have been able to trace them, as also
blood-vessels, into the fibro-cartilaginous mass, with which, al-
though obliterated, they formed but one substance. (See pi. II.
fig. 1, and pi. V. fig. 2.) This fact seems to me to leave no doubt

48 DISEASES OF THE LUNGS.

of the nature of these productions, and of the possibility of cicatri-
zation in ulcers of the lungs. It further proves, that a bronchial
tube may traverse a tubercle, and afterwards a tuberculous exca-
vation, without being destroyed; — a case, however, as we have
already observed, which is extremely rare. Those wrinkled de-
pressions, then, on the exterior surface of the lungs, are not them-
selves cicatrices, but the consequence of a true cicatrization in
the interior of the lung.

These cicatrizations, especially when complete and composed
of a substance analogous to other natural tissues, produce no
symptoms whatever that can denote their existence. I have only
remarked in some cases, when there was reason to believe their
existence, that the respiration Was less distinctly audible in the
supposed diseased point. In such instances, also, where there is
much of the black pulmonary matter intermixed, and still more
where there are calcareous concretions, there generally exists a
small degree of cough, and an expectoration of mucus which is
very viscid, semitransparent and marked by dark dots.

The two following cases afford remarkable instances of these
pulmonary cicatrices.

Case 6 A man, aged 65 years, came into hospital affected
with slight pulmonary symptoms, chiefly marked by dyspnoea, to
which he had been long subject, and which he considered as asth-
ma. At first he coughed but little, and had scarcely any expecto-
ration. After remaining in the hospital two months, with no very
marked pectoral symptoms, he was seized with peritonitis, &c. and
died. Besides some fluid in the cavity of the pleura — very gene-
ral cellular adhesions between it and the lungs — -and the produc-
tion of some albuminous membranous concretions, the following
evident cicatrization was found in the left superior lobe. In a
point where this adhered to the pleura by a cellular tissue, there
was an irregular depression, in the centre of which lay a small
ossification. From this point could be traced into the substance
of the lung a band of very white cellular tissue, very dense, yet
scarcely amounting to the consistence of a membrane. This band
was about an inch long, six lines broad, and three or four thick.
Its white colour formed a striking contrast with the natural pul-
monary tissue. Some bronchial tubes of the size of a crow-quill,
or larger, terminated, and became lost in this band. An acciden-
tal cir. umstance prevented me from examining this substance more
minutely

Case 7. A labourer, aged 62, had been affected five years with
4n habitual cough, but was otherwise of a good constitution. He

PHTHISIS PULMONALIS. 49

was suddenly attacked with peripneumony, which carried him off
on (he fifth day, he having been admitted into the hospital only
the day before. On examination after death, the lungs, exclusive-
ly of the peculiar characters denoting recent pulmonic inflamma-
tion (which will be particularly noticed in another place), and of
some old adhesions, presented the following appearance. On the
top of the right lung there was a fibrocartilaginous mass, three
lines in thickness in the centre, which connected it with the pleu-
ra of the ribs. In the same lobe, included in the pulmonary
tissue and strongly adhering to it by continuity of substance, there
was found a fibro-oartilaginous mass of a similar kind, of the
size of a walnut, and of an irregular conic shape. This mass
was of a brilliant white colour and opaque, and formed a striking
contrast with the surrounding pulmonary tissue, which contained
an unusual quantity of black pulmonary matter. The part of the
pulmonary substance interposed between it and the superficial
mass about two lines in thickness', was quite black, and was quite
destitute of air, although its texture was very perceptible. This
fibrocartilaginous mass, when cut into, presented all the charac-
ters of a pulmonary cicatrice. Several bronchial tubes terminated
and were obliterated in its substance. Two, especially, which
terminated in it in forming a cul de sac, were of the size of a
goose-quill. One of these, after forming the cul de sac of a dia-
meter of two lines, became all at once contracted to a size scarce-
ly equal to that of a crow-quill, on entering the tumour, into
which it could be traced half an inch. In this tract, however,
its cavity was entirely obliterated, and it resembled in colour and
texture the tumour, from which it was only distinguished by the
direction of its fibres, or by a slight shade of colour which pointed
out both its coats and its obliterated canal. (See plate U. fig. 1.)

In the superior lobe of the left lung there was a small cavity
capable of containing a filbert, lined by a fine semitransparent
membrane, of a demi-cartilaginous consistence, and through
which the black pulmonary matter could be distinguished. This
excavation contained a small quantity of tuberculous matter,
friable, and of the consistence of soft cheese. The pulmonary
tissue amid which it was placed was perfectly sound and crepitous.
Near the origin of the bronchia was observed a single tubercle of
the size of a barley-corn, softened to the consistence of soft cheese,
and surrounded by a dense membrane, greyish or semitransparent,
of the nature of semi-cartilaginous bodies, or imperfect cartilages.

The foregoing observations prove, I think, that tubercles in the
lungs are not in every case a necessary and inevitable cause of

7

50 DISEASES OF THE LUNGS,

death; and that a cure may take place in two different ways, after
the ormation of an ulcerous excavation:— first, by the cavity
becoming invested by a new membrane; and secondly, by the
obliteration of the excavation by means of a cicatrix, more or less
complete, consisting of cellular, fibrous, or cartilaginous substance.

The identity of the excavations observed in the 1st, 2nd, 3rd,
5th, and 6th cases, leaves no question that they had one and the
same origin, namely, in the maturation and discharge of the tuber-
culous matter originally contained in them. The first case may
be considered as affording an example of a perfect cure, since no
more tubercles existed in the lungs. *The same may be said of
the 7th, — inasmuch as there was only one very small tubercle in
the lungs. The subjects of the 2nd, 3rd, and 5th cases would, no
doubt, have had relapses of their disease, since their lungs all
contained tubercles more or less advanced, and which, necessarily,
must have been eventually developed. This development, how-
ever, might have been remote; since it has been truly shown by
M. Bayle, that immature, and still more, miliary tubercles con-
tinue to exist for a great many years without materially affecting
the general health

Were it in our power to ascertain the previous history of such
cases as exhibit these cartilaginous excavations and cicatrizations
in the lungs after death, we should, in all probability, find that
the paiients had been subject to a long continued cough, and
severe catarrh, or even to a disease considered at the time as
true consumption, and which had been very unexpectedly cured.
These morbid appearances, at least, sufficiently explain the fact
of the seemingly intermittent character of certain cases of con-
sumption, and the extraordinary cure of others.*

These pulmonary fistula; and cicatrices are very common, as
any one will be convinced who practises morbid dissections in an
hospital for any length of time. I have only mentioned a few of
those that I have met with lately; and, indeed, it is only lately
that I have paid any minute attention to such appearances. I
had, however, frequently met with them long before, and have,
indeed, partly described them in another place. f They are very
various in their appearance; still it would seem that it is espe-
cially by the production of this extraneous cartilaginous tissue
that nature attempts a cure of tuberculous excavations. With

* l am aware that Phthisis may be closely simulated by a common catarrh
I shall notice a case of this kind hereafter, and M. Bayle details two in his
work, viz. cases 48 and 49

t lrict, des Science. Med. Art. Cart. Occident.

PHTHISIS PULMONALIS. Q\

ihis end she seems occasionally to throw out a superabundance
of it; as the exterior portion of the lung is sometimes coated
with it, as in one of the cases already deailed. On other occa-
sions the cartilaginous walls of the cavity are observed of very
unequal thickness,— -as thick in some places as half an inch or
an inch, — as if the remedial powers of nature were undetermined
whether to form a perfect cicatrix or only a fistula. (See plate
HI. fig. 2.) . P

The merely temporary cure of many phthisical cases is readily
explained, as above remarked, by the cicatrization of a softened
tubercle, and by the eventual softening of others which were
only in their first stage at the period of the cicatrization of the
first. For example, we can easily fancy that the subject of case
5th, detailed above, had he not been carried off hv another dis-
ease, might, after the perfect cicatrization of the cavity in the
right lung, have enjoyed tolerable health for several years until
the ultimate maturation of the miliary tubercles. The following
is a brief note of a case of this sort: —

Case 8. In 1814 M. Recamier and* myself were consulted
by a young lady who had every symptom of pulmonary consump-
tion, such as frequent cough, purulent expectoration, much ema-
ciation, hectic fever and night sweats. Several of the lymphatic
glands of the neck were swollen, and for a few days she bad
been affected with very severe diarrhoea. Astringents, sulpbur-
baths, and ass's milk were prescribed. In the course of two
months her strength, flesh, and colour were quite restored, the
cervical glands were diminished by one half, and, in short, she
was in a state of perfect health. She passed the winter very
well, but in April the cough and all the other phthisical symptoms
returned, and she died in the end of summer.

Such examples of perfect, though only temporary cures of
consumption are rare; but it is by no means unusual to find persons
affected with all the symptoms of this disease surviving for many
years, alternately experiencing imperfect convalescences and re-
lapses more or less severe. It is such cases M. Bayle had
in view when he said consumption may continue forty years.
These imperfect cures may, I think, be attributed to the succes-
sive softening of several tubercles, and their subsequent conver-
sion into fistula?; whilst the more perfect, though still temporary
cures, may depend on the formation of a cicatrix. The results
of these two kinds of cure, as far as I am able to judge from the
cases I have met with, seem to me to be the following : — the
cure by fistulas usually leaves behind it a chronic catarrh, more

52 DISEASES OF THE LUNGS.

or less severe, and accompanied by an expectoration which is
sometimes very copious; cicatrization, on the contrary, produces
no other invonvenience than a dry cough, neither frequent nor se-
vere. Sometimes, indeed, there is no cough, especially where
the texture of such cicatrices clearly resembles that of other
natural tissues in the animal economy, especially the cellular or
fibro-cartilaginous. When, however, the substance of the
cicatrice is less perfect, and more remote from the healthy tissues
of the body, and when it is impregnated with much of the black
pulmonary matter, we find an habitual cough, either dry or ac-
companied by a mucous expectoration, and cachectic condition
of the body.

When we consider that (he formation of tubercles in the lungs
seems to be the consequence of a general diathesis; that thesa
are frequently found contemporaneously in the intestines, where
they ultimately occasion ulceration and colliquative diarrhoea ;
and that, in some cases, also, they exist in the lymphatic glands,
the prostate, the testicles, the. muscles, bones, &c; we must be
Jed to believe the most perfect cure that can take place in con-
sumption as merely temporary. Admitting, however, the justness
of this conclusion in those extreme cases of tubercular diathesis
(which, after all, are but rare when compared with the vast
number of consumptions), we are still entitled to hope for the
cure of many cases of phthisis, or at least, for such a suspension
of their symptoms as may be deemed almost equal to a cure,
since the individuals may enjoy such a state of health, as may
enable them to fulfil all the duties of civil life, for several years,
or until such time as a fresh development of tubercles, at present
immature, produces a fresh and final seizure.

It is further worthy of remark, that, although in the majority
of the subjects in which J have observed these fistulas and cica-
trices, the lungs contained tubercles in different stages of their
progress, and, consequently, a certain though perhaps remote
cause of a return of the disease, still I have found the same
marks of a cure in subjects in whom there were no tubercles
whatever, neither in the lungs nor in any other organ. In such
instances it may be supposed, perhaps, that the excavations had
been the product of simple inflammation of the pulmonary tissue,
and not of tubercular degeneration. Such a supposition is, how-
ever, quite gratuitous Those accustomed to much morbid dis-
section have almost daily experience of the formation of these
membranes on the surface of tuberculous excavations ; while
the formation of pus, or true abscess of the substance of the

PHTHISIS PULMONALIS. 53

Sungs, is so extremely rare (as we shall see more particularly
when treating of peripneumony) as to be justly esteemed one of
the most extraordinary appearances in morbid anatomy, and,
therefore, quite inadequate to account for an occurrence so com-
mon as that of fistulas and cicatrizations of the lungs.

These considerations ought to induce us still to entertain some
hope in those cases of consumption wherein we have reason to
believe the greater portion of the lungs remains still permeable to
the air. Although we are, therefore, certain that a subject that is
pectoriloquous has an exulcerated cavity in the lungs, we are not,
on this account, equally certain that this will prove fatal.

We may even be justified in believing that a case, wherein all
the ordinary symptoms of consumption exist together with pectori-
loquism, is more favourable than one in which they exist without
this peculiar phenomenon; since, in the first case, we may attri-
bute the symptoms to the efforts of nature in maturing and evacu-
ating the tuberculous matter, and may hope for their cessation
when this is effected, provided the greater portion of the lungs is in
other respects healthy, (as we can ascertain by the stethoscope);*
while, in the second case, we must imagine that the tubercles are
very numerous, since they produce such violent general effects
previous to the period of their softening, and that therefore they
will, in all probability, occasion death before the epoch of possi-
ble cure arrives.

The two following cases, as well as the others already related,
prove the curability of Phthisis.

Case 9. An English gentleman, aged 36, detained in Paris as
prisoner of war, in September 1813 had an attack of haemoptysis,
followed by a cough, at first dry, but, in the course of a few
weeks, accompanied by purulent sputa. To these symptoms were
added a well-marked hectic, considerable dyspnoea, night sweats,
emaciation and great debility. The haemoptysis returned, in a
slight degree, now and then, and in December he had diarrhoea.
In the beginning of January he was so much reduced that both
M Halle and Bayle agreed with me in opinion that his death
might be daily looked for. On the 5th of January, during a se-
vere fit of coughing, and after bringing up some blood, he expec-
torated a solid mass, of the size of a filbert, which, on examina-
tion, I found to be evidently a tubercle in the second stage, sur-
rounded by a portion of the pulmonary tissue, such as has been
already described as impregnated with grey tubercular matter in

* The instrument for ascertaining the existence of pectoriloquism. See
Part II. Trans.

54 DISEASES OF THE LUNGS.

the first stage, often met with around these bodies when large.
Th,s p ' n« remained in the same degree of extreme emaciation
and debility all January; but in the beginning of February the
nersnirations and diarrhoea ceased spontaneously, the expectoration
Lsibly diminished, and the pulse, which had been constantly as
high as 120, fell to 90. In a few days the appetite returned, the
patient began to move about in his room, his emaciation became
less, and, against the end of the month, his convalescence was
evident. In the beginning of April he was perfectly recovered;
and his health has continued good ever since, without even the
least cough, and without his being at all particularly guarded m
his climate or regimen. In 1818 this patient again consulted me
for a different complaint, and I took the opportunity of examining
his chesf by means of the stethoscope. The only thing 1 could
delect was the comparative indistinctness of respiration in the
superior portion of the right lung. There was no pector.loqu.sm.
From these circumstances I am of opinion that the excavation
which contained the expectorated tubercle must have been cica-
trized ; and as the total absence of cough, dyspnoea and expectora-
tion for four vears, forbids the supposition of the existence ot
others in the lungs, I think we have a right to consider this pa-
tient as perfectlv cured.

I think there" can be no doubt that bad this patient been ex-
amined by the stethoscope after the expectoration of the tubercle,
he would have been found pectoriloquous, and the subsequent ces-
sation of this phenomenon would have indicated the formation of
a cicatrice. And I am convinced that when the use of this in-
strument shall have become more general, the development and
subsequent cessation of (J ectoriloquism will be often detected, not
only in cases of decided phthisis, but also in many cases of obsti-
nate cough, which are usually rather dreaded as a cause of the
future development of tubercles, than as a sign of their actual
presence, and which are found to get well after a longer or shorter
continuance.

Case 10. This case is detailed in M. Bayle's treatise (see case
54), and is that of a gentleman who, after having experienced all
the symptoms of consumption in the greatest degree, perfectly re-
covered by change of air and living by the sea-side. As both M.
Bayle and myself (for this was my patient) then conceived the
cure of phthisis impossible, we considered the case as one of
chronic catarrh, and it is so entitled in M. Bayle's book. Since
then I have had an opportunity of satisfying myself, by means of
the cylinder, that our patient had had more than a mere catarrh.

PHTHISIS PULMONALIS. 55

His respiration is quite perfect throughout the whole chest, except
at the top of the right lung, in which point it is totally wanting.
On this account I am certain that this portion of lung had been
the seat of an ulcerous excavation, and that this had been replac-
ed by a complete and solid cicatrice. The health of this gentleman
continues good, although he has often occasion to speak in public.
He has sometimes a little dry cough, on the change of weather,
but takes cold very seldom.

SECTION THIRD.

Of Vomicoiy and the Expectoration of Tuberculous Matter.

The morbid condition usually denominated Vomica, is one bet-
ter known in theory than it is common in practice: its phenomena
are readily explained by the cicatrization of the tuberculated cavi-
ties, or the formation of fistulas as above described. By the term
vomica, we commonly understand a sudden and abundant expec-
toration of purulent matter, supervening upon a disease which had
all the usual symptoms of an incipient consumption. In these
cases we sometimes find, after an expectoration so copious as
would almost, in the course of twenty-four hours, fill one of the
cavities of the chest, the cough gradually lessen after a few days,
the sputa decrease in like proportion, and the patient gradually re-
cover a complete and durable state of health. More commonly,
however, the amendment is merely temporary, and the return of
all the bad symptoms puts an end to the patient's life.

Cases like these had attracted the attention of medical men in
the very infancy of the art. Hippocrates treats of them at great
length in different parts of his writings. He considered vomicae
as true abscesses of the lungs, and, in consequence, designated
those affected with them, empyical or suppurated; a term which
he extended to this particular affection, in whatever organ it might
be seated,, but which has been confined, by modern surgeons, to
purulent collections in the cavity of the pleura. He seems to
have considered such a disease as different from phthisis. He
imagined that the abscess might be evacuated either by the bron-
chia or into the cavity of the pleura. The former termination ap-
peared to him fortunate, and he sometimes attempted to produce it

56 DISEASES OF THE LUNGS.

by the succussion of the patient's body: the second termination
he considered as the usual cause of empyema.

These notions, very incorrect in many respects, are still held
by many medical men unacquainted with morbid anatomy. They
are especially false in respect of the origin of the pus, since, as I
have already observed, and as 1 shall more fully prove hereafter,
the formation of an abscess or of a collection of pus in the Sub-
stance of the lungs, as a consequence of inflammation, is an ex-
tremely rare case; — at least a hundred times less frequent than a
well marked vomica, and a thousand times rarer than a case of
empyema.

I consider vomica?, such as are met with in practice and as 1 have
described, as produced by thesoftening or solution of a tuberculous
mass of great extent. The copious expectoration, however, which
usually continues for several days alter their rupture, cannot be
considered as entirely supplied by the tuberculous contents of the
excavation. A patient, who had been affected for several months
"with a dry cough, dyspnoea, hectic fever, and other symptoms in-
dicative of the existence of immature tubercles, during a violent
fit of coughing suddenly expectorated a glass full of pus. For eight
days he spit up, during every twenty-four hours, about three pounds
of a similar fluid. After this the expectoration diminished gradu-
ally, and finally ceased along with the other symptoms, and the
patient was disclwrged, at the end of a month, perfectly cured.
An expectoration so copious as this can only be explained by a con-
tinuous secretion; and in the particular case just mentioned the
matter was, doubtless, furnished bj; the walls of a very extensive
tuberculous excavation, and probably, also, by the bronchia, irri-
tated by the tuberculous matter. It is also probable, that, in this
instance, the termination of the expectoration was owing to the
cicatrization of the cavity.

The case of a vomica, as usually characterized in practice, and
which is justly considered as of rare occurrence, differs merely in
degree of intensity from a condition which is very common, and
which may be frequently observed by any one who takes the trou-
ble to observe and compare the sputa of a number of phthisical
patients at one time, as can be done in the wards of an hospital.

The truth is, that phthisis, considered relatively to the expecto-
ration, presents two very distinct stages during its progress. In the
first, the cough is dry, hard, and fatiguing; or, if there be expec-
toration, the sputa are entirely supplied by the saliva, and mucus
from the [bronchia] mouth and throat. The reunion of these
may form a copious expectoration, which will be transparent.

PHTHISIS PULMONALIS. 57

colourless, liquid, ropy, and somewhat frothy at top. To this
there will be occasionally superadjed a little of that grey, viscid,
semitransparent matter, often mixed with black specks, to which
we commonly give the name of bronchial mucus. When this
takes place the expectoration is very scanty; otherwise, it is often
abundant. Both these kinds of expectoration indicate the exist-
ence of immature tubercles.

In some cases, however, the expectoration is extremely copious
and ropy, but always nearly colourless and semitransparent. This
condition of the expectoration indicates, as has been truly remark-
ed by M. Bayle, the existence of a great number of immature
miliary tubercles; but not exclusively, as he imagined, that variety
which he denominated granular.

In the second stage the sputa put on quite a different character.
They then become opaque, of a pale yellow, and sometimes slightly
greenish, with more or less of tenacity. Sometimes they per-
fectly resemble those of a simple catarrh, and, on the other hand,
they are occasionally loose and puriform. In some cases we can
discover fragments of tuberculous matter imperfectly dissolved.
This last character may, perhaps, be deemed quite pathognomonic.
It is not, however, so; as portions of a sebaceous, concrete, and
friable matter, entirely resembling these, are occasionally formed
in the tonsils, and expectorated by many persons in a state of
health.*

The transition from the one stage to the other is sometimes
sudden and complete, that is to say, the transparent mucoid sputa
cease at the instant the yellow and puriform begin to make their
appearance. The accession of these last is sometimes accom-
panied by a slight hemorrhage, and a temporary relief almost
always follows. Instances of this kind are not at all uncommon:
they offer examples of vomica? in miniature.

Very often the transition from the first to the second stage is
not so distinct as this. The transparent mucous expectoration
will frequently continue along with the opaque and puriform
sputa; and in this case, if we merely looked to the nature of
the discharge, we should be at a loss to decide whether the new
sputa originated in the softening of the tubercles, or were produc-
ed by the supervention of a pulmonary catarrh upon the old
cough of the patient.

* There are, however, two characters by which these substances may be
distinguished : the cheesy matter has usually a peculiar foetor, and when
heated on paper it greases it. These characters are wanting in the tuber
culous matter.

8

58 DISEASES OF THE LUNGS.

These two different conditions of the expectorated fluid are in
perfect accordance with the organic affeclion which constitutes
phthisis, since they indicate — first, the crude state of the tuber-
cles; and, secondly, the evacuation of these, by the bronchia,
when mature. The first species of sputa is merely the mucus
of the bronchia, secreted in greater quantity than usual, on ac-
count of the irritation excited by the tubercles contained in the
pulmonary tissue; the second species, on the contrary, consists
partly (especially in the beginning) of the softened matter of the
tubercles, and partly of a purulent or puriform fluid secreted by
the lining membrane of the tubercular excavations, and by that
of the bronchial tubes themselves. The truth of the latter part
of this statement is proved by the fact that most consumptive pa-
tients daily expectorate a greater quantity of sputa, both in weight
and volume, than the substance of all the tubercles in their lungs
would supply.

The general symptoms of the disease are by no means so exactly
coincident, either with the nature of the expectorated matter, or
with the extent of disorganization in the lungs. Hectic fever
and emaciation sometimes exist in a great degree before the ap-
pearance of the puriform sputa, and sometimes even death takes
place in this early stage* On the other hand, a state of com-
parative robustness and tolerable health shall continue long after
the occurrence of the opaque expectoration, and the discovery
of pectoriloquism. Indeed, I am led to believe from many facts,
that, in the majority of cases of consumption which terminate
favourably by the formation of fistulae or cicatrices, the patients
have undergone the different processes of the development, solu-
tion, and evacuation of the tubercles, without any suspicion of
being affected by a more serious disease than a nervous cough,
or, at most, a suspicious catarrh.

There is not one patient in ten that dies consumptive before
the complete softening of a part of the tubercles, and, conse-
quently, before the formation of one or more excavations. It is
still more uncommon for such excavations to take place without
communicating with the bronchia; nay, it sometimes happens
that these organic lesions take place long before any perceptible
change in the general health. This fact is readily explained by
a reference to the morbid anatomy of the affected organ. The
simultaneous existence, in the lungs of almost all phthisical
subjects, of tubercles in every stage, from the miliary tubercle

* See Bayle's Cases 14 and 15.

PERIPNEUMONY. 59

to the ulcerous excavation, must convince us that their develop-
ment is successive, and that some may have reached their last
stage at the very period of the formation of others. And we
can readily understand how a single tubercle may pass through
all the stages of its progress without materially affecting the
general health, while a great number of similar tubercles may
prove highly deleterious and destructive. We have an instance
perfectly analogous to this in the case of scrophulous lymphatic
glands: for example, we often observe a single cervical gland
to tumefy, and eventually to discharge the tuberculous or scro-
phulous matter (the development of which had caused the morbid
affection), without the general health being at all affected; while
the very same disease, when it extends to many similar glands,
gives rise to hectic fever, marasmus, and death.

In concluding this discussion I would observe, that the cure of
consumption, in cases where the lungs are not entirely disorganiz-
ed, seems to me to present no character of impossibility, neither
in regard to the nature of the disease, nor the nature of the or-
gan affected. In the first place, the tubercles of the lui.gs differ
in no respect from those situated in the glands, and which, under
the name of scrophula, after being softened and evacuated, are
often followed by a perfect cure. Secondly, the destruction of a
portion of the pulmonary tissue is not necessarily fatal in its na-
ture, since we know that wounds of this organ are frequently
cured, notwithstanding the aggravation of the case produced by
the perforation of the thorax and admission of air into the cavity
of the pleura.

CHAP. II.

OF PERIPNEUMONY, OR INFLAMMATION OF THE

LUNGS.

Peripneumonv, or Pneumonia, is inflammation of the sub-
stance of the lungs. Considered in an anatomical point of view,
this disease presents three different varieties, or degrees, very
distinctly marked.

In the first, the lung is of a livid or violet colour externally, is
much firmer internally, and heavier than in its healthy state. It

60 DISEASES OF THE LUNGS,

is still crepitous, but much less so than a sound lung, and, on
pressing it between the fingers, we perceive that it is injected by
a liquid. When cut into, it appears of a livid red, is quite in-
jected by a frothy serous fluid, more or less sanguinolent, which
flows from it abundantly. We can still, however, discover very
clearly the natural alveolar and spongy texture of the viscus.
This is the condition of lung entitled by M. Bayle, obstruction,
(engoument).

In the second variety, the lung has entirely lost its crepitous
feel under the finger, and has acquired a consistence and weight
altogether resembling those of liver. From this circumstance,
modern anatomists have named this condition of the organ He-
patization or Carnification. The former of these terms is suf-
ficiently correct; the last is very improper, and would be more
applicable to a morbid condition of the lungs to be hereafter de-
scribed.

In this, the second degree of inflammation, the lungs are fre-
quently less livid externally than in the first variety; but they ex-
hibit in their interior a red colour more or less deep, which forms
a striking contrast with the spots of black pulmonary matter, the
bronchial tubes, the blood-vessels and air-cells, all visible on the
cut surface. The air-cells, especially, which are so indistinct in
the natural condition, become very obvious. Their membranous
walls seem frequently exempted from the general inflammation,
and their whiteness thus renders them very visible.

If we cut into slices a lung so affected, there is scarcely any fluid
whatever flows from the incised surfaces; but if we scrape these
with the scalpel, we can force out a small portion of bloody serum,
which is thicker and less clear than that above described, and in
which we can often distinguish a matter still thicker, opaque,
whitish and puriform. In examining the incised surfaces in a
proper light, we find the lung to have entirely lost the cellular
structure, and to have acquired a sort of granulated appearance,
as if composed of little red grains, of a roundish and somewhat
flattened shape. This species of granulation appears to me to be
the proper anatomical characteristic of inflammation of the pulmo-
nary tissue, by which it can be best distinguished from the tuber-
cular, and from the various other kinds of induration to which it
is liable.

When a lung is entirely hepatized it seems, at first sight, to be
larger than natural, but this seeming enlargement is merely caused
by its not being able to collapse, and its thus continuing to fill the
cavity of the pleura. I have often measured the dimensions of

PERIPNEUMONY. 6 J

this cavity, in cases of pneumonia, both in the dead and living sub-
ject, and have never found the slightest degree of enlargement in
the side affected; a circumstance, as we shall more particularly see
hereafter, which establishes a great difference between this com-
plaint and pleurisy.

It even appears that the lungs when inflamed are totally without
any power of impressing, with any force, the surrounding parts, as
I have seen, on the surface of a completely hepatized lung, an
indentation, of a line in depth, produced by a patch of coagulable
lymph, extravasated on the corresponding point of the pleura cos-
talis, and not of firmer consistence than the white of egg boiled.
In the third variety or degree of inflammation, the pulmonary
tissue has the same consistence and granular texture as we have
just described, but it is of a yellowish pale or straw colour, and
discharges, from the cut surfaces, in considerable quantity, an
opaque, yellowish, viscid matter, which is evidently purulent, but
with a heavy smell which is not nearly so disagreeable as that of
pus in an open wound. This is, properly speaking, suppuration
of the substance of the lungs; for, as we have already shown,
what are usually considered as such, viz. vomica, are merely
softenings of the matter of tubercles.

In several hundreds of cases of peripneumony, wherein I have
examined the lungs after death, I have met with collections of pus
in the inflamed organ not more than five or six times. These ab-
scesses were very few in number, and inconsiderable in extent.
They were found in cases of the third variety, above described,
and were dispersed here and there throughout the lung. Their
walls consisted of the pulmonary tissue, injected with pus, and in
a sort of putrid condition, which gradually disappeared in reced-
ing from the abscess. Once only have I met with an abscess of
considerable extent. In this case, the patient died on the twen-
tieth day of his disease The abscess was seated in the anterior
and middle portion of the lung; it was long and flat, and would
have contained three fingers. Correctly speaking, it could hardly
be said to have any direct boundaries. In proceeding from the
centre of the collection the pus became gradually converted into a
sort of purulent detritus; a little further on, the pulmonary tissue
was more firm, but profoundly gorged with pus: at the distance of
half an inch the substance of the lung exhibited merely the com-
mon characters ( f the third variety or degree of inflammation. In
this case, as in every other instance of purulent collections in the
lungs, the peripneumonic affection occupied only one portion of a
/ingle lung. This circumstance may assist us in accounting ftfi

G2 DISEASES OF THE LUNGS.

the infrequency of such appearances; since we can believe that a
partial peripneumony is usually removed by nature or art, while one
involving the greater part of the viscus, will prove fatal before it
has reached the stage of the entire destruction of any portion of
the lung by abscess.

From this description we perceive the marked difference between
such purulent depositions and the cavities formed by the softening
of the matter of tubercles. This last, although sometimes resem-
bling pus in colour, commonly differs from it by containing tubercu-
lous fragments of a friable consistence. Besides, the compactness,
the exact circumscription of the tuberculous cavities, the soft
false membrane which uniformly invests these, and the semi-carti-
laginous one which occasionally succeeds it; — all suffice to denote
a morbid state of parts very different from that noticed above.

The three varieties of inflammation above described, are very
commonly conjoined in different ways. Very commonly one lung
is inflamed throughout in the third degree, while the other exhibits
only some spots in the first or second degree. Sometimes the three
varieties exist in the same lung, dividing it into different zones a
which are either very strikingly contrasted, or shaded into one
another by insensible gradations.

The transition from one degree to another is marked by the de-
velopment of some spots of greater inflammation. Thus, the
transition from the first to the second is characterised by a red-co-
loured tissue, containing much frothy and bloody serosity, and still
somewhat crepitous on pressure, in the midst of which we observe
some portions of a redder colour, much firmer, not crepitous, con-
taining much less serosity, and presenting. granulated surfaces on
incision.

The transition from the second to the third degree is marked by
yellowish, irregular, uncircumscribed spots, which pass insensibly
into the red colour of the second degree of inflammation. This
character of coulouring, added to the grey or black striae arising
from the intermixture of the black pulmonary matter, exactly resem-
bles some species of granite, consisting of red and yellow felspar,
grey quartz, and black mica.

The lower parts of the lungs are those most commonly affected
in peripneumony; and when the disease extends to the whole of
them, it is in this part that it almost always commences.

When all the varieties of peripnemony exist in the same lung,
the greatest degree generally is observed in thesame inferior portion.
It is extremely rare to find the inflammation confined to the supe-
rior lobe: and it in nearly equallv so to find it seated in the centra

TERIPNEUMONY. (];i

of the lungs, while the surface throughout retains its crepitious cha-
racter.

We never find the whole of both lungs inflamed in the third,
or even in the second degree; but it is not uncommon to find one
whole lung, and half the other, entirely impermeable to the air.

In other- cases, on the contrary, death takes place before the
fourth part of the lungs is affected by the inflammation; a fact
(among many others) which proves that death is often produced by
the exhaustion of the vital principle, rather than by the intensity
or extent of the local lesion.

Peripneumony, even when it has reached the third stage, or that
of purulent deposition, may still admit of cure without disorganiza-
tion of the pulmonary tissue. In such cases, if the patient happens
to die during convalescence, we find the hepatization gone, and
only the hardness of the first stage of the disease remaining. The
lungs are slighly crepitous, do not always sink in water, and still
contain a portion of purulent fluid. The incised surfaces present
a dirty yellow or pale green colour, very different from that of the
healthy lung. In a still farther advanced period of restoration the
same colour remains; the lung still continues more humid than
natural, but contains no perceptible portion of pus.

Chronic peripneumony, when uncombined with tubercles or
other morbid growth, presents entirely the same anatomical charac-
ters as the acute; and it would be therefore extremely difficult, even
for those most accustomed to morbid dissections, to form any
probable opinion of the duration of the disease from the appear-
ances after death.

The only symptom of peripneumony, that can with any propriety-
be treated of in this place, is the nature of the expectoration. And
of all the symptoms of the disease, this is the only one that can be
at all regarded as pathognomonic, since it is the only one that is
found exclusively in it. The sputa are white, slightly yellowish,
or gieenish, somewhat diaphanous, and intermixed with bubbles
of air which are retained by its extreme tenacity. This tenacity
is so great that we may often reverse the vessel containing the
sputa, and even retain it in this position for a long Jkne, without
being able to detach them from its sides.

$4 DISEASES OK THE LUNGS,

CHAP. HI

OF GANGRENE OF THE LUNGS.

Gangrene of the lungs is extremely rare. It can hardly be
considered as one of the terminations of the inflammation of that
viscus, and still less can it be regarded as a consequence of the
intensity of the inflammation. In truth, in such cases the inflam-
matory character is very little conspicuous, either in the symptoms,
or in the morbid condition of the injured organ. I would, therefore,
say that this disease is allied to those which are essentially or
idiopathically gangrenous; such, for instance, as the different va-
rieties of anthrax; and that the inflammation existing around the
gangrened part, is rather the effect, than the cause of the mortifica-
tion.

There are two varieties of this disease, which are both conspicu-
ously marked, as well by their general symptoms, as by their
anatomical character; — the uncircumscribed and the circumscribed
gangrene of the lungs. The first is one of the rarest of organic
diseases. I have only met with two cases in eighteen years; and
I am not aware of more than five cases having been seen in all the
hospitals of Paris during the same period. This variety has the
following characters: — the pulmonary tissue is more humid, and
much more easily torn than natural, and has the same degree of
density as in the first variety of peripneumony; its colour varies
from a dirty white or slight greenish, to a deep green or almost
perfect black, intermixed, sometimes, with a brown or earthy
yellow colour. These different tints are mixed irregularly in dif-
ferent parts of the lungs, and are, further, interspersed with portions
of a livid red, altogether resembling the state of parts in the first
degree of peripneumony. Some points here and ihere are com-
pletely softened down to a sort of liquid and putrid mass. A dirty
sanies, or greenish liquid, of an insufferably putrid odour, flows
from the affected parts when cut into. This affection occupies, at
least, the greater part of one of the lobes; sometimes it txtends to
nearly the whole lung; in no case is it at all circumscribed. In
some places, the sound parts of the lung, or, at least, those scarcely
altered from the healthy state, pass ins nsibly into tht gangrened
portions; in other places, the sound and mortified portions arf

GANGRENE. 65

separated by a band inflamed in the first degree, and, more rarely,
by one arrived at the state of hepatization.

The progress of this disease, even when of small extent, is ex-
tremely rapid. From the very first the patient falls into a state of
complete prostration of strength and oppression; the pulse is small,
weak, and very quick; cough rather frequent than strong; expec-
toration loose, the sputa of a very remarkable green colour, and
extremely fetid like that of a mortified limb. The expectoration,
very copious at first, soon ceases through debility, and the patient
dies suffocated by the accumulation of the sputa.

The partial or circumscribed gangrene of the lungs differs from
the preceding species in occupying only a small part of the viscus,
and in having no apparent tendency to extend itself to the surround-
ing parts. On this account its progress is often very slow ; so much
so, indeed, as sometimes to give it some resemblance to consump-
tion: and, in truth, it has been ranged by M. Bayle as a species of
this disease.

Partial or circumscribed gangrene of the lungs may have its seat
in any part of the organ. It ought to be distinguished in three
different states: 1st, recent mortification, or gangrenous escharj
2nd, deliquescent sphacelus; and 3rd, grangrenous excavation,
formed by the complete softening down, and discharge, of the gan-
grened portion.

The gangrenous eschars are very irregular in form, and very
variable in size. Their colour is greenish black ; their texture
more humid, more compact, and harder than that of the healthy
lung; they are, in short, completely similar to the sloughs produced
by caustic, and exhale strongly the peculiar fetor of mortification.
The part of the lung immediately surrounding them exhibits, to a
little distance, the first or second degree of inflammation. Some-
times the eschar, during its disorganization, becomes detached, like
the slough from caustic, and forms a sort of button or core, of a
darkish, gfeenish, Of yellowish tint, somewhat filamentous in its
texiure, and softer and drier than the recent eschar. It remains
isolated in the centre of the excavation formed by the mortified
portion.

More commonly the eschar becomes softened throughout, with-
out forming any distinct core, and is converted into a sort of putrid
jelly, of a dirty greenish grey, sometimes sanious, and horribly fetid.
This matter soon escapes into some of the neighbouring bronchia,
and is thus gradually discharged, leaving behind it a true ulcerous
cavity.

The interior of these cavities then becomes the seat of a secon*

9

tftj DISEASES OF THE LUNGS

dary inflammation, which seems to retain for a long tune somewhat
of (tie gangrenous character: the surface becomes covered by an
exiran >ous membrane, of a greyish colour, opaque and soft, which
seen tes either a dirty pus of the same colour, or a black sanies,
h m mg he grangrenous fetor.

Fr< quemly, however, this new or false membrane does not exist.,
tht (e id and various-coloured pus or sanies being secreted imme-
diately by the walls of the ulcerous cavity. These walls are com-
monly firm, of a brownish or greyish red, exhibiting, when cut into T
ft granulated surface. This state of parts (which is evidently a
species of chronic peripneumony, not tending to suppuration,) does
not commonly extend more than half an inch, or an inch from the
uher; occasionally, however, it occupies the whole extent of the
lobe in which it is seated. On other occasions the boundaries oi
the excavation are soft and fungous, and easily desroyed by scrap-
ing with the scalpel. Blood-vessels of a considerable size, quite
isolated and denuded, yet still sound, sometimes cross these cavi-
ties; at other limes these vessels are quite destroyed, and pour from
their open mouths a sufficient hemorrhage to fill the whole cavity
with clots of blood.

These gangrenous excavations constitute the ulcerous phthisis
of M. Bayle. Although he does not distinctly state their origin,
he appears to have suspected it. (See his cases 25 — 30.)

Sometimes the esrhar makes its way into the cavity of the pleu-
ra, and gives rise to a species of pleurisy usually accompanied by
the extrication of air in that cavity. This seems in some cases to
arise from the process of putridity alone, but, in others, it is evi
dentlv assisted by the access of the external air through the bron-
chia.

The symptoms of the partial gangrene of the lungs are ex-
tremely various, and differ much in different stages of the disease.
In the commencement it is marked by the symptoms of a slight
degree of peripneumony, but attended with a prostration of
strength and degree of anxiety quite disproportioned to the small
extent and moderate intensity of the local affection. Later in the
disease there are sputa of a green or greenish colour, and of a
gangrenous fetor, and followed by expectoration of a purulent fluid
of a grey or greenish yellow colour. In both these stages the pa
tient often experiences very severe pain in the chest, and sometimes
very copious hemorrhages from the lungs. The countenance assumes
a sallow or rather leaden hue. When the disease reaches the chronic
stage, there is constantly present a degree of hectic fever, sometimes
high, but commonly less intense than in most consumptive cases:

GANGRENE. 67

the skin is hot, sometimes extremely so; the sputa and breath retain
something of the gangrenous odour, being excessively fetid, and
perceptible at a great distance. In this state the patient often
wastes with great rapidity, and his case may then be easily mista-
ken for true phthisis. More commonly, however, death takes place
before emaciation has made great progress, this complaint seeming
to have a greater tendency to produce cachexy than marasmus

I shall here subjoin the heads of four cases of this disease, — the
1st, showing the eschar still entire ; the 2nd, in the state of a I > ilf-
detached core ; the 3rd, in the state of deliquescence; and the 4th,
exhibiting the rupture of the matter into the pleura and bronchia at
the same time.

Case 11. A man, aged 40, was seized, after a fit of intoxica-
tion, with pain in his joints, with fever and very violent delirium,
which symptoms proved fatal on the 13ih day, without any other
sign of disease of the chest, but a slight difficulty of breathing, a few
days before death. There were found effusion in the ventricles of
the brain, and the following appearances in the thorax : the right
lung was adherent to the pleura anteriorly and on the diaphragm;
the right side of the chest contained about a pint and half of a sero-
purulent fluid ; the lung of the same side, reduced to nearly half
its natural size and containing little air, was of a natural character
throughout, except at its inferior and posterior margin, where there
was a dark greenish spot of the size of a large bean (feve de marais)
exhaling the gangrenous fetor ; it was soft, and very like the eschar
produced by caustic. It entered about six lines deep into the
substance of the lungs, to which it adhered. The pulmonary tissue,
to the distance of an inch around, was of the consistence of liver
and exhibited, when cut, a red and granulated surface.

Case 12. A man, aged 53, after being ill six weeks, came
into hospital, affected with dyspnoea, frequent cough, with expec-
toration of very thick, opaque, yellow sputa, possessing (as did,
also, still more so, his breath,) the fetor of gangrene. His debi-
lity had gradually augmented from the commencement of the dis-
ease ; he was sallow and flaccid, but without any considerable
emaciation. He died shortly after without any material alteration
of symptoms. The following were the appearances on dissection:
the left side of the chest contained much air, and also two or three
pints of a black turbid serosity, both of which were extremely
fetid. The lung was reduced to one-fifth of its natural size, and
contained in its upper lobe an irregular cavity, capable of hold-
ing a duck's egg, and filled with the same matter as was contained
in the cavity of the pleura. The internal surface of this excava

68 DISEASES OF THE LUN6&

lion exhibited no trace of the purulent membranous-like covering
usually seen in ulcerous cavities of the lungs, but showed the pul-
monary tissue quite bare, blackened, soft, and easily torn. The
main excavation communicated with several smaller ones, and, in
the centre of each, there was a detached putrid mass of some con-
sistence, evidently the remains of the gangrenous eschar. The
superior lobe adhered to the pleura, and its substance was some-
what denser than natural. In every other part the pulmonary tis-
sue was blackish, soft, inelastic, and without any trace either of
inflammation or tubercles. There were other diseased appear-
ances in the chest, but none that seemed essentially connected
with the particular disease in question.

Case 13. A man, aged 55, came into hospital affected with
what was supposed to be a local affection of the nares. He had
no pectoral symptom whatever, but a slight dry cough, which ap-
peared to depend on the local disease: only towards the period of
his death, the respiration became difficult, and he complained of a
sharp pain in the region of the larynx. The only diseased ap-
pearances, found on dissection, were the following: the inferior
part of the left lung was slightly inflamed throughout, and contain-
ed, in its interior, a portion of the pulmonary tissue quite reduced
to a thin putrid mass with the gangrenous fetor. This diseased
mass was perfectly continuous with the surrounding tissue of the
lung, which was merely red and engorged. The putrid mass was
about the size of a large walnut, and completely filled its contain-
ing boundaries, so as to leave no sort of excavation, until after it
was artificially discharged.

Case 14. A labourer, aged 42, subject for six years to occa-
sional pains in the chest, &c. began to have cough and very fetid
expectoration in 1818, when he came into hospital. This patient
died after remaining in the hospital for several months affected
with violent pain of the chest, cough, and frequent purulent ex-
pectoration, often in great quantities. The following appearances
were found on dissection. The left side of the thorax was less
than the right. When cut into, a great quantity of extremely
fetid gas escaped. The lung adhered in many places to the pleura,
and both these exhibited extensive recent depositions of coagulable
lymph. The lung was much compressed. The cavity left by
this compression was partly filled by a yellowish, semitransparent
fluid, having at its bottom a copious deposition of a puriform fluid,
resembling that effused on the pleura, but softer. In the inferior
border of the lung, there was found a small dark jagged opening,
of the size of a goose-quill, which was evidently contained in the

HAEMOPTYSIS. $9

centre of a gangrenous eschar. This opening led to a cavity the
size of a large walnut, about six lines deep in the lung. The
walls of this cavity were very irregular, and lined by a dirty white
membrane, covered with a puruloid fluid. Several bronchial tubes
opened into it, and the whole was imbued with the strong gangre-
nous fetor. The tissue of the lungs was flaccid, fleshy, and con-
tained little blood; its density was much greater, almost hepatic,
to the extent of half an inch around the excavation. The bron-
chial tubes in the vicinity were much dilated.

Besides the idiopathic gangrene just described, there is one
other circumscribed variety of this affection of the lungs, that,
namely, which takes place in the boundaries of a tuberculous ex-
cavation. This is an extremely rare case; — at least ten times
more rare than that we have been giving an account of. In this
case the walls of the tuberculous cavity slough to the depth of one
or two lines: this slough, when softened down, is gradually expec-
torated; but the walls of the excavation continue for a long time
thereafter to secrete a greyish sanious pus possessing the gangre
nous fetor.

CHAP. IV.

OF HAEMOPTYSIS, or PULMONARY APOPLEXY,

The disease which I designate by the name of Pulmonary Apo-
plexy, though very frequent, is yet very little known in respect of
its anatomical characters. It is, however, well known by its prin-
cipal symptom, viz haemoptysis, or hemorrhage from the lungs.

The anofents attributed haemoptysis to a rupture of some of the
pulmonary vessels, and this is still the opinion of the vulgar, and
also of many practitioners. JM >dern anatomis's, however, have
long been aware that this pretended cause* of haemoptysis is alto-
gether false. Two varieties of this disease may, indeed, arise
from such a cause; and these are, 1st, when an aneurism bursts
into the bronchia or trachea, and 2ndly, when there is a rupture
of a blood-vessel in a tuberculous excavation, — an event which I
have already shown to be extremely uncommon. These two spe-
cies of haemoptysis are followed by immediate, or almost imme*

70 - DISEASES OF THE LUNGS.

diate death, and can by no means explain the phenomena of a dis-
ease so common, and often so slight, as haemoptysis. Accord-
ingly, haemoptysis is now very generally considered as depending
on some functional derangement of the bronchial membrane, which
causes it to exhale blood in place of its ordinary mucous secretion.
And this opinion is unquestionably correct as far as regards the
slighter varieties of the disease, such, for instance, as occur in
pulmonary catarrh, peripneumony, and in the earlier stages of
phthisis.

Those cases, however, of violent and extreme hemorrhage,
which often resist all medical treatment, arise from a very differ-
ent and more dangerous cause. In these, some part, of the pul-
monary substance has undergone great changes, being indurated
to a degree equal to the completest hepatization. The induration,
however, is very different from the inflammatory affection of the
lungs distinguished by this term. It is always partial, and never
occupies a considerable portion of the lungs; its more ordinary
extent being from one to four cubic inches. It is always very
exactly circumscribed, the induration being as considerable at the
very point of termination as in the centre. The pulmonary tissue
around is quite sound and crepitous, and has no appearance what-
ever of that progressive induration found in the peripneumonic af-
fection. The substance of the lung is, indeed, often very pale
around the haemoptysical induration; sometimes, however, it is
rose-coloured, or even red, as if tinged with fresh blood; but, even
in this case, the circumscription of the indurated part is equally
distinct.

The indurated portion is of a very dark red, exactly like that
of a clot of venous blood. When cut into, the surface of the in-
cisions is granulated as in a hepatized lung; but in their other
characters, these two kinds of pulmonic induration are entirely
different. In the second degree of hepatization, along with the
red colour of the inflamed pulmonary tissue, we can perceive dis-
tinctly the dark pulmonary spots, the blood-vessels, and the fine
cellular intersections, all of which together give to this morbid
state the aspect of certain kinds of granite, as has been already
observed. The same thing is observable in the third stage of
peripneumony, and even when the infiltration of pus has convert-
ed the lungs into a yellowish mass. In the induration of haemop-
tysis, on the contrary, the diseased part appears quite homogene-
ou ieing altogether black, or of a very deep brown, and disclos-
ing nothing of the natural texture of the part, except the bronchial

HAEMOPTYSIS. 71

tubes and the larger blood-vessels. The laltcr have even lost
their natural colour, and are stained with blood.

In scraping the incised surfaces of these parts, we detach a
small portion of very dark, half-congealed blood, but in a much
less proportion than we can press out the bloody serum from a
hepatized lung. The granulations on the incised surfaces have
also appeared to me larger than in cases of hepatization. Some-
times the centre of these indurated masses is soft and filled by a
clot of pure blood.

This morbid affection is evidently produced by an effusion of
blood into the parenchyma of the lungs, in other words, into the
air-cells. From its exact resemblance to the effusion that takes
place in the brain in apoplexy, I have thought the name pulmo
nary apoplexy very applicable to it. The lungs and brain, how-
ever, are not the only organs in which a similar effusion may take,
place. I have seen such take place instantaneously in the subcu
taneous cellular substance, and I have met with them, during dis-
section, in almost every part of the body, — between the intestinal
tunics, among the muscular fibres of the heart, and under the cel-
lular coverings of the pancreas and kidneys In a case of fatal
apoplexy I have found large effusions of blood in the cellular
membrane of every limb, of the trunk, and in that surrounding
most of the abdominal viscera. Some examples have occurred of
sudden death from haemoptysis, wherein the substance of the lungs
was found lacerated, and containing clots of blood. Corvisart
mentions one extraordinary case of this kind, in which the extra-
vasation had lacerated the lung and filled the cavity of the
pleura.*

The hsemoplysical engorgement above described, is only a les-
ser degree of the same affection, in which the effused blood (still,
in some degree, under the influence of vital action,) coagulates in
the air-cells in such a manner as to form an intimate union with
the pulmonary tissue, very different from what would be produced
by the mere physical coagulation of the blood. We sometimes
find two or three similar indurations in the same lung, and fre-
quently both lungs are affected at the same time. They take
place most commonly in the central parts of the lower lobe, o>
towards the middle and posterior part of the lungs.

The hemorrhagic induration »f the lungs is as easily distin-
guishable from the congestions that take place after death, as from
the altera! ions produced by peripneumony. The sanguineous con-
gestions of the dead body consist of an accumulation of blood in-

* Nouvelle Methode, Sec

12 DISEASES OF THE LUNGS

termixed with serum, often spumous, which flows plentifully on an
incision of the part, and t'mgrs the lungs of a livid or vinous
colour. Being the mere consequence of gravitation, the engorge-
ment is found most considerable in the most depending parts
of the lungs, and gradually lessens towards the superior parts.
Where most engorged, the part still retains some crepitation, and
the incised surfaces are never granulated, even when the conges-
tion is so great as to destroy the spongy character of the lung.
By washing, we can, in every case, remove all the blood, and le-
store the lung to that sort of flaccidity which it possesses when
compressed by a pleuritic effusion. The engorgement of haemop-
tysis, on the contrary, is accurately circumscribed, very dense,
dark red or brown, granulated, and almost dry when incised, and
grows pale by' washing, but without losing any part of its consis-
tence.

Whatever may be the severity of this disease, resolution seems,
to take place with considerable facility, since we find a great
many cases of cure after severe haemoptysis. I have not had op-
portunities of tracing the progress of this resolution by morbid
dissection; but I think it must often be quite complete, since I
have never been able to trace any vestige of the induration in
subjects who had been affected with severe hemorrhage at a
period of some years anterior to their death.

The above condition of parts exists in every severe case of
haemoptysis; but, when the symptoms are moderate, and especially
when the hemorrhage is slight, the only morbid alteration of
structure may be a reddening and thickening of the bronchial
membrane, which, in this case, seems to secrete, as it were, or at
least to permit, the transudation of the blood. The quantity of
blood spit up is not of itself a sufficient indication of the nature
of the organic lesion of the lung. The haemoptysical induration
or engorgement may be very extensive, while the expectoration
of blood is inconsiderable, — for instance, only a wine-glassful in
the 24 hours; — while a much larger quantity than this may be
discharged by the mere change in the bronchial membrane.

The hemorrhagic induration of the lungs may be, and often
is, accompanied by the simple bronchial extravasation, as we al-
most always find the mucous membrane of the bronchia highly
reddened and swollen, in those-cases where the pulmonary eu-
gorgement exists in any extent. When this is very great and
takes place very suddenly, the patient may be suffocated before
any expectoration of blood has taken place.

The two following cases exhibit the disease in different degrees*

HiEMOPTfSIS. 73

the First, with a moderate local lesion, and slow course; the se-
cond, more severe and more rapid.

Case 15. A woman, between 50 and 60 years of age, came
into hospital labouring under haemoptysis, accompanied by great
prostration of strength and emaciation, great dyspnoea, the gene-
ral anasarca. No account of her previous state could be obtained.
She died in the course of a few weeks thereafter, continuing to
spit up blood to the last. On examination after death there
were found marks of inflammation in the pleura, and considerable
disease of the heart. The state of the lungs shall only be here
noticed. The left lung contained here and there in its subtance,
portions of a reddish brown colour, firm, granular when incised,
exactly circumscribed, and surrounded by parts perfectly crepi-
tus. These indurated portions were not at all like those of
peripneumony, but seemed to be the consequence of a peculiar
combination of the blood (strongly coagulated and dried) with
the pulmonary tissue. In the inferior lobe there was a similar
mass, more than a cubic inch in extent, formed by three concen-
tric layers, separated from each other by thinner layers of a
tissue still retaining its original soft and crepitous character, but
only much redder than natural. The larger layers (obviously
the product of effused blood) were of a dark red, granular when
incised, very firm, fragile, and so dry that it was with difficulty
that even a small portion of clotted blood could be expressed from
them. One of these layers was so soft in one point as to resem-
ble a clot of blood. The portions of lung thus indurated yielded,
when cut into, no humidity, unless when pressed or scraped;
while the other parts of the lungs were, more than ordinarily
imbued with a yellowish frothy serum, which escaped from them
when incised. There were a few tubercles. In the right lung
there was one morbid spot like those in the Jeft. The mucous
membrane of the bronchia was of a deep red colour, in different
points, in both lungs.

Case 16 A man, aged 45 years, who had been affected for
six months with a disease of the heart (hypertrophia) similar to
that alluded to in the last case, accompanied with much dyspnoea
occasionally, and also partial oedema, came into hospital, for the
third time, in January 1819, affected with an aggravation of the
same symptoms, viz. — great dyspnoea, pain of prascordia, cough,
diarrhoea, &c. A fortnight after, subsequently to an aggravation
of the dyspnoea, he discharged, almost without effort or cough, a
large quantity of red frothy blood: he died four days after. The
right lung, to the extent of three fourths of its yolume superiorly,

10

74 DISEASES OF THE LUNGS.

was reddened, rather than infiltrated, by blood of very bright
colour, iis tissue being, in other respects, quite crepitous, and
rather dry than otherwise. Towards the base there was a zone
or band (of the width of two or three fingers, and occupying the
whole thickness of the lung), of a consistence equal to- that of
liver, of a reddish black colour, and exhibiting the granular surface
when cut into. This zone was exactly circumscribed, and united
immediately to the sound and crepitous tissue without any grada-
tion. There were three or four portions of the same kind, and
equally circumscribed, in the superior part of the same lung, but
of a size scarcely equal to an almond or walnut. The largest
of these was divided, in a part of its inferior border, from the
sound tissue of the organ, by a fine membrane, which was evi-
dently one of the natural intersections of the viscus. The left
king contained, in the posterior part of its lower lobe, two or
three engorgements of the same kind, and equally circumscribed.
In both lungs the bronchial tubes were somewhat dilated, and
filled with an opaque grey mucus. The lining membrane of the
trachea was redder than natural, and that of the bronchia, in
many places, particularly in the smaller ramifications, was nota-
bly thickened and of a violet red colour.

CHAP. V.

OF PULMONARY CATARRH, Oft BRONCHITIS.

SECTION FIRST.

Of the Acute Pulmonary Catarrh.

Pulmonary Catarrh is unquestionably one of the mos*
frequent of diseases, insomuch that most persons are affected
with it, in some degree or other, almost every year. Notwith-
standing this frequency, it is perhaps less understood than many
rarer diseases. In most cases it occurs in so slight a degree as
scarcely to derange, in any respect, the functions of the body, or
to prevent the individual from following his usual occupations;
occasionally, however, it is of sufficient violence to endanger life

FULMONARY CATAUKH. 75

Pulmonary catarrh is inflammation of the mucous membrane of
»he bronchia. A greater or less redness, and a certain degree of
thickening of the membrane, are the only anatomical characters
of this affection; and even these sometimes disappear after death.
In the case of an old man who died of this disease, I found these
appearances much less distinct than in the body of a woman v\ho
had died the same day of fever, during the course of which she
had coughed very little.

This inflammation is attended, from the commencement, with a
secretion of. mucus more abundant than natural, and possessing
characters which vary in the different stages of the disease. At
first it is thin, transparent, and somewhat acrid or saltish to the
taste; it becomes gradually thicker, more viscid, and less transpa-
rent; and, towards the close of the disease, it grows quite opaque,
and assumes a whitish, yellow, or slightly green colour. In this
state it obstructs, more or less completely, the bronchial tubes,
especially those of a small calibre; and the impeded transmission
of air, in consequence of this, produces the sound usually denomi-
nated the rattles,

The inflammation which constitutes pulmonary catarrh very
rarely occupies the whole bronchial membrane, even of one lung.
When the contrary is the case, the disease is very severe, and ac-
companied by a violent fever. Commonly, in the severest ca-
tarrhs, even when there are much fever and expectoration, there is
only inflammation of some portions of the membrane, either in
both lungs or only in one. In slighter catarrh, unattended by any
perceptible fever, the whole seat of the disease does not extend
beyond a small part of a single lung.

The only difference between this disease and croup, is, that, in
the latter, the mucus secreted is coagulated so as to resemble the
false membranes produced by the inflammation of serous mem-
branes. This variety of the pulmonary catarrh is strongly mark-
ed, as well by its symptoms as by its pathological character: yet
there are many other intermediate shades, in which the chief
symptoms are only change of the voice, extreme dyspnoea, and the
secretion of a mucus very tenacious and difficult of expectoration.
It is especially in the catarrhal affections of children that we can
trace all the gradations of this disease, from the mere pulmonary
catarrh with an expectoration quite liquid, to the severest croup,
in which the false membrane is of the firmest consistence, and
lines the bronchia to their extreme ramifications.

There is nothing peculiar or characteristic in the cough attend-
ing acute catarrh. In the commencement of the disease it is hard.

76 DISEASES OF THE LUNGS'.

painful, and accompanied by much irritation; and the sputa arc
watery, transparent, slightly frothy, and nearly colourless, and
seem to be entirely composed of an intermixture of saliva and the
mucus of the mouth and throat. Sometimes, especially when the
cough is neither severe nor frequent, the expectoration is very
little, and consists for the most part of the grey, glutinous, semi-
transparent matter, intermixed with dark or grey opaque spots,
which usually goes by the name of bronchial mucus.

In this stage, the expectorated matter is very different from the
viscid, adherent, and united sputa of peripneumony, but differs in
no respect from that which attends pleurisy or the early stage of
phthisis. In a later stage of catarrh, this thin and transparent
fluid becomes intermixed, in small quantity, with sputa of a whit-
ish, yellowish, or greenish colour, and opaque. Still later, the
thin fluid disappears entirely, being replaced by a copious forma-
tion of this opaque mucous expectoration, which, notwithstanding
its consistence, is commonly intermixed with bubbles of air. This
kind of sputa is also very distinguishable from that of peripneu-
mony, especially in the first and middle stages of that disease; but
very frequently there is no difference between it and the expecto-
ration in the last stage of peripneumony, or in a pleurisy which
terminates by resolution, or indeed from that of the greater num-
ber of phthisical patients.

SECTION SECOND.

Of the Chronic Pulmonary Catarrh.

The chronic, like the acute catarrh, has a great variety of symp-
toms; they may all, however, be reduced under two principal spe-
cies, viz. — the humid and the dry; the former being attended by
copious expectoration, the latter with scarcely any expectoration.
The humid species may be further divided into two varieties, viz:
mucous catarrh, or with opaque and yellow sputa; and pituitous ca-
tarrh, or with transparent, colourless, ropy sputa, exactly like the
white of egg diluted with water.

The mucous catarrh is often the habitual infirmity of the aged.
I have seen it, also, exist for twenty years in persons of middle
age; but this is very rare in adults. Most commonly the mucous

PULMONARY CATARRH. 77

chronic catarrh has succeeded a severe attack of the acute, the
lever whicn attended the latter having gone off, or, at least, be-
come very slight and irregular, without any diminution of the
cough or expectoration. After this change to the chronic stale.
the sputa continue copious, and retain nearly the same character
as in the latter stage of the acute disease. Sometimes, however
they become more opaque, slightly greyish, and more puriform'
and are in every respect like those of phthisis. In this state the
expectoration is in general easy, and the cough neither frequent
nor latiguing. ^

Sometimes this disease, after lasting several months, or even a
year or two, gradually disappears without leaving behind any trace
of it; at other times, it changes into the dry species, to be noticed
directly; and occasionally, though rarely, it proves fatal, after hav-
ing exhibited all the symptoms of consumption, so strongly marked
as to render the real character of the disease unknown until after
death.

When chronic catarrh has become habitual, and is attended by
much dyspnoea, it constitutes one of the diseases usually confound-
ed under the general name of asthma. In a nosological system,
tounded, like that of Sauvages, on the character of the symptoms
this affection might be named Asthma a nimia respirations This
is one of the least troublesome kinds of asthma; it is rarely marked
by any paroxysms, and remains usually in the same degree of in-
tensity, unless when aggravated by an increase of the catarrhal
symptoms, or an attack of some other disease of the chest. This
variety of chronic catarrh is chiefly met with in old persons and
in delicate and nervous habits. When, in the former, the' pro-
gress of years, or any other cause has greatly weakened the indi-
vidual, the power of expectoration is lost, and the rattle on the
lungs, and finally in the trachea, becomes very great, and consti-
tutes the suffocating catarrh of practical medicine.

The pituitous catarrh is usually attended by a much stronger
harder, and sharper cough, than the foregoing species. The
cough comes m paroxysms, and is often followed by nausea, wh.ch
seems to facilitate the expectoration of the pituitous matter. There
is often not very much dyspnoea. This variety of catarrh is com .
monly met with among the aged,— in incipient consumption, and
also, in cases where the cicatrization of tuberculous excavations
has been followed by the formation of cretaceous productions or
a great accumulation of the black matter, in the lungs.

The dry chronic catarrh is that which we shall describe more
particularly under Emphysema pf the lungs. It generally succeeds

78 DISEASES OF THE LUNGS.

to an acute catarrh, after the cessation of the expectoration of the
latter stage, and is sometimes attended by much irritation; at
other times it is very little felt. Occasionally this variety of cough
makes its appearance without being preceded by the acute catarrh
In this case it is commonly called nervous; and too often, consi-
dering it as sympathetic, we search for its cause in other, and some-
times distant", organs — as, for instance, the stomach, the liver, the
kidneys, and even the uterujs.

I do not wish here to deny the existence of sympathetic coughs,
much less the reciprocal influence of affections of the lungs and
liver, when these exist simultaneously; but I am certainly of opi-
nion that our imperfect knowledge of the anatomical characters
of the diseases of those organs, has given a degree of importance
to many supposed sympathies which these little merited.

The dry catarrh ceases sometimes spontaneously, but it readily
becomes habitual, and the more so the less violent it had originally
been; indeed it is chiefly from the infrequency and decreased vio-
lence of the cough, joined to the slight degree of oppression, that
we are led to suspect its continuance. This slight oppression be-
comes gradually more considerable, and often augments in propor-
tion to the decreasing frequency of the cough. This is often so
slight as to be insensible to the patient, and, indeed, may not at all
recur for several days. The expectoration consists of small por-
tions of greyish semitransparent mucus, or, occasionally, a few
very acThesive specks of the yellow opaque sputa.

After a time, symptoms of emphysema of the lungs supervene
to the preceeding. Sometimes the cough ceases entirely during
the summer, and, in this case, the oppression on the chest becomes
less, — no doubt because the augmentation of the cutaneous dis-
charge lessens the mucous secretions of the bronchia. When a
person habitually subject to the dry catarrh, has an attack of
acute catarrh, the oppression on the chest is generally at first aug-
mented; but this lessens on the supervention of expectoration, and
indeed becomes much less than before the attack of the recent dis-
ease. This effect appears to me to be accounted for by the
increased liquidity, and consequent easier expectoration, of the
bronchial mucus during the prevalence of the acute catarrh.

Before terminating this chapter, it may be useful to make a few
observations on one symptom which many nosologists have erect-
ed into a distinct disease — I mean Jlsthma. This word, which
properly signifies difficulty of breathing, has been as much misused,
and has been made the cognomen of as many different diseases
as any word in medicine. It has been proved by Corvisart that

DILATATION OF THE BRONCHIA. 79

a great part of the diseases usually so denominated, are, in fact,
diseases of the heart and large vessels; and every person accus-
tomed to morbid dissection is now aware that the cases denomi-
nated humid or humoral asthma, are simply examples of chronic
catarrh. The extended use of the stethoscope will, I doubt not,
further enable us to trace many cases of this disease now consi-
dered as nervous, to particular organic lesions now little known.
Of this numbep is emphysema of the lungs, as I shall show here-
after; an affection which I am more and more led to consider as
constituting one of the most common species of asthma.

I do not mean, however, to deny that there may be asthmas, or,
to speak more exactly, dyspnoeas, purely nervous, or unattended
by any organic lesion of the parts concerned in respiration. In-
deed, we meet with cases in practice, where there is neither ob-
struction to the air from organic disease, nor accumulated sputa,
and where, nevertheless, the breathing is habitually difficult and
oppressed.

Under the same head of purely nervous, may perhaps be ranged
the spasmodic asthma, when this is well characterised by an even-
ing paroxysm, and a morning remission, after a slight expectora-
tion. I must confess, however, that I have even doubts on this
case. Characterised by the regularity of paroxysm mentioned, it
is an extremely rare disease; and when irregular in its recur-
rence, it differs in nothing from a case of emphysema of the
luns:s.

CHAP. VI.

OF DILATATION OF THE BRONCHIA.

T«E organic lesion which I am now to notice, seems to have
been hitherto entirely overlooked, both by the anatomist and the
practitioner. This oversight is easily accounted for by the cir-
cumstance that, as it generally occurs in a small portion of a
bronchial tube, when observed, it has been mistaken for a larger
branch. It can only be detested by tracing the individual bron-
chial tubes to their ultimate ramifications, — a thing which is rarely-
done in our examination of the lungs.

This species of dilatation is generally met with only in subjects
that have died, after being affected by chronic catarrh. It is

SO DISEASES OF* THE LUNGS.

sometimes so considerable, that the bronchial ramifications, which
in their natural conditionwould scarcely admit the point of a very
fine probe, acquire the diameter of a goose-quill, or even of the
finger. These dilated portions terminate in culs-de-sac capable of
containing a hemp-seed, a cherry-stone, a filbert, or even an almond.
The mucous membrane of these is commonly of a red or violet
colour, and is evidently thickened. The cartilaginous circles
seem to be converted into a fibrous tissue, and are so closely united
with the mucous coat as not to be separable by dissection.

This affection may exist in any part of the lungs, but is most
common in the superior lobe. Ordinarily it exists in only a small
number of the ramifications of the bronchia; sometimes, however,
it extends to all the branches of one of the lobes. In this case,
the dilatation is always greater (not relatively merely, but abso-
lutely) in the smaller than in the larger ramifications, and greater
in these latter than in the trunks whence they originate. The
common trunks are rarely dilated, in any perceptible degree, even
in the cases where some of their branches emulate them in dia-
meter. When the dilatation of the bronchia is so great as this, the
intermediate substance of the lung is flabby, void of air, evidently
compressed, and, in short, resembling, in every respect, the same
substance when compressed towards the spine, by an effusion of
serous or purulent fluid into the cavity of the pleura.

This affection of the bronchia is always produced by chronic
catarrh, or by some other disease attended by long, violent, and
often repeated fits of coughing. The hooping-cough, for this rea-
son, is the most frequent cause of all.

When the dilatation is confined to one or two of the bronchia,
it produces no other inconvenience but an habitual cough, not very
frequent nor severe, and a moderate degree of mucous expectora-
tion; but when a great number of the bronchia are dilated, through
their whole ramifications, the result is a chronic catarrh which
lasts for life, and which, indeed, may sometimes shorten its dura-
lion, through means of the exhaustion produced by the dyspnoea,
the severe and long continued fits of coughing, and, more espe-
cially, by the abundance of the expectorated sputa, which are of a
greyish yellow colour and altogether puriform. Sometimes, how-
• ver, patients affected with all these symptoms, and the degree of
infirmity the necessary consequence of these, live to an advanced
age.

I shall conclude this short account of this rare organic lesion,
by a brief detail of two cases of it furnished me by M. Cayol.

Case 17. A child, three and half years old, had been affected

DILATATION OF THE BRONCHIA. 81

with cough for three months, after an attack of hooping-cough,
The cough came on in paroxysms after intervals of several hours,
and was followed by an abundant expectoration of a yellow puri-
form matter, excessively fetid, like that from a carious bone. It
was sometimes intermixed with mucus. It was evacuated not in
the usual manner of sputa, but rather in mouthfuls, which conti-
nued to flow for some time, from the child's mouth, after the fits of
coughing, which were violent and painful, and attended by red-
ness of the face. In the intervals of the cough there was no pain,
and ihe child slept well, and it looked fresh and plump. The
child gradually got worse, and died after a fortnight, having pre-
viously become feverish, anasarcous, and affected with diarrhoea.
On examining the lungs after death, the only material organic
alteration found in them was in the inferior lobe of the left side,
the bronchial ramifications of which were found dilated in the
manner already detailed, and containing more or less of the same
purulent fluid expectorated during the life of the child. Upon
laying open these bronchial tubes through their whole length, it
was found that each of them, at the distance of about half an inch
after entering the substance of the lung, began to be dilated, and
progressively augmented in diameter until it finally terminated in
a large cul-de-sac, at the distance of a line or two from the sur-
face of the lung. Towards their termination most of these tubes
would have admitted the little finger, and others would only have
received an ordinary sized quill. During their course they gave
off several branches which ended in similar culs-de-sac, after run-
ning two inches or more. The mucous membrane of these dilated
tubes was, throughout, of a deep red or livid colour, thinner than
natural, but without any breach of continuity, and was evidently
the secreting source of the purulent matter contained in it.

Case 18. A woman, 62 years of age, had been affected, ever
since she was sixteen, with a disease of the chest, which exhibited
most of the usual symptoms of consumption. The principal of
these were — haemoptysis, very frequent, and renewed by the
slightest causes; constant cough, with expectoration of opaque,
yellow sputa, having sometimes the character of pus, sometimes
of a puriform mucus; and respiration more or less impeded. These
symptoms varied much; they had very marked remissions, but
scarcely ever any positive intermission: they never prevented her
from following her occupation of teaching the piano-forte. Her
chest was well formed, and she had nothing of the consumptive
configuration. Without any material aggravation of the pectoral

11

$% DISEASES OF THE LUNGS.

affection, this woman became universally anasarcous, and died
shortly after entering ihe hospital.

On examining the body after death, we could discover, in press-
ing the body of the lungs, which were soft and flabby, various
hardened portions of different sizes, especially in the superior lobe
Upon cutting into the lungs, these proved to be the hardened coats
of various of the bronchial tubes dilated in the manner of the
former case. Indeed they agreed in almost every respect with
these The largest of them would have contained the end of the
thumb; some were empty, and others contained a yellow purulent
matter like that expectorated by the patient. They ramified in
the manner detailed in the preceding case. The natural tunics
of the dilated portions seemed all converted into a single one,
much harder and more polished than the natural coats of the bron-
chia, and intimately connected with the tissue of the lungs. There
was not the slightest mark of ulceration in any part of the inner
coat, so that the pus contained in these cavities must have been
evidently secreted or exhaled by it. The greater portion of the
bronchial tubes in the superior lobe was in this condition, some of
them being dilated to a size seven or eight times greater than na-
tural. All the cavities taken together might probably occupy three
fourth parts of the lobe. Some of them were divided merely by
very thin bands of the pulmonary tissue, compressed into the ap-
pearance of a membrane. In some of the other lobes there were
a few bronchia similarly dilated, but in a lesser degree. The
mucous membrane of the trachea and larynx was sound.

CHAP. VII.

OF EMPHYSEMA OF THE LUNGS

The disease which I designate by this title is very little known,
and has not hitherto been correctly described by any author. 1 for
a long time thought it very uncommon, because I had observed
only a few cases of it; but since I have made use of the stetho-
scope, I have verified its existence as well on the living as the
dead subject, and am led to consider it as by no means infrequent
I consider many cases of asthma, usually deemed nervous, as de-

EMPHYSEMA. 83

pending on this cause. The chief reason of this affection having
been so completely overlooked \s, that it is in some sort merely
the exaggeration of the natural erudition of the viscus.

In order that we may have a clear idea of the disease in ques-
tion, it may be useful to advert to the natural organization of the
pulmonary tissue. In examining, in a good light, the surface of
the healthy lung, we can perceive, even with the naked eye,
through the transparent pleura, which forms its covering, that the
parenchyma of the viscus consisis of an aggregation of small
vesicles, irregularly spheriod or ovoid, filled with air, and separat-
ed from each oiher by opaque white partitions. -These- vesicles,
— which, as seen on the surface of the King, have the appearance
of small transparent points,-^-are not all of one size. The largest
are one third or one fourth part the size of a millet-seed. These
are grouped in masses or lobules, which are circumscribed by
pariitions of condensed cellular substance, very thin, but yet thicker
and more opaque than the partitions which separate the indi-
vidual air-cells. These larger partitions traverse the lungs in all
directions, and, consequently, in cutting each other at every pos-
sible angle, tbrm, on the surface, figures of very various shapes —
lozenges, squares, triangles, &c It is along these partitions that
the black pulmonary matter of which we have already spoken, is
most plentifully deposited.

In emphysema of the lungs, the size of the vesicles is much in-
creased, and is less uniform. The greater number equal, or ex-
ceed the size of millet-seed, while some attain the magnitude of
hemp-seed, cherry-stones, or even French beans (haricot). These
latter are probably produced by the reunion of several of the air-
cells through rupture of the intermediate partitions; sometimes,
however, they appear to arise from the simple enlargement of a
single vesicle. The largest of these dilated cells are often in no
respect prominent on the surface of the lung; sometimes they form
a slight projection. In the latter case the structure of the lung
acquires a striking resemblance to the vesicular lungs of the
Linnsean order of Keptilia. Sometimes, though more rarely, we
observe on the surface of the lung single vesicles, distended to the
size of a cherry-stone or larger, quite prominent, exactly globular,
and apparently pediculated I say apparently pediculaied, be-
cause on cutting into them we find that there is no real pedicle,
but merely a constriction at the point where the cell begins to
rise beyond the surface of the lung. The cavity of these dilated
cells descends some little way into the substance of the viscus,
and there its walls do not collapse, when cut, as in the projecting

84 DISEASES OP THE LUNGS.

portion. At the bottom of this inferior portion of the cavity, w<j
find small openings by which the iilated cell communicates With
the adjoining ones, and with tl.Vnronchia. That these projecting
vesicles are produced by the dilatation of an air-cell, and are not
owing to the extravasation of air under the pleura, is proved, as
well by the prolongation, just mentioned, of their cavity into the
pulmonary substance, as by the circumstance that we cannot force
the contained air, by pressure with the finger, to leave its place
and to pass under the contiguous pleura, — as would be the case
if it were extravasated.

As long as the parts continue in the state above described, the
disease consists merely in an excessive, permanent, and unnatural
distention of the air-cells, the air being still contained in its pro-
per cavities; but when the distention becomes still more consi-
derable, or takes place with greater rapidity, the air-cells are rup-
tured in certain points, and the surrounding cellular substance of
the lung becomes distended by extravasated air, exactly in the
same manner as in emphysema of the sabcutaneous adipose mem-
brane. In this case we find on the surface of the lung vesicles
of an irregular form, which can be made to change their place by
pressure with the finger. They vary in size from that of a hemp-
seed to «hat of a walnut, or even an egg. Like the simply dilat-
ed cells, these vesicles contain nothing but air, which makes its
escape on their being punctured with a pin. Sometimes the air,
though truly extravasated under the pleura, cannot be displaced by
pressure in the manner just mentioned. This happens when the
extravasation is situated at the point of reunion of the partitions
which divide the different groups of air-cells, as above mention-
ed. In this case the projection has usually a triangular shape, and
is not very considerable.

I have never found this extravasated air penetrate, to any con-
siderable extent, into the substance of these interlobular partitions,
nor into the cellular substance which surrounds the larger blood-
vessels and bronchial trunks; but I have seen the pulmonary sub-
stance in the interior of the lung lacerated by over-distention of
the air-cells. These lacerated portions contain air, and sometimes
also a small quantity of blood, either coagulated or loose; and the
surrounding air-cells, which form the immediate walls of the ex-
cavation produced by the rupture, are observed to be loose, flabby,
and without their natural globular figure.

The bronchial tubes, especially those of a small calibre, are
sometimes very evidently dilated in those portions of the lung
where the emphysema exists. This is easily proved by compar-

EMPHYSEMA. 86

ing the diseased and sound portions of the lungs. It is a thing to
be expected; and it is, indeed, singular that it is not more com-
mon, since the cause which dilates the air-cells must act equally
on the bronchia: it is, notwithstanding, very rare.

Emphysema may affect both lungs at the same time, one only,
or a part of one or of both. In the latter case, — and indeed in
any case, as long as there do not exist vesicles of considerable size
on the superficies of the lungs, — it is easy to overlook the disease
in the dead subject, and, as I have already said, I am convinced
that this has often been done, not only by myself but by the best
practical anatomists. For my own part I am convinced, that if
we carefully examine the lungs of subjects who have long suffered
from dyspnoea, from whatever cause, we shall almost always find
more or fewer of the air-cells dilated. In lungs studded with tu-
bercles, which presented no other symptom of emphysema. I have
sometimes found two or three of the cells dilated to the. size of a
hemp-seed.

When the disease exists in a high degree, and occupies the whole
of one or both lungs, one cannot help being struck with the ap-
pearance of the parts. The lungs seem as if confined in their na-
tural cavity, and, when exposed, instead of collapsing as usual, they
rise in some degree and project beyond the borders of the thorax,
If we examine them in this state they feel firmer than natural, and
it is more than usually difficult to flatten them. The crepitation
they afford on pressure, or on being cut into, is less, and of a kind
somewhat different; it is more like the sound produced by the slow
escape of air from a pair of bellows; and the air makes its escape
from the* cells much quicker than in a healthy state of the organ.
When we detach the lung, the crepitation is found to be still less
perceptible, and the sensation conveyed by pressing the parts is
very like that produced by handling a pillow of down. On plac-
ing an emphysematous lung into a vessel of water it sinks much
less than a healthy lung; sometimes it floats on the surface with
scarcely any obvious immersion. The pulmonary tissue is drier
in a lung affected with «mphysema, than in a healthy one; and it
is unusual to find, even towards the root of the lungs, any trace of
the common serous or sanguineous engorgements usually found
after death. The contrary, however, is sometimes the case.
When a single lung is affected, it becomes much more voluminous
than that of the other side, so much so, indeed, as sometimes to
press on one side the heart and mediastinum, and to cause an evi-
dent enlargement of the bony compages of that side of the chest.

From these observations it results, that Emphysema of the lungs

^jj DISEASES OF THE LUNGS.

consists essentially in the dilatation of the air-cells, and that Hue
extravasation of the air on the surface of the lungs, constituting
the larger and more prominent vesicles, is a posterior affection,
and not necessarily connected with the disease in question. The
latter species of lesion is, moreover, one of slight consequence
compared with the dilatation of the cells, as wc can hope for iis
removal by absorption, as in other similar cases; whilst we can
hardly conceive in what manner either nature or art can remedy
the other morbid derangement.

The disease, the morbid anatomy of which has just been de-
scribed, appears to me, as I have already observed, to have been
hitherto unknown No general description of it certainly exists;
although facts, that evidently can be only referred to it, are to be
found in several authors. Bonetus and Morgagni give several ex-
amples of the lungs being found very voluminous and distended
with air. Van Swieten and Stork have some cases wherein ve-
sicles of air were found under the pleura; and Floyer noticed the
same thing in a broken-winded mare. The author of the article
Emphyseme, in the Diet, des Sciences Med. relates a case pre
cisely similar to these last mentioned, which had been communi-
cated to him by M. Majendie; but none of these various authors
appears to have been acquainted with the real character of the af-
fection, viz. — dilatation of the bronchial cells. All of them seem
to have thought, with the last mentioned writer, who expresses
his opinion in a positive manner, that the derangement in ques-
tion consisted in the infiltration of the cellular substance of the
lung with air. Ruysch and Valsalva are the only authors, as far
as I know, who have observed, in individual cases, the dilatation
of the cells. The case noticed by the latter is an example of par-
tial emphysema of the lungs complicated with empyema. It has
been noticed by Morgagni, under its latter character, who does
not appear to have understood the nature of the former change of
structure. This, however, he has described in a manner to leave
no doubt of its true nature. " Sinistri pulmonis lobus superior

qua claviculam spectabat, vesiculas ex quibus constat mirum

in modum auctas habebat; ut nonnullae avellanae raagnitudinem
aequarent; caeterae multo minores erant. Quaedam globuli figura,
reliquae oblonga et ovali: omnes plenae erant aeris .... una insuper
minima quasdam foraminula per interiorem faciem hiantia osten-
dit."*

The case noticed by Ruysch is also one of partial emphysema

* De Sed. et Caus. Morb., lib. ii. epist, 22, nos. 12 et 13.

EMPHYSEMA. 87

of the lungs: " In aliqua autem pulmonis parte inveni vesicula-
rum pellucidarum acervum, ab aere expansarum et ita obstructa-
rum ut levi compressione ens ab aere evacuare haud potuerim.
Impulsum per a9peram arteriam flatum nullum commercium cum
hisce expansis vesiculis ampiius habere propter tarum obstructio-
nem expertus sum. Post, aere per asperam arteriam vehementer
adacto disrumpebantur nonnullae ex his vesiculis."* This author
has, perhaps, a second case of the same kind (obs. 20), but it is
too imperfectly described to justify any deductions from it.

Dr. Baillie, author of the Morbid Anatomy, has correctly ob-
served the three principal circumstances which constitute em-
physema of the lungs, namely — the great size of these organs, —
the dilatation of the cells, — and the vesicles formed by the extra-
vasation of air under the pleura; but he does not appear to have
been acquainted with the mutual dependance of these three states,
and describes them as three different affections, as is evident
from the following passages, which contain all that he says on
this subject.

" Lungs distended with air In opening into the chest, it is
not unusual to find that the lungs do not collapse, but that they
fill up the cavity completely on each side of the heart. When
examined, their cells appear full of air, so that a prodigious num-
ber of small white vesicles are seen upon the surface of the Jungs
immediately under the pleura The branches of the trachea are
often at the same time a good, deal filled with the mucous fluid.
This fluid had probably prevented the ready egress of the air,
so that it had gradually distended the air-cells of the lungs, and
had prevented tiie lungs from collapsing."

u Jlir Cells of the Lungs enlarged. The lungs are sometimes,
although I believe very rarely, formed into pretty large cells, so
as to resemble somewhat the lungs of an amphibious animal.
Of this I have now seen three instances. The enlargement of
the cells cannot well be supposed to arise from any other cause,
than the air being not allowed the common free egress from the
lungs, and therefore accumulating in them. It is not improba-
ble also, that this accumulation may sometimes break down two
or three contiguous cells into one, and thereby form a cell of a
very large size."

" Air Vesicles attached to the edge of the lungs. Vesicles
containing air have occasionally been seen attached to the edge
of the lungs. They do not communicate, however, with the

* Bujsh, Obs. anat. centur., obs. xix.

SS DISEASES OF THE LUNGS.

structure of this organ, but are complete in themselves. Upon
the tirst view, it might be thought probable that they were merely
some of the air-cells enlarged; but as they do not communicate
with any of the air-cells, this opinion is not well founded. It is
most likely that they are a morbid structure, formed in the same
manner as the air vesicles attached to the intestines and mesentery
of some quadrupeds, and that the very minute blood-vessels which
ramify upon the vesicles, have the power of secreting the air."*

These observations I wish to confine to the emphysema from
internal causes, without at all including the disease mentioned
by surgical writers under this name, produced by the introduction
of foreign bodies into the trachea, and which disease they de-
scribe as consisting in an extravasation of air into the cellular sub-
stance interposed between the air-cells. It is indeed true that
such an accident, as well as violent exertions of the lungs, as in
childbirth, &c. can and do sometimes produce emphysema of the
neck, chest, &c; but such an affection can only arise from rup-
ture of the bronchial tubes or air-cells: and I am disposed to
believe that in no such case is there any actual penetration, by
the extravasated air, of the interlobular cellular substance of the
lungs themselves.

The following cases afford examples of most of the facts noticed
in this chapter.

Case 19. A woman, aged 50, came into hospital affected
with great dyspnoea and cough, whic.h were said to have existed
three weeks. She died the same night. The right auricle of
the heart was found much enlarged and distended with blood:
and a great part of the right lung, and almost all the inferior
lobe of the left, were affected with emphysema, such as describ-
ed in the preceding pages. v

Case 20. A woman had been subject to frequent and severe
catarrhal affections from infancy, one of which, in her twenty-
eighth year, was followed by nocturnal paroxysms of dyspnoea,
which, together with cough, continued and became more frequent,
so as to attack her in the day-time. When admitted into the
hospital, in her forty-first year, she laboured under an aggravation
of the same symptoms, to which had been recently superadded
frequent palpitations and very general anasarca. She died
shortly after her entrance. The whole of the right lung was
emphysematous, and exhibited on its surface vesicles full of air,
of the size of a small pigeon's egg The left lung was partially

* Morbid Anat. Chap. Ill,

EMPHYSEMA. 89

affected in the same manner. There was hypcrtrophia of the
heart.

Case 21. A man had been affected from infancy with an ha-
bitual cough, mucous expectoration and dyspnoea, which were
always so much augmented in winter as to confine him, for several
days, to bed. In his thir'y-seventh year, on the supervention of
anasarca of the abdomen and lower extremities, he came into
hospital. At this time there was much dyspnoea, wfih livid lips,
cough, very severe and sonorous, accompanied by copious expec-
toration of colourless, ropy and frothy sputa. Percussion of the
chest produced a distinct sound, but the murmur of respiration
(see Part II.) was almost extinct over the whole chest. Thesje
symptoms continued with much variation of intensity, and after
leaving the hospital twice, he returned and died in it the samg
year.

The whole of both lungs were found emphysematous, as de-
scribed in the present chapter, and there were vesicles of extra-
vasated air under the pleura. There was no other disease of
these organs, nor of any other, except the heart, which was en-
larged to twice its natural size.

Case 22. A man, of delicate health in childhood, and affect-
ed with spinal curvature, in his twenty-eighth year became sub-
ject to slight cough and habitual dyspnoea. Two years after-
wards he caught a severe cold, with much aggravation of his
former symptoms, and came into hospital in January. At this
time there was much dyspnoea and severe fits of cough, with
mucous expectoration; inability to lie in the horizontal posture,
and lividity of cheeks, lips aud nails. On percussion the chest
was sonorous, but the respiratory murmur was not perceptible in
ihe greater part of it. This man died in two days. The whole
of the left lung was affected with emphysema, but was in other re-
spects quite healthy. The bronchial tubes appeared to be dilat-
ed; they were very red internally and riiltd with a white ropy mu-
cus. The upper and middle lobes of the right lung were in the
same emphysematous condition; but in the inferior lobe a portion
of the tissue was in the state characteristic of inflammation, as
described in the chapter on peripneumony. One portion was
hepatized.

Case 23. A woman, aged 52, had been affected for the last
eighteen years with dyspnoea, habitual cough, attended with little
expectoration, +iut often so severe as to prevent sleep. She had
never been prevented from following her occupation until the pe-
riod of her entry into nospital. At this time there was consider*

12

90 DISEASES OF TFIE LUNGS,

able emaciation, complete incapacity to lie in the horizontal pos
ture, respiration short and difficult, very frequent and severe cough,
of a convulsive character like that of the hooping-cough, and mu-
cous expectoration, the pulse quick, and skin of the natural tem-
perature. The chest sounded well on percussion, but respiration
was inaudible in the greater part of it: pecloriloquism was very
distinct above the right clavicle. This woman died three days
after her admission.

Both lungs were found adhering strongly to the ribs by old
attachments. The whole of the left lung was emphysematous,
the air-cells in many places being very prominent on the surface
and large. In several places on the surface of the lungs there
were four or five marks of an irregular oval form, and of the size
of an almond. These marks corresponded to excavations situat-
ed two or three lines deep in the lung, which were produced by
laceration of its substance. These cavities, — of which the largest
might have contained a middling-sized walnut, and the smallest a
filbert, — were full of air, and collapsed on being cut into. The
internal surface of two of these was tinged with blood, and one
of them contained a small clot of blood, one-fourth of its own
size. The walls of the others were of the natural colour of the
lung, and presented a layer of ruptured and compressed cells to
the depth of a line and half. Beyond this depth, on all sides, the
cells were distended beyond the natural size. It is to be remark-
ed that the ruptured portions did not exist in any place at a greater
depth under the surface than an inch, and that, below this the em-
physematous dilatation of the cells was not very distinguishable. It
was equally evident that the cells in the vicinity of these lacera-
tions were neither larger nor more numerous than elsewhere, and
that there was no infiltration or extravasation of air into the inter-
alveolar tissue. The right lung exhibited, but in a lesser degree,
the same dilatation of the cells, but no rupture of substance. In
the upper and posterior part of this lung, however, there was found
an excavation of an oval shape, about two inehes in length, fifteen
lines broad in its centre, and two lines deep. The inner surface
of this cavity was smooth and polished, though somewhat irregular;
it was white, but interspersed with red specks arising from nu-
merous small vessels. It contained some small fragments of an
opaque, very dry, semi-friable matter, of a pale ochre yellow
colour, and attached to the walls of the cyst. Three bronchial tubes,
of the size of a goose-quill, terminated with open mouths in this
cavity. Their coals were continuous with its walls, and their com-
munication with their trunks was quite free In detaching the lun™

EMPHYSEMA. 91

from the pleura costal is, this cyst was ruptured, so that one portion
remained adheren; to the side. It was of very unequal thickness, the
part just mentioned heing about two lines, while that imbedded in the
lung was from three to seven or eight lines thick. Its substance
was of a white brilliant hue, slightly semitransparent, and of a
texture entirely similar to that of the intervertebral cartilages, only,
perhaps, with a superior degree of density. It was entirely empty.
At the lower and middle part of this cyst, where its walls were
thickened, it gave off, in different directions, four or five bands
(of an irregular thickness, and an inch in length), of 'the same
cartilaginous structure. The pulmonary substance interposed be-
tween these bands (to which, as well as to the cyst, it was inti-
mately adherent,) was flaccid, compressed, and of a greyish
colour, but, in other respects, quite sound In different parts of
the same lung there were a few small rounded cysts, of the «ize
of hemp-seed or cherry-stones, containing a dry cretaceous fatty
matter, which seemed intemediate between chalk and the matter
of tubercles. These cysts were of an equable thickness, of a line
or a line and half, greyish, semitransparent, and of a semi-cartila-
ginous texture. The heart was slightly diseased; the other viscera
were sound.

The four cases, of which I have now given a brief outline, ex-
hibit emphysema of the lungs in its different degrees. The last
case gives, further, an example of a cure of what is usually call-
ed an ulcer of the lungs, (see Chap i.) It even exhibits both the
modes in which this cure can be effected, viz: by cicatrization
and fistula; as we must regard the great thickness of some part
of the cyst, and the cartilaginous bands connected with it, as the
consequence of that superabundance of the cartilaginous forma-
tion which we have seen occasionally take place in such cases.

It may be questioned what was the nature of the matter origi-
nally contained in this cavity, and of which I have noticed a few
dried fragments as still remaining. Most probably it was a mixture
of chalky and tuberculous matter. Whatever it may have been,
I am disposed to consider it as being dead matter. In explanation
of this term I may observe, that I agree with M Bayle, in believ-
ing that such extraneous productions as tubercles, cancers, &c
do certainly possess vitality, but with a duration and laws dif-
ferent from those of the natural tissues of the animal economy.

In their origin these productions are of a firm consistence; they
are nourished by blood-vessels, or, at least, by lymphatics. The
rapidity of their growth, as, likewise, the extent of it, is quite in-
definite. When this is accomplished, the tumour may- remain sta-

Q2 DISEASES OF THE LUNGS.

tionary for a greater or less time, retaining its original organization;
or it may at once pass into a second slate, that, viz. of softening,
which must terminate in its destruction. This process, also, is a
vital process, entirely independent of chemical action; and, on this
account, it reacts on* the living system, producing on it an impres-
sion more or less deleterious; — for example, fever, emaciation, and
general disorder of functions * But should any part of this sub-
stance, in any stage of its solution or softening, be detached from
the rest, it then ceases to advance in its progressive decay, be-
coming an inert, or dead substance, and capable of acting on the
System merely as a foreign body. Case 5, p. 45, affords a still
more striking example of what I mean.

CHAPTER VIII.

OF (EDEMA, OR ANASARCA, OF THE LUNGS.

(Edema of the lungs is the infiltration of serum into the sub-
stance of this organ, in such degree as notably to diminish its
permeability to the air in respiration. Although very common,
this disease is very little known. None of the authors who have
treated formally of dropsy have mentioned it, and the expression
dropsy of the lungs, which occasionally occurs in their writings, is
generally applied to cases of hydrothorax, or to the supposed ex-
istence of cysts of serous fluids in the lungs, the rupture of which
was considered as giving rise to Hydrothorax.f Among practical
writers, AlbertiniJ and Barrere§ are the only ones who have paid
any attention to this disease, and who have given any cases of it.
The observations of the latter, particularly, prove that he was well
acquainted with the affection, although he, perhaps, attached too
much importance to it, and did not distinguish sufficiently between
it and the first stage of peripneumony.

(Edema of the lungs is rarely a primary and idiopathic disease.

* Tide Diet, des Scienc. Med. AnT. Jlnat. Pathol.

t Hippoc. de Intern. Affect. — Carol. Piso, de Morb. a serosa Colluvie. —
De Haen, Katio Med. torn. ii. De Hydrope Pectoris.
i Comment, de Bonon, sc. inst. torn. i.
§ Observat. Anatom. — Perpignan, 1753.

OEDEMA. y^

H comes on, most commonly, with other dropsical affections, in
cachectic subjects, towards the fatal termination of long conti-
nued fevers, or organic affections, especially those of the heart.
Peripneumony that has terminated by resolution, appears also to
leave a great predisposition to it; and the most extensive and se-
vere cases that I have met with,, occurred during a temporary
convalescence from severe attacks of this disease. Chronic ca-
tarrh, likewise, predisposes to it; and in such cases it often proves
fatal by suffocation.

Although this disease commonly is merely consequent on other
affections, and often takes place merely a few hours before death,
nevertheless, in some cases, it has certainly lasted several weeksj
and even months; and, in a few of these, it even seems to have
been idiopathic. The suffocative orthopncea, which sometimes
carries off children after attacks of measles, is probably idiopa-
thic anasarca of the lungs. I have not hitherto been able to
verify this conjecture by dissection; but, when we consider the
dropsical tendency of such cases, and the frequent complication of
measles with peripneumony, it would seem to be well founded.

The following are the anatomical characters of this disease
When it occupies the whole lungs, and has been of some duration,
the pulmonary tissue has entirely lost the slight rose tint which is
natural to it, and is now of a pale grey colour; it is denser and
heavier than in its sound state, and does not collapse on opening
the chest. It is, however, still nearly as crepitous as before. It
retains the impression of the finger more tenaciously than a sound
lung. Its vessels seem to contain less blood than usual, and,
when cut into, there flows from it an abundance of serum, which
is either colourless or very slightly tawny, transparent, and just
perceptibly spumous.

The characters last mentioned would suffice to distinguish this
disease from the first degree of peripneumony, (in which the serum
effused into the inflamed lung is strongly tinged with blood, and
very frothy,) even if the characteristic redness of inflammation
did not establish a very marked distinction between the two dis
eases. However, it is by no means uncommon to find, in ana
sarcous lungs, some spots inflamed (as in peripneumony) in the
first, and even second degree, — the inflammatory affection gradu*
ally shading into the merely cedematous condition of the surrouno\
ing parts. Facts of this kind point to the great affinity (which
will be noticed more particularly hereafter) between inflamma-
tion and the dropsical diathesis.

Whatever may be the intensity of the cedema, it produces no

94 DISEASES OF THE LUNGS.

change in the integrity of the alveolar structure of the organ.
This fact is not, however, quite obvious until we cut into the dis-
eased lung, owing to the fluid contained in the cellular tissue.
When oedema of the lungs has been of long standing and univer-
sal, we do noi commonly perceive the sanguineous congestion of
the posterior parts of the lungs, as in ordinary cases. The ana-
sarcous affection, which takes place merely a short time before
death, is partial, and commonly occupies the posterior parts of the
lungs, like the congestion just mentioned, with which it is often
combined.

We must not confound with the true pulmonary anasarca a
species of infiltration which often takes place in phthisis, in the
intervals of the tuberculous masses. This latter, which is always
partial, and of small extent, is formed of a half liquid, gelatinous
looking matter, which is semitransparent, greyish, or slightly san-
guinolent. Its presence completely hides the air-cells, and <he
parts so affected have quite lost their crepitous character. When
pressed they give out a very small quantity of serum, which is not
at all frothy. I have already given it as my opinion (p. 57) that
this matter is the same as that composing tubercles in their first or
semitransparent stage, only it has here a less degree of consistence.
This opinion rests principally on the circumstance of there being
frequently found, in the thicker parts of this species of infiltration,
a great many small points, which are yellow and opaque, and
obviously consisting of true tuberculous matter.

The first of the following cases exhibits oedema of the lungs in
its simple state; the second, with the complication above mention-
ed; and the third is an example of it supervening to a severe pe-
ripneumony before its complete resolution.

Case 24. A woman, aged 47, subject to irregular menstruation
for a twelvemonth, was suddenly seized with a severe pain in the
left side, attended by dyspnoea and cough. She came into hos-
pital a fortnight thereafter, affected with oedema of the superior
extremities, particularly the left, — dyspnoea and cough (not very
frequent), with expectoration of while viscid sputa, intermixed
with much saliva. These symptoms got better during the first
month; but during the second the anasarca greatly increased, and
extended over the whole body, except the face. She had some-
times pain in the chest, and sometimes in the abdomen. The
pulsation of the heart was irregular, and the pulse very indistinct;
— the patient took little sleep, coughed a little, and expectorated
blackish sputa. During all this time the respiration was pretty
distinctly audible throughout the chest, but accompanied by that

4EDEMA. 95

particular noise which I call ihe crepitous rattle. (See Part II.)
This person died three months after her entry into the hospital.

On examining the body, the cavities of the pleura contained
somewhat less than a pint of a limpid serum; the lungs adhered
nearly through their whole extent by long cellular attachments',
and their substance was throughout little crepitous, and injected
by a frothy and nearly colourless serum, which gave the lungs a.
sort of transparency, and flowed copiously from them when cut
into. In other respects the pulmonary tissue was sound, of a pale
rose-colour, free from tubercles, and exhibiting no traceof peripneu-
mony, nor even of sanguineous congestion. There was found
water in the cavities of the pericardium and peritoneum. The
head was not examined.

Case 25. A woman who had been affected (according to hei-
own account) with asthma and habitual cough, attended by a
slight expectoration, ever since she was nine years old, came into
hospital in her forty-fifth year, on account of an aggravation of
her dyspnoea and a local pain of the leg. At this time the respi-
ration was short, difficult, and interrupted by fits of coughing, fol-
lowed by yellow mucous expectoration; the skin was rather cold,
the action of the heart regular, and the pulse a little frequent.
The chest sounded rather indistinctly in some places, and the res*
piration was very imperfectly heard throughout its whole extent,
and was occasionally attended with a peculiar rattle. During the
succeeding month the oedema of the lower extremities, which was
very slight on her entrance, increased; and she had comatose
symptoms, which seemed to threaten apoplexy. This continued
more or less; the anasarca became general, and, together with a
severe attack of diarrhoea, exhausted the patient, who died about
six weeks after her entry.

There was a good deal of water in the head. The right lung
exactly filled the cavity of the chest and remained uncollapsed; it
adhered throughout to the pleura by well organized cellular laminae,
which were in some places infiltrated with a yellowish serosity.
On the anterior surface of the lung several of the air-cells were
dilated to the size of a hemp-seed. The lung seemed pretty firm;
on compression it was found to retain the impression of the finger,
and, when cut into, allowed a large quantity of a clear and very
frothy serum to escape. In the upper part of the lung there were
some points of small extent, here and there, which were somewhat
red, compact and not alveolar, and which exhibited the granulated
surface when incised. The renaaindet of the viscus had the natu
ral aspect, and was still sufficiently crepitous, but heavy; it did

96 DISEASES OF THE LUNGS.

yield, like the sound organ, to pressure, being injected throughout
with a large quantity of an almost colourless serum, which could
be squeezed from it like water from a sponge The left lung ad-
hered, in like manner, to the pleura, and, with the exception of the
peripneumonic appearances, exhibited the same morbid condition
as the right. There was, furiher, on ihe superior part, a patch of
ribro-cartilaginous membrane, two or three lines thick, which, in
this place, formed the medium of adhesion between the lungs and
pleura of the ribs, to both of which it was intimately united. In
the interior of this lobe there was a vast tuberculous excavation,
capable of containing a middle-sized apple (reinette), and which
contained merely a small quantity of a very liquid mucosity. It
was lined throughout with a polished diaphanous membrane, of a
consistence between that of the mucous membranes and cartilage.
This cavity was traversed, in different directions, by very white,
small, rounded columns, which proved, on close examination, to be
obliterated blood-vessels, and which, although continuous with the
lining membrane of the excavation, were sufficiently distinguished
from it by their shining whiteness and their opacity. The trunks
of these obliterated vessels terminated in culs-de-sac, either a few
lines within or without the excavation. In the obliterated portions-
the original cavity of the vessel was still distinguishable by a
longitudinal band of greater transparency. Five or six bronchial
tubes opened into this cavity, in the manner described In the chap-
ter on Phthisis. (See plate I. fig. 1.) The pulmonary tissue in the
inferior part of this excavation was crepitous, though injected with
serum; in every other part of the boundaries of the cavity, it form-
ed a layer, two or three lines in thickness, which was flaccid, and
of a very deep black colour, owing to the accumulation of black
pulmonary matter. There were no tubercles in either lung.
There was some water in the pericardium and peritoneum.

The above case is remarkable from the circumstance of the
tuberculous cavity being traversed by blood-vessels, a thing which
I have already stated (page 34) to be of a very rare occurrence.
This case further offers a new proof of the possibility of cure of
tuberculous excavations. From the parent's history it would seem
that this vast pulmonary fistula had existed ever since her ninth
year.

Case 26. A woman, aged 40, bad been always from her child-
hood of delicate health, and habitually snhject to great difficulty of
breathing and palpitation of the heart. This stale was aggravated,
in her twenty-seventh year, by the supervention of general dropsy,
of which, however, she was cured by diuretics; from this time her

LED EM A. $?

trealth continued still to decline. In the beginning of January,
after having sat up with a sick person for several nights, her res-
piration became extremely difficult, especially on motion, she lost
her sleep and appetite, and she had a slight cough with mucous
expectoration. In this state she came into hospital, with oedema
of the lower limbs, livid lips, extreme oppression, frequent palpi-
tation, and startings during sleep. The anasarca increased during
the whole of this and two following months; she complained of a
severe impediment in the region of the diaphragm, and of a pain
between the scapulae. She died in the beginning of June.

The brain was found natural, but with a small quantity of
serum in the ventricles. There was about half a pint of serum in
each side of the chest, and some cellular adhesions on the right.
The upper part of the right lung was sound, only injected with a
colourless serum. The middle and inferior lobes were more com-
pact, and discharged, when cut into, a great quantity of transparent
colourless serum, intermixed with a thicker, yellowish, puriform
fluid. These lobes were, nevertheless, crepftous, with the excep-
tion of a few spots, of small extent, here and there, which had a
density equal to that of liver, a yellow and somewhat reddish
colour, and a granulated surface on incision. The left lung was
in the same state, only without the more solid portions. Both
lungs had the yellowish-grey colour, like that of this viscus when
infiltrated with pus after an attack of peripneumony, only paler.
Indeed, it appeared evident that, in this case, a peripneumony of
the inferior portion of both lungs had ended in suppuration, and
that the greater part of the pus had been absorbed, the final resto-
ration of the part failing through the debility of the system. The
pericardium contained two ounces of serum. The heart was large,
its substance soft and easily torn, and its cavities very voluminous.

It may be proper, in this place, to take some notice of that con-
dition of the lungs so often mentioned in this work, and which, if
not well understood, may frequently be mis'taken as a cause and
sign of disease; I allude to the engorgement — (serous, sanguinolent,
or sanguineous,) — met with towards the root and posierior parts of
the lungs in almost every subject. Bichat first distinctly called
the attention of anatomists to this appearance.

This congestion is very variable as to its appearance and degree.
Exteriorly, in the engorged parts, the lung possesses a violet colour,
more or less deep; interiorly, it is more dense and less crepitous
than in other parts, and is gorged with a greater or less quantity
of blood. Sometimes this blood appears in a state of semi-coagu-
lation, and is with difficulty completely expressed from the part; it

13

98 DISK ASKS OF THE LUNGS.

is, however, by no means so intimately combined with the pulmo-
nary tissue, as in the haemoptysical congestion formerly described.

The state of this congestion just described, is such as we meet
with in plethoric subjects, whose large vessels and capillary
system contain much blood, especially in such as have died of
acute fevers or scorbutic affections. In cases of exhaustion, on
the contrary, particularly in those who have died of marasmus con-
sequent on cancerous affections, the congestion shows itself merely
by reddish colour of the parts, without any diminution of their
crepitous character, and without any discharge of fluid on their
being cut into.

In dropsical subjects, on the other hand, these parts, in place of
blood, contain a very frothy serum, more or less sanguinolent, and
sometimes hardly yellowish. In this case, the congestion some-
times greatly resembles the first degree of peripneumony, or
oedema of the lungs; and the only means whereby we can distin-
guish them is afforded by the fact — that the latter affections exist
indifferently in any part of the lung, without regard to the laws of
gravitation, while the engorgement of the dead body, in obedience
to these laws, is always most considerable in the most dependent
parts.

Bichat considered the pulmonic engorgement of the dead body,
like the marks and bluish stains met wi(h on the back and poste-
rior parts of the limbs of almost all subjects, — as caused by the
custom of placing dead persons on their backs. This is doubtless
the case; yet I am of opinion that the same posture before death,
especially in cases of great prostration of strength, may give rise
to the accumulation even while life still remains — at least some
hours before death. The few attempts I have made to ascertain
the correctness of this opinion, by means of the stethoscope, be-
fore death, tend to confirm it; if correct in reality, it would ac-
count for the rattle and the oppression of breathing observable in
most dying persons, even in those whose respiratory organs had
remained quite unaffected through the whole course of their dig-
ease.

ACCIDENTAL PRODUCTIONS. 99

CHAP. VIII.

OF EXTRANEOUS, OR ACCIDENTAL PRODUCTIONS
OF THE LUNGS.

SECTION FIRST.

Of accidental productions of the Lungs in general.

Various species of cancer, of cysts containing fluids of dif-
ferent kinds, hydatids, cartilaginous, bony or cretaceous tumours,
are occasionally developed in the lungs. At present I shall only
take notice of such as I have had occasion to study thoroughly, or
which have been particularly noticed by others. These produc-
tions are: 1st, cysts, properly so called; 2nd, cysts containing hy-
datids; 3rd, fibrous, cartilaginous, bony, or osteo-cretaceous tu-
mours; 4th, tubercles; 5th, the species of cancer which I have
named Encephaloid or brain-like tumour; and 6th, and last, the
species of cancer which I have denominated Melanosis.

The effect of these various productions on the surrounding tissue
of the lungs, is much less than might be expected. In cases of
tubercles, for instance, (and the same thing applies to all kinds of
accidental productions found in this organ) the substance of the
lungs, in the intervals of these, continues equally crepitous as in
the sound viscus, and exhibits no trace of the compression which
such tumours might be supposed to produce. This is the more
remarkable, as, in many cases, the united volume of the tubercles
is more than equal to the fourth part of the lung itself, while their
weight is one or two pounds: and the circumstance is the more
striking when we consider, that a few ounces of effused serum al-
ways produces upon some portion of the lung a degree of compres-
sion sufficient to render it impermeable to the inspired air, and to
produce in it a particular flaccidity, which will be noticed more
fullv when we come to treat of pleurisy. Sometimes, indeed, we
find in the vicinity of one species of tumours (tubercles) the pul-
monary tissue impermeable to air, but this obstruction is the pro-

(00 DISEASES OP THE LUNGS.

duct either of the tubercular impregnation (noticed in Ohap. I.
Sect. 1.), or of the serous infiltration which sometimes takes the
place of this, or finally, of true inflammation of the part: in no case,
does lie change of structure resemble the flaccidity produced by
compression. This flaccidity, however, is frequently observed in
the vicinity of pulmonary cicatrices, particularly of those which
are hard, cartilaginous, and of an irregular form. I have found
tumours of the size of the fist, around which the substance of the
lung was quite crepitous, and without any mark of compression.

SECTION SECOND.

Of Cysts in the Lungs.

Br the term Cyst I understand, with the greater number ol mo-
dern anatomists, a species of shut sac, commonly rounded, some-
times, however, irregular and anfractuous, and containing a liquid,
or, at least, soft matter secreted by the membrane which forms
the sac.

There is, indeed, another Species of cyst, — namely, that which
contains substances of a more solid kind, and which are in their
nature different from the ordinary products of the animal economy,
and to which productions the cysts, now alluded to, merely serve
as an envelope: examples of this species are furnished by tuber-
cles, and the different kinds of cancer. In the present section it
is my intention to speak only of the former species of cysts. These
are always formed of a natural tissue, that is to say — of a tissue
similar to some of those which exist naturally in the healthysub-
ject. Most commonly they resemble, in every respect, the serous
membranes, for instance the pleura and peritoneum— as has been
observed by Bichat; sometimes, however, they are more allied to
the mucous membranes, as those of the bladder and intestines
Very generally a layer of a fibrous substance, or of condensed cel-
lular tissue, more or less thick and usually incomplete, surrounds
these cysts and unites them to the neighbouring parts.

Sometimes we find cysts entirely formed of these two last men-
tioned i issues, except that, in this case, there is commonly super-
added cartilaginous substance, and also bony plates of greater o

CVSTS. 101

less extent. The internal surface of these compound cysts has
never the smooth polished aspect of the serous or mucous varieties,
but is, on the contrary, unequal, rugged, and frequently studded
here and there by a half concrete, albuminous or fibrous matter,
which is intimately united with the cyst itself, and passes insensi-
bly into its peculiar structure.

Of all morbid growths, encysted turnouts are most rare in the
human lungs. Morgagni gives only one example of the sort. It
is, however, by no means uncommon to find them in the lungs of
certain animals, particularly of the ox and sheep. These are com-
monly of the serous kind, consist of a very fine membrane, and
contain a thin and very clear fluid. In the human subject I have
only met with three or four examples of cysts, and they were all
of the kind described in the former part of this section. The
largest I have met with was capable of containing an apple, and
was seated in the inferior lobe of the right side. This cyst was
very irregular in its shape, and varied in thickness from two to
four lines. It was covered infernally with an albuminous or fi-
brinous substance of a yellowish white colour, very similar in ap-
pearance to the middle coat of an artery. This substance had an
irregular surface, and seemed in some points as if falling into de-
cay (detritus). Externally the cyst was completely fibrous, and
resembled tendon in appearance. In some spots it had the cha-
racter of cartilage, and, moreover, contained several plates or spi-
culae of bone. These were of different lengths, and some were
placed parallel with the sides of the sac, and some perpendicular to
it, so as to project on one side into the cyst, and, on the other,
into the surrounding pulmonary tissue. In their latter direction
they were, however, separated from the true tissue of the lung,
by a thick layer of a fibrous character, which adhered very firmly
both to the ossified point and to the substance of the lung, so as to
be not at all separable from the latter, although the line of de-
marcation between the two was very distinctly marked. The en-
velope or sheath which surrounded these spiculae, both in the pul-
monary tissue and in the coals of the cyst, forsook them on their
passing into the cavity of the latter, so that they projected into it
quite bare. This cyst contained a yellowish puriform fluid.

|0"2 DISEASES OF THE LUNGS

SECTION THIRD.

Of Hydatids in the Lungs.

The only species of Hydatids which I have found in the lungs
belongs to the genus to which I have given the name of Jlcephalo-
cystes.* These animalcules, for a long time confounded with
cysts, or encysted tumours properly so called, consist of a simple
vesicle of an ovoid or spheriod shape, and of very variable size,
soft, and of a consistence and appearance analogous to that of
white of egg half boiled. Their coats are diaphanous or semi-
transparent, colourless, or of a milky colour, varying sometimes
towards reddish, yellowish, greenish, or greyish. The fluid con-
tained in these vesicles is usually serous and limpid, sometimes
turbid, and tinged with a yellowish or sanguine hue. Sometimes
.a large vesicle includes several smaller ones; at other times, still
smaller ones are found adherent to the internal or external surface
of their parent, from which they only . appear tobe separated
when they have attained a certain size.

Hydatids present no distinguishable organ, and offer the simplest
example of an animal that can be imagined. This extreme sim-
plicity of conformation has induced some writers to call in question
their animalcular character. In this place I shall merely observe
that M. Percy has seen this species of hydatids move in a very
distinct manner, and I have myself observed all the stages of
their reproduction. This takes place, as in Gertain polypi, by a
process somewhat like budding. Small buds form in the thickness
of the coats of the animalcule, which project either exteriorly or
interiorly, grow hollow, assume the rounded form as they enlarge,
and finally detatch themselves from their parent.

Hydatids are always inclosed in a cyst which completely sepa-
rates them from the surrounding parts. These cysts arecommonl)
of a fibrous nature, but frequently there are found in them portions
of a cartilaginous or bony character. Their internal surface is
rarely smooth; frequently it is so unequal as to have the appear-
ance of being torn. Sometimes it is lined by an opaque albumi-
nous matter, semi-concrete, and partially reduced to detritus, and

* Bulletin de Faculty de Mede'cine, No. 10—180*

HYDATIDS. . 103

Qf a yellow ochrey or tawny colour. When there are several hy-
datids in one cyst, this further contains a fluid in which they float,
which is sometimes limpid, sometimes turbid, yellowish or san-
guinolent. When the cyst contains only one hydatid, this some-
times fills it completely, and lines, as it were, its internal parietes.

This species of hydatids may originate in almost every organ
in the body. They have been often met with in the lungs; at
least, all the cases of hydatids recorded as being found in this
viscus, appear to me to belong to this species. The most remark-
able are those published by Johnson,* Collet,f Malloet,J Baumes,§
and GeofTroy.j| I shall here give an abridgment of the case of
M. Geoffroy.

Case 27. A young man had an attack of peripneumony when
18 years of age, which was perfectly cuced, and he remained
well two years; he then caught a violent cold, which was attended
by acute pain in the left side preventing him lying on it. He
never got q«ite well of this last symptom. He was afterwards
attacked with jaundice ,which lasted three months, and he also
passed some portions of taenia. The cough and pain of side re-
turned after this, very violently, and, upon their cessation, he dis-
covered a small moveable tumour situated in the right hypo-
chondre. This tumour increased and extended towards the um-
bilicus, being attended by colic and headach. 'She pulsation
of the heart was very strong in the epigastric region. The princi-
pal symptoms at the end of three years were constant dyspnoea,
which increased to a feeling of suffocation on going up stairs; —
frequent faintings; — occasional cough and spitting of blood, and
constant tremblings. After a year and half, these symptoms in-
creased, and the fits of suffocation became more violent. In om
of these he suddenly expired.

On examination after death, a large hydatid was found partly
contained in the liver, and partly projecting into the abdomen.
Its coats were thin, yet fibrous. It contained a fluid of a brown
colour, and a great number of smaller hydatids, most of them of
the size of peas, one or two as large as the yolk of an egg. The
lower end of the sac adhered to the small curvature of the stomach.
In the chest there was found on each side an enormous hydatid
containing five pints of fluid. They adhered to the ribs and the
mediastinum, and by their increase had compressed the lungs into

* Philos. Trans. Abridg.

f Comment, de reb. in. scient. nat. vol. xiv.

* Mem. de l'Acad. des Scienc. an. 1782.
§ Annates de Montpel. torn. i.

II Bulletin de rEcol.de Med. an. 180$

104 DISEASES OF THE LUNGS.

a thin leaf on the anterior part of the cavity. The heart was
completely thrust out of the thorax into the epigastrium. Each
hydatid was eleven inches long, and contained five pints and a
half of a perfectly limpid fluid. It is difficult to learn, from the
description of these hydatids, whether they originated in the sub-
stance of the lungs, or merely beneath the pleura pulmonalis or
costalis. I think it, however, most probable, that they originated
in the substance of the lungs. M. Cayol has since presented a
case very similar to the above, which has not yet been made
public.

In the Journal deMe^decine for 1801, there is the case of a man
who expectorated for several months, rounded pellicles which were
evidently the remains of dydatids, and some seemed to be these
merely flattened. I have since seen two similar cases, both of
which, as well as that recorded in the Journ. de Med. were cured.
On this account the actual seat of these bodies could not be de-
termined, but there can be little doubt of its having been the
lungs.

A young woman consulted me being affected with severe dysp-
noea, cough, abundant expectoration and emaciation: in short, all
the ordinary symptoms of phthisis pulmonalis. One day, after
acute pain of the epigastrium, she evacuated by stool a consider
able quantity of hydatids, of a size from that of a filbert to a
pigeon's egg. From this very day the hectic fever, the catarrhal
symptoms, and dyspnoea ceased, and shortly after the patient re-
gained her flesh and strength. May we believe in this case, that
a cyst situated in the left lung made a passage into the stomach or
colon through the diaphragm?

SECTION FOURTH.

Of Bodies of a Cartilaginous, Bony, Calculous, and Chalky
nature, formed in the Lungs.

These various productions are frequently met with in the
longs, and they have, indeed, been noticed by almost every
pathological anatomist since the sixteenth century.

Besides the cartilaginous productions already described in a

OSSEOUS CONCRETIONS, ETC. 105

former chapter, we sometimes find in the lungs cartilaginous cysts
inclosing bony or chalky concretions, of the kind immediately to
be described; and also cartilages of no regular shape or size,
containing here and ihere points of incipient ossification. The
bone which is formed in these cartilaginous bodies, or, without
their previous piesence, in the substance of the lung, is never of
a perfect kind; or, at least, I have never met with any accidental
production of this kind in the lungs which had either the fibrous
texture or solidify of the middle of the long bones, or the spongy
character of the ends of the same bones It appears, that, In
their formation, a greater quantity of calcareous phosphate, and
a much less proportion of gelatine is employed, than in true bone:

hence these bodies resemble more a piece of stone than bone,

a character which accounts for the epithets calculous and to-
phaceous given to them by authors. In some cases they do not
contain a particle of gelatine; and, in this case, the calcareous
phosphate resembles moistened chalk.

I shall notice these different varieties under the name of im-
perfect ossifications and chalky concretions.

The imperfect ossifications are encysted, or not encysted. The
former are very rare in the lungs. They are of a rounded form,
of a size from that of a hemp-seed to that of a hazel-nut, and
are inclosed in a cartilaginous cyst, of a line or line and half in
thickness, which adheres closely the them.

The non-encysted ossifications are of a very irregular shape.
Their surface is rugged and rough. Interiorly they are white,
opaque, very similar to calculous productions, and readily reduced'
to powder by being bruised. On the other hand, their external
parts are somewhat yellowish, slightly diaphanous, more difficult-
ly pulverizable, and, in short, in a more perfect state of ossifica-
tion.

These ossifications are found sometimes included in, and inti-
mately adherent to the pulmonary tissue; at other times they are
observed in the centre of a cartilaginous production; and fre-
quently in the body of a tubercle, especially those of the bron-
chial glands. In the latter case, when the'tubercle softens, the
bony concretion may be found loose in the cavity, or may be
expectorated, if it is not of too great a size to pass through the
bronchia.

The chalky concretions are found in two states, — one re-
sembling chalk slightly moistened, the other like chalk complete-
ly softened in water. In the last state they are always encysted;
in the first, they may, or may not be, although tbey are most

14

jQQ DISEASES OF THE LUNGS.

commonly so. When crushed between the finger and thumb, they
are sometimes reduced to an impalpable powder, but frequently
they give the feeling as if grains of sand were intermixed with
the soft chalk. These grains are small ossified poinls.

The cysts enclosing these cretaceous productions are commonly
cartilaginous. They are rounded, or without any regular figure.
I have seen one in the form of a pyramid with four unequal
sides. The rounded cysts are sometimes bony, but of an imper-
fect ossification, and resembling in all respects, the semitranspa-
rent external crust of the osseo-calcareous concretions described
above. I have sometimes found concretions of this sort composed
of several bony or cartilaginous cysts, one included within the
other, and each separated by a layer of soft cretaceous matter.
It is much more common to find this half fluid chalky matter in
the centre of a tubercle, particularly in tubercles of the bronchial
glands. In this case, although the matter is equally soft as the
substance of the tubercle itself, still it is easily distinguished
from it, by its greater opacity, and by its whiteness, which forms
a considerable contrast with the pale yellow colour of the tuber-
culous matter. When allowed to dry, this cretaceous matter be-
comes white, and acquires a degree of cohesion which prevents
it being pulverised by the mere pressure of the finger.

The bony or cretaceous concretions of the lungs are commonly
very small; I have never seen them larger than an almond.
Neither have I ever seen the complete conversion of a portion of
lung into a substance of this sort, but sometimes I have observed
the pulmonary tissue around an imperfect cicatrization as if in-
jected, or impregnated with a small quantity of disseminated
chalky matter.

Very singular opinions as to the cause and origin of these cal-
careous productions are to be found in the writings of most patho-
logists. Cullen, with many others, regards them as a frequent
cause of asthma, and thinks that they may be occasioned by the
powdery substances diffused through the air breathed by different
kinds of artisans — such, for instance, as starch-makers, lapidaries,
lime-burners, &c The chemical nature of the concretions, so
much better known than formerly, renders this opinion quite un-
tenable at the present day. I do not mean to deny that the ha-
bitual respiration of a powdery atmosphere may cause a tempora-
ry dyspnoea? and even be the source of a formal disease of the
lungs; but as a proof that too much stress has been laid on this
circumstance as a cause of pulmonary disease, we have only to
examine the expectoration of a person who has passed the night

OSSEOUS CONCRETIONS, ETC. 107

in an apartment the air of which has been rendered turbid by
the smoke of a lamp, or of a carrier who has been all day on a
road enveloped in clouds of dusl: — in either case, we shall find
that, in the course of four-arid-twenty hours, the whole of the
extraneous matter has been expelled along with the bronchial
mucus. Besides, if such substances could be retained in the
lungs, they would be retained in the bronchia, and we should, in
such a case, find there an accumulation of such matters, differing
in their nature according to the particular kind of occupation of
the individual. Now, I believe, nothing of this kind has ever
been discovered on dissection; at least, I can assert that I have
never met with any thing of the sort, though I have examined
the lungs of a great number of persons who had passed their
lives in workshops of which the atmosphere was constantly
charged with calcareous or other kinds of dust.

Furthermore, I do not intend denying that the existence of a
great number of bony concretions in the lungs may be productive
of habitual dyspnoea, more or less severe; but I can assert that I
have met with such concretions^ and in great quantity, in the lungs
of persons who had never experienced any affection of the respi-
ration; and 1 am convinced, as well by my own dissections, as
by those given by other observers, that those concretions have never
been found sufficiently voluminous, numerous, or congregated, to
justify our attributing to them any case of dyspnoea sufficiently
intense to be reckoned by any practitioner under the head of
asthma.

The opinions of M. Bayle respecting the effect of these concre-
tions are very singular, quite unsupported by either reasoning or
analogy, and, indeed, raiher invalidated than confirmed by the
facts he has himself adduced. He considers them as one cause of
Phthisis, and gives the following statement of the symptoms produc-
ed by them: " The greater part of subjects (he says) affected with
this disease, expectorate small calcareous fragments, of a greyish or
whitish colour, often in great number, and they have a dry cough
for a long period."

It is remarkable that M Bayle mentions neither expectoration,
dyspnoea, wasting, nor hectic fever, as symptoms of the complaint,
and it is therefore singular how he has been led to reckon it as a
species of consumption. The two examples adduced by him are
very little to the purpose. The first (case 33) is the case of a
man affected for nine months with a slimy expectoration, inter-
mixed with puriform sputa, and occasionally with small chalky
fragments. Hectic fever supervened and carried him off in six

JOS DISEASES OF THE LUNGS.

weeks. A great number of small cretaceous concretions, some
soft, some hard, some encysted, some not encysted, were found in
thelungs. The substance of the lungs was slightly indurated
around these concretions, but, in other respects, healthy. In this
instance it is evident that the consumption and death were pro-
duced by a chronic catarrh: and I see no reason to attribute the
result to the concretions, since we often find them equally numer-
ous without any such consequence. The second example (case
34) is that of a man who died of fever complicated by pleuro-
peripneumony. He had experienced for twelve months dyspnoea,
frequent cough, and consequent mucous expectoration, but very
little emaciation. In this as well as the former case, we find no-
thing characteristic of true consumption.

In examining ihe cases of pulmonary concretions of this kind,
contained in the writings of Morgagni, Bonetus, and various other
authors, it is easy to perceive that, in most of them, the existence
of these was productive of no severe symptom, and that even the
dry cough, or cough with ropy expectoration, — symptoms most
nearly allied to consumption, — was by no means a constant attend-
ant on such a condition of parts. My own dissections afford a
similar result. I have often found concretions of this kind in per-
sons who had no disorder of the respiration. Others had a dry
cough, or cough with expectoration of different kinds, and with or
without dyspnoea; but there was in almost all these, some other
morbid alteration of the pulmonary tissue, to which the symptoms
might be attributed with as much (or more) justice as to the con-
cretions.

In particular it is very common to find coexisting with these
concretions, traces of cicatrizations in the lungs, of the kind de-
scribed in a former chapter; and, at the same time, to observe the
pulmonary tissue flaccid, hard, and impregnated with a great
quantity of black pulmonary matter around the concretions, and
the interstices that separate them from the cellular, fibrous, or car-
tilaginous cicatrices alluded to, (see page 47).

From these facts I am led to believe, that, in most cases, these
concretions are consequent on tuberculous affections that have been
cured, and are the product of the curative efforts of nature, which
appear 'o have elaborated a superabundance of the calcareous
phosphate, which is necessary to the formation of the cartilagi-
nous bodies which constitute, for the most part, the fistula; and
cicatrices that are found in such cases in the lungs. Several of
the cases related (3 and 6) countenance this opinion, and others to-
the same purpose will be given afterwards.

MELANOSIS. 109

I by no means, however, wish to assert that concretions of this
kind may not take place in the lungs primarily, and independently
of the previous existence of tubercles; but I look upon such cases
as very rare; and, when they do occur, I am assured that they give
rise to little or no disorder of the system.

SECTION FIFTH.

Of Melanosis of the Lungs.

The older surgeons, and, after them, the modern anatomists,
have confounded, under the name of Scirrhus, Cancer, or Carci-
noma, different morbid growths which have no common character
but that of their being unlike any of the natural or healthy tissues of
the body, — their originating in an indurated state, — and their subse-
quent softening and self-destruction. This confusion has proved a
great bar to the progress of morbid anatomy. Convinced of this, I
have paid particular attention to the discrimination of these various
productions, and have succeeded in pointings out several very
distinct species. That which I am now to notice, and which I de-
scribed many years ago (1806) in an unpublished memoir present-
ed to the Faculte de Medecine, is the most easily recognised in
all the organs except the lungs, in which, owing to its colour, it is
sometimes very difficultly distinguishable from the black pulmonary
matter.

In their early or crude state, these productions possess a consist-
ence equal to that of the lymphatic glands, and a homogeneous
and somewhat humid composition; they are opaque, and, in struc-
ture, very much resemble the bronchial glands. When they begin
to soften, a minute portion of fluid can be expressed from them, of
a thin reddish character, intermixed with small blackish portions,
which is sometimes firm, sometimes friable, but which, even when
friable, conveys to the touch an impression of flaccidity: in a more
advanced stage, these portions first, and subsequently the whole
mass in which they are contained, become quite friable and are
soon converted into a black paste.

Melanosis may exist in four different forms, viz: 1st, encysted;
2nd, non-encysted; 3rd, impregnating, or infiltrated into the na-
tural substance of an organ; and 4th, deposited on the surface of
an organ.

First kind. Encysted Melanosis. The cysts enclosing this

U q DISEASES OF THE LUNGS.

species are very regularly rounded, and vary in size from that of
a small hazel-nut to that of a walnut. At least, I have never met
with any that did not come within these dimensions. They have
a very regular and equal thickness, whrh is never greater than
half a line. Cellular substance appears to be the only tissue that
enters into their composition. They adhere, by means of a very
fine cellular tissue, to the substance of the organ in which they
are situated, and from which they can be readily separated by dis-
section. Their interior surface is rather smooth, but adheres to
the morbid matter which it surrounds. The medium of this ad-
hesion appears to me to be a very fine imperfect cellular tissue,
though it cannot always be distinguished. I have hitherto only
found this variety of melanosis in the liver and lungs; and, in the
latter organ, I have only as yet met with a single mass of it.

Second kind. Un-encysted Melanosis. This variety is much
less rare than the preceding: I have met with it in the lungs, the
liver, pituitary gland, and the nerves. The volume of masses of
this kind is quite undeterminate, — varying from that of a millet-
seed to that of an egg, or more. They are also quite irregular in
figure. They commonly adhere very closely to the parts in which
they are situated; sometimes, however, they are united to these by
a very fine, though sufficiently visible, cellular tissue, which per-
mits their removal without any laceration. In this last case they
are commonly of a rounded shape.

Third kind. Impregnation of the natural tissue with the mat-
ter of Melanosis. It frequently happens that this morbid matter,
in place of being segregated in distinct masses, is disseminated
throughout the organs in which it is found, and deposited between
the particles or molecules of the natural tissue. The appearance
and colour of parts affected in this manner present a good many
varieties, according to the texture of the organ, the quantity of
morbid matter deposited, and the particular condition of this mat-
ter. When the infiltration is recent, and in moderate quantity,
the appearance of the affected part merely differs from the natural
condition in being intermixed with small black dots or striae, the
intermediate portions being quite of a healthy character. As the
disease increases, the dots and striae enlarge in number and vo-
lume, until the whole of the natural tissue of the part is lost in the
morbid degeneration. It is usually only at this period of its pro-
gress that the melanotic matter begins to soften; but if the soften-
ing takes place before the complete removal of the natural tissue
of the part, it frequently happens that this softens also, and inter-

MELANOSIS. Ill

mingles with the morbid matter, the colour of which is thereby
changed to brownish, yellowish, or greenish.

Melanosis, like all the other accidental productions which dif-
fer from the natural tissues of the animal economy, gives rise to
constitutional and local disorder. Among the constitutional or
general effects, the most constant are the gradual diminution of
the vital powers, and a marked change in the process of nutrition,
whence result emaciation, to a considerable degree, and dropsy of
the cellular membrane, and, sometimes, of the serous membranes.
The subjects whom I have known to die in consequence of mela-
nosis in any organ, had no continuous or well-marked fever; and
this is true of cases wherein the disease extended to a great por-
tion of the lungs, and is also observable in the two cases (a() and
21) of the same affection given in the work of M. Bayle. If this
circumstance holds good generally, as I am much disposed to be-
lieve, it will assist in enabling us to distinguish, during life, Con-
sumption produced by Melanosis of the Lungs, from that depend-
ing on tubercles; which last, as is well known, is accompanied,
almost through its whole course, by a hectic fever, which is usu-
ally characterised by two exacerbations, — one towards mid-day,
and the other in the night.

The most constant of the local effects produced by melanosis of
the lungs are dyspnoea, proportioned to the extent of the disease,
and cough, which is often dry, but sometimes attended by a mu-
cous expectoration intermixed with some puriform sputa.

The melanotic masses in the lungs may be sometimes com-
pletely softened, so as to leave, after their evacuation into the
bronchia, cavities resembling those produced by the softening down
of tubercles. I have myself never met with excavations of this
sort in the lungs; I have met with them, however, in the liver;
and the work of M. Bayle contains two cases (20 and 21) which
incontestibly prove the possibility of their formation in the lungs.
In these cases the pulmonary tissue, so much impregnated with
melanotic matter as to be as firm as liver (or even firmer) con-
tained a multitude of small excavations evidently formed by the
partial softening of the same matter.

Melanosis is one of the rarest species of cancer, and is ex-
tremely seldom met with in the lungs. This may seem an extra-
ordinary assertion after the contrary assertion of M. Bayle, and
the cases given in his work under the name of Phthisis with Me-
lanosis. Whatever distrust I may have of my own opinions when
they differ from those of that excellent observer, with whose ex-
treme correctness I had better opportunities of being acquainted

112

DISEASES OF THE LUNGS.

than any other person,— I cannot help, nevertheless, being ot opi-
nion that he was deceived on this particular point, and that he
sometimes confounded with melanosis, the natural black pulmo-
nary matter. I admit that these two substances are very much
alike in their external characters, and I am not sure that the most
experienced observer could discover any difference between a me-
lanotic mass in the liver or any other organ, and a bronchial
gland of a perfectly black colour, such as they are often found
in very sound lungs. I will not say that the following charac-
ters suffice to distinguish the two substances, but they may at
least assist us in discriminating them: — The matter of melano-
sis, when softened, and even that which can be expressed from it
while yet solid, dyes the skin black; but this colour is not very
permanent, and can be easily removed by washing; while the
blackness produced by the matter of the bronchial glands, if this
be left to dry before washing, will remain on the skin for several
days. The chemical composition of the two bodies also differs
very considerably. The bronchial glands, according to Fourcroy,
contain a large portion of carbon and hydrogen, while the matter
of melanosis contains neither of these, but is almost entirely com-
posed of albumen and a peculiar colouring matter.

Notwithstanding its resemblance to this natural substance, me-
lanosis is evidently a morbid and very deleterious production, in-
asmuch as it produces all the local and general effects of other
cancers, when it exists in a certain extent; and since it is found
united with other morbid productions in compound cancerous tu-
mours.

When melanosis forms masses of considerable extent, or when
it impregnates the pulmonary tissue so thoroughly as to give it a
deep black colour, and a consistence equal to that of liver, it is
easily recognised; but when the impregnation is recent, and not
sufficiently abundant to produce any notable induration of the
lung, it can, with difficulty, be distinguished from the black pul-
monary matter.

1 have already mentioned this black pulmonay matter several
times. It has been little noticed by anatomists; yet it exists so
commonly in the lungs, and even in those of persons in the most
perfect health, that we can hardly consider it as an unnatural or
morbid production. It is found more or less abundant in the
lungs of almost every adult, and seems to increase with the age of
the individual. In early infancy, we perceive no trace of it, and
the lungs are of as pure a rose colour as those of the ox, and se-
veral other animals. Perhaps this peculiar matter exists only in

MELANOSIS. 113

man, and the carnivorous animals; but I have been too little prac*
Used in comparative anatomy to advance any thing on the subject.
When it exists only in small quantity it merely gives to the lung
a slight grey tint. On the surface of the lung it appears in small
disseminated black dots, which are more numerous and thicker
along the intersecting lines of the cells, so as to form striae, small
spots, or punctuated lines. These spots, still further crowded in
different places, as well in the interior as on the surface of the
lung, form spots still larger and more numerous, so as sometimes
to give a black colour to large portions of these organs In no
case, however, does this matier affect the suppleness or permea-
bility of the lung, a circumstance which forms a striking contrast
with the melanotic infiltration.

It is particularly in the bronchial glands that this peculiar mat-
ter* is found most abundant. In adults, and especially in old
persons, they are often found completely black; in others they are
only partially impregnated, as if touched by a pencil. A condi-
tion of parts so common cannot be regarded as morbid, especially
as it is often unattended by any symptom whatever of disorder.
This matter in the bronchial glands would appear to be the cause
of the grey colour of the bronchial mucus, which many healthy
persons expectorate, and of the small black specks found fre-
quently intermixed with that transparent secretion. This cha-
racter of the bronchial mucus, establishes another distinction
between the black pulmonary matter and the substance of mela-
nosis, as the existence of the latter, even in the greatest degree,
never gives rise to an expectoration of a black colour, unless, per-
haps, at the very moment of the escape of the softened melanotic
mass into the bronchia. (See Bayle's cases 20 and 21.)

The formation of tubercles in the lungs, and, more especially,
the cicatrization of the tuberculous excavations, frequently pro-
duces, as I have previously observed, a more abundant secretion
of the black pulmonary matter. In some cases this abundance is
such, as — in conjunction with the compression of the pulmonary
tissue produced by the tubercles, the cartilaginous cicatrices and
the chalky matter that accompanies them, — to render the affected
part notably indurated, flaccid, and more or less impermeable to
air. In extreme cases of this kind, it is difficult to say whether
the colour and density of the affected part are the consequence of
black pulmonary matter or of melanosis. The rule of distinc-
tion we ought to follow in such cases is the following: — We ought

* Orif*. matiere de melanoses — evidently a mistake. — Trans

15

1J4 DISEASES OF THE LUNGS.

not to admit the existence of [circumscribed] melanosis, unless
we find some of it in portions of some extent, and already soften-
ed, or, at least, so deposited and shaped as to distinguish ii from
bronchial glands. We ought not to admit the existence of the
infiltration of this matter, unless it has produced in the lungs a
degree of induration equal to that of liver: and when this degree
of hardness can be (meed to ihe presence of bony or cartilagi-
nous bodies, we ought to consider the black colour as derived from
the black pulmonary matter.

To render this distinction more easy I shall here detail two
cases. The Hist is an instance of melanosis occurring in the lungs
and in several other parts of the body. I prefer it because it ex-
hibits the disease in a great degree of development, and because
it was drawn up neither by myself nor by my direction: it is ex-
tracted from the register of cases by the hospital pupils for 1816,
preserved in the office of the board of administration. The se-
cond case offers an example of the difficulty of distinguishing the
black pulmonary matter from the matter of melanosis.

Case 28. A woman, aged 59, entered the hospital for an af-
fection of two months' standing, which had arisen after violent
grief. The disease commenced with greaf prostration of strength,
loss of appetite and sleep. These symptoms were followed by
vomiting and diarrhoea, and the development of small tumours, of
a black colour, in different parts of the skin. When she came
into hospital, a great number of these tumours, of the form and
colour of grains of cassia (cassis) occupied the anterior part of the
thorax. The spaces between some of these were filled with small
spots very like flea-biles. The tumours were so close on the
breasts as to form a large plate or crust. Some of the same sort
existed in the abdomen, the largest being two inches in circumfer-
ence. The arms and thighs, especially on their inside, were
marked in a similar manner; the fore-arms and legs were without
any. In addition to the symptoms already mentioned, the respi-
ration was difficult, there was frequent cough, and the pulse was
extremely quick. These symptoms gradually increasing in de-
gree and being followed by oedema, the patient shortly after died.

On dissection the cutaneous tumours were found to consist of a
homogeneous substance, of a more or less deep black colour, and
of a consistence in some cases very considerable, in others merely
pulpy. . These tumours had all cysts of cellular substance, and ap-
peared to be evidently of the kind already described as Melanosis.
They were found in almost the whole of the subcutaneous cellular
tissue; also in the same tissue which incloses the vessels, nerves.

MELANOSIS. 115

and the lymphatic glands. In some places they formed by their
aggregation masses as large as the fist. The nerves in their vici-
nity were sound, but the blood-vessels could not be separated
from (hem without rupture. These tumours were found in the
thyroid gland; also, in small quantity, in the lungs. In the
neighbourhood of the bronchial glands they were numerous and
larger: the bronchial glands themselves were not black. They
were seen in the substance of the mediastinum, and under the
pleura; also, in great numbers, in the mesentery and omentum.
All the abdominal viscera, except the liver, were sound, but the
cellular substance around them contained similar tumours. The
heart and brain were sound.

Case 29. A man, 60 years of age, died after having laboured
under cough and expectoration, and other symptoms more or less
allied to consumption, but not well marking this disease. For
several weeks there were swelling and fluctuation of the abdo-
men.

On dissection there was found, in the superior lobe of each lung, .,

a large cartilaginous cicatrice, with an external depression similar \
to those described in the chapter on Phthisis. The neighbouring ,

parts contained a vast quantity of black pulmonary matter, so as I

to give to the lung the blackness of ink, and were also interspersed '

with bony and cretaceous particles. The other lobes were slightly
tinged with black pulmonary matter, and contained a few imma-
ture tubercles. There were adhesions between the heart and pe-
ricardium, and the ventricles were enlarged. The abdomen con-
tained a large quantity of a yellowish limpid fluid. The whole
peritoneum was of a dirty grey colour, and studded with innumer-
able small, red, grey, or black points. The red points, united in
flakes, had all the marks of being the result of an ancient inflam-
mation. The others seemed to be tubercles in the first stage, grey
and semitransparent; they formed small tumours on the surface of
the membrane, and some of them were of the size of large hemp-
seeds. Those which were of a black colour, and opaque, were
evidently formed of the matter of melanosis. These two species
of tubercles were most numerous on the intestinal portion of the
peritoneum; the red spots or flakes were, on the other hand, most
plentiful on the mesentery and omentum. This last was rolled
together so as to form a sort of hard and irregular tumour in the
left hypochondrium. The peritoneum seemed much thicker and
much softer than natural; but this arose from its being covered
throughout, between the granulations above mentioned, with a thin
and soft coating or layer of albumen.

116 DISEASES OF THE LUNGS.

In the first of these cases there can be no doubt of the nature
of the black tumours found in the lungs. The coexistence of
similar tumours in divers other parts of the body, and the absence
of the black colour in the bronchial glands themselves, leave no
doubt on the subject. In the second case, the question as to the
nature of the black matter in the indurated portions of the lungs,
is imich more difficult. The fact of the existence of bodies an-
swering lo the character already assigned to pulmonary cicatrices,
and, also, of bony and cretaceous tumours; and further, the imma-
ture tubercles in other parts of the lungs, as well as on the surface
of the peritoneum — all tend to support the opinion of the black
matter being merely the common black pulmonary matter. On the
other hand, the existence of some melanotic tumours on the peri-
toneum gives some colour to the suspicion of the black portions of
the lungs having derived their origin from the same source. The
arguments, however, are decidedly in favour of the former opinion.

I have already observed that M Bayle appears to have some-
times confounded the matter of melanosis with the common black
pulmonary matter I think he has been equally wrong in classing
melanosis of the lungs as a species of phthisis. In fact, the me-
lanotic affection, in place of producing progressive emaciation and
hectie fever, the most constant symptoms of tubercular plvhisis, —
rather tends to produce cachexy and anasarca, and usually proves
fatal before the supervention of any marked degree of emaciation.
If we were to class diseases from so feeble analogies, we ought to
range among consumptive diseases chronic pleurisy, peripneumony,
and catarrh, as well as several diseases of the heart, or, indeed,
every disease attended by dyspnoea and emaciation.

In medical writings we find but few cases which can be re-
ferred to this disease, melanosis; a circumstance which, no doubt,
proves its extreme rarity, since its characters, especially when
occurring in any other organ besides the lungs, are so well marked
as hardly to be mistaken. Haller relates some of the best mark-
ed instances of it. " I have observed," he says, •' a horrible
species of pulmonary consumption. In one man I found one lung
filled, not with pus, but with a matter black as ink; and in
another, I have since found a similar fluid in the cavity of the
pleura." Notwithstanding the brevity of these notices, it is im-
possible to mistake, in the first, the infiltration of the lungs with
the melanotic matter in a soft state; and, in the second, a secre-
tion of the same matter into the pleura.

MEDULLARY TUMOUR. U7

SECTION SIXTH.

Of the Medullary Tumour, or Soft Cancer of the Lungs.

This species of accidental production, which was described
for the first time in (he Diet, des Sciences Med. (Art. Encepha-
loides), is one of those that has been most frequently confounded
under the name of Scirrhus and Cancer. It is, indeed, the only
species of cancer found in the lungs by M. Bayle, and myself.
It has received its name from its striking resemblance to the
brain.

M. Bayle has considered this disease as constituting a variety
of consumption, and has named it Cancerous Phthisis. I will
not here detail my reasons for rejecting this species, as they are
nearly the same as already adduced against the admission of the
Phthisis with Melanosis of the same author. I may add, that in
all the cases which I have met with of soft cancer of the lungs,
death has been produced by suffocation before the period when
any thing like phthisical symptoms could have been produced.
And I am of opinion that the cases of this cancer uncomplicated
with tubercles, detailed in M. Bayle's work, — and even his gen-
eral description of the disease, — tend to establish the same con-
clusion. Soft cancer may exist under three different forms, viz.
1st, encysted, — 2nd, in irregular masses, — and 3rd, without cyst,
and diffused in the tissue of an organ. In whichever of these
forms it exists, it presents, in its progress, three different and dis-
tinct stages, — viz 1st, the incipient or crude state; 2nd, its per-
fect state, in which it exhibits the resemblance to brain which
forms its especial characteristic; and 3rd, its soft or dissolved
state. I shall first describe it as it is observed in the second, or
perfect, state; as this is the condition in which the three varieties
most nearly resemble each other, there being much difference
between these in their first and last stages.

Soft cancer in its perfect state is homogeneous, of a milky
white, and very like the medullary substance of the brain. In
different parts it has commonly a slight rose tint. It is opaque
when examined in mass, but in thin slices it is in a slight degree
semitransparent. Its consistence is like that of the human brain,
but it is commonly less coherent, being more easily broken and
comminuted by the finger. According to its degrees of density

118 DISEASES OF THE LUNGS.

it resembles one part of the brain more than another, but it is
more commonly like the medullary substance of a brain that is
more than ordinarily soft, (or like that of a child's,) than any
other part of the brain. When existing in any considerable ex-
tent, this species of cancer is, in general, supplied by a great
many blood-vessels, the trunks of which ramify on the exterior
of the tumours, or between their lobes only while the minuter
branches penetrate the substance of the tumours. The coats of
these blood-vessels are very fine, and readily ruptured: and (his
accident gives rise to clots of extravasated blood in the interior
of the tumours, sometimes of considerable size, which bear oc-
casionally a striking resemblance to those found in the brain of
subjects dead of apoplexy. Extravasations of this kind may
sometimes be so considerable as to supplant almost the whole of
the brain-like matter, so that the true nature of the tumour can
only be ascertained by some small points, still remaining, of the
original growth This change occurring in superficial tumours
of this kind, and being productive of much hemorrhage, appears
to me to have given rise to the name of fungus Hozmatodes ap-
plied to certain ca-ncers by modern surgeons. Under this name,
however;, 1 am also convinced thai they have confounded tumours
of different kinds, especially those commonly called varicose,
which are composed of an accidental tissue vtry analogous to
that of the corpus cavernosum penis. I have never observed
any lymphatics in tumours of this sort, but it is probable that the
* circulating system is complete in them, as 1 have seen their sub-
stance deeply tinged with yellow in cases of icterus. . The mat-
ter of this species of cancer does not continue long in the state
just described; it tends incessantly towards a softer condition,
and in a short space its consistence scarcely equals that of a
thickish bouillie or paste Then begins the last stage: the pro-
cess of softening becomes more rapid until the morbid matter be-
comes as liquid as thick pus, still, however, retaining its whitish
or rosy-white tint. Sometimes at this period, or a little earlier,
the blood extravasated from the vessels contained in the tumour,
becomes intermixed with the morbid matter, so as to give it a
dark red colour, and the resemblance of clots of pure blood. In
a short time the extravasated blood is decomposed; the fibrin
concretes, and, together with the colouring matter, unites with the
brain-like matter of the tumour; and the serum is absorbed. In
this condition the morbid growth retains no resemblance to brain;
it is of a reddish or blackish colour, and of a consistence like
that of paste somewhat dry and friable. Sometimes the change

MEDULLARY TUMOUK. ]J9

of structure and appearance is so complete, that one would be
Jed to consider the tumours as of a peculiar kind, but for the ex-
istence in them of portions of the original matter still unchanged.
In other cases, contemporaneously with tumours that have been
changed in this manner, there will be found others retaining the
original cerebral character: so that, in all cases, we are able
with a little practice, to discover the true nature of the tumour
in all its stages.

Such are the characters which this species of cancer presents in
its two latter stages, and equally in all the three varieties. I shall
now describe the characters of each of these varieties in the first
or crude state of the morbid matter.

First kind Encysted Medullary Tumour. The size of this
species is very various: I have seen the tumours as small as a
hazel-nut, and larger than a middle-sized apple. I have found
them as Jarge as this in the lungs. The cysts are of pretty equable
thickness; and this is never more than half a. line; they are of a
greyish white, silvery, or milky colour, and have a semitranspa-
rency, more or less, according to their thickness Their texture
is altogether cartilaginous, and rarely fibrous; but it is much softer,
and less easily broken by bending, than cartilage: on this account
they must be ranged among the imperfect cartilages.

The medullary matter contained in these cysts can be easily
detached from their inner coat. It is commonly divided into
several lobes, by a very fine cellular tissue, which may be compar-
ed with the pia mater, and the more so from the great number of
blood-vessels which traverse it. The fineness and brittleness of
these has been already noticed, and also their penetration of the
cerebriform matter itself. It is commonly in their early or crude
stage that these tumours are divided into distinct lobes. These
are especially observable on their superficies, and have sometimes
considerable resemblance to the convolutions of the brain. The
cyst does not at all enter between these convolutions, nor does it
even indicate on its surface their place or configuration. In this
stage the medullary matter is pretty firm, often firmer than the fat
of bacon. It is of a dull white, peari grey, or even yellowish
colour, and, in thin slices, has a slight degree of semitransparency.
When cut into, it appears interiorly subdivided into lobules
much smaller than those seen on its surface. These lobules are in
such close contact as to leave no interval whatever; and their
separation is merely indicated by the reddish lines traced by the
vascular cellular tissue by which their separation is effected. These
lines rarely cross each other, but exhibit many irregular curves
and convolutions.

120 DISEASES OF THE LUNGS.

When these tumours pass into the second stage, their texturf
becomes more homogeneous, and all distinction of the small
interior lobules is quite lost; the distinction, however, of the larger
exterior lobes still continues. The blood-vessels which run between
these lobes, and in the cellular tissue immediately investing the
tumour, are much more developed than in the early stage of the
disease, and it is only at this second stage, or as it approaches the
third, that the extravasations of blood take place.

The third slage begins, as I have already mentioned, when the
medullary matter has acquired a consistence like pap or paste, or
like that of a brain softened by commencing putrefaction. In this
state it has still much resemblance to cerebral substance. 1 have
never found that this morbid growth ever softens still more, or
that it is absorbed or evacuated, so as to leave an empty cyst or
cavity like tubercles. Hitherto I have only found these encysted
medullary tumours in the lungs, liver, and cellular substance of the
mediastinum.

Second kind. Unencysled Medullary Tumour. Medullary tu-
mours of this species are very frequently met with. Their size
is very variable; I have seen them from the 6ize of the head of a
full grown foetus lo that of a hemp-seed. Their shape is com-
monly spheroid, but occasionally flattened, ovoid, or altogether
irregular. Their external suriace is tabulated, but the divisions
are less regular than in the encysted species; their internal struc-
ture, in the two last stages, is precisely the same. The cellular
membrane which invests them is more or less marked, according
as they are placed in a loose cellular tissue, or in the substance
of a viscus of (irm texture: in the latter case, their investing mem-
brane is thinner and less distinct.

In their first or crude stage, their semitransparency is greater
than afterwards; they are almost colourless, or have a very slight
bluish tint in ocellated patches: they are pretty hard, and divided
into numerous tabes The aspect of this morbid matter is fatty,
like lard; but when incised it does not at al' grease jhe scalpel,
and it coagulates by heat without showing a panicle of fat. The
transition from the first to the second stage takes place in the
following manner: — the substance of (he tumour becomes more
opaque, softer, whiter, and its interior distinction into lobules for
the mosi part disappears. The original texture is observed longest
in the neighbourhood of the ex'ernal interlobular fissures. In
this situation I have found portions still in a state of induration after
the mass of the tumours had passed into the third stage. I am

MEDULLARY TUMOUR. Ijgj

Jed to conclude that the encysted medullary tuniour follows pre^
cisely the same progress as that just described.

The non-encysted medullary tumours may exist in any part of the
body; but they are most frequently met with in the loose and
abundant cellular tissue of the limbs, and in the larger internal
cavities. I have met with them in the cellular membrane of the
fore-arm, thigh, neck, and mediastinum; they are still more fre-
quently found in the cellular substance around the kidneys and the
anterior part of the spine, and in these situations they often have a
very large size. Although they are frequently found in the viscera,
they are, however, much rarer there than in the cellular substance.

Third kind. Interstitial impregnation of organs by the matter of
the medullary tumour. As I have never met with this variety in the
lungs, I shall not describe it is this place. I may merely observe
that it is distinguished from the unencysted tumour by forming
masses not at all circumscribed, in which the medullary matter
approaches nearer to the Imperfect or crude state, the more distant
it is from the centre of the tumour. It exhibits, moreover, a very
heterogeneous appearance, produced by its intermixture, in different
proportions, with the different organic tissues amid which it is
developed. In" the work of M. Bayle there is a case of this desease
in the lungs (case 36) communicated to him by me. I shall not
add any in this place, as the medullary is very easily distinguish-
able from every other species of cancer.

IjB

j 22 DISEASES OF THE PLEURA

&OOK SECOND

OF THE PLEURA.

CHAR L

OF PLEURISY, OR INFLAMMATION OF THE
PLEURA.

SECTION FIRST

Of Jlcute Pleurisy.

Pleurisy is inflammation of the pleura. It derives its name
from the stitch in the side, which is generally its most characteris-
tic symptom. Until very lately, there has been much difference
of opinion respecting the actual seat of pleurisy; some placing it
in the pleura, others in the lungs, others, again, in both these, and
some in the morbid adhesions existing between the lungs and
pleura. By the term pleurisy, however, we now almost univer-
sally mean, inflammation of the pleura alone, and it is in this li-
mited sense I shall use it in this chapter.

It is, nevertheless, true, that, in many instances, pleurisy and
peripneumony exist together; that, in cases where the pleura alone
is inflamed, the stitch of the side, which constitutes the principal
symptom of the pleuritis of the ancients, and also of many mo-
derns, — is either not at all, or scarcely perceptible, and then only

ACUTE PLEURISY. 123

momentarily; whilst, in other cases where a violent peripneumony
is combined with a slight pleurisy, the pain of the side will be ex-
tremely severe: still it holds good, that both pleurisy and peripneu-
mony may, and do, exist singly. There are particular epidemics
in which they are ordinarily conjoined, others in which they exist
separately: but we, in general, find more frequently on dissection,
peripneumony without pleurisy, than pleurisy without peripneu-
mony, — a circumstance which may be accounted for by the fact of
almost all the cases of simple pleurisy being cured.

Pleurisy is either chronic or acute. The anatomical character
of acute pleurisy, like that of the inflammation of all serous mem-
branes, is redness of the part affected. This redness is in some
sort punctuated, and looks as if one had traced with a pencil upon
the pleura an infinity of small bloody spots of very irregular figure,
and very close to one another. These red points occupy the
whole thickness of the membrane, and leave small intermediate
portions retaining the natural white colour. This punctuated ap-
pearance is unquestionably a character of the inflammation, and
not at all attributable, as some have supposed, to the partial disap-
pearance of the redness after death. Besides this particular red-
ness, — and even in those instances, where it is very inconsidera-
ble, — we- always find the superficial blood-vessels of-the pleura
redder, more distinct, and more distended than in the natural
state.

Many consider thickening of the pleura as a very common con«
sequence of inflammation. I must say, however, that I have
never clearly perceived this; and I think there can be no doubt,
that, in the greater number of cases wherein it had been thought
to exist, the supposed thickening has either been an extensive con-
geries of miliary tubercles on the outer or inner surface of the
pleura, — or a cartilaginous incrustation on the parts covered by it,
or, lastly, false membranes, more or less dense, closely adherent
to its internal surface.

Inflammation of the pleura is always accompanied by an extra-
vasation on its internal surface, and which may be considered as
the species of suppuration proper to serous membranes. This ex*
travasation appears to commence with the inflammation itself. It
consists of two very different matters. The one, of a firmer,
semi-concrete consistence, is usually termed false membrane, or
coagulable lymph; the other, very thin and watery, is called sero-
sity or sero-purulcnt effusion. Both of these exhibit great variation
of character.

The fake memhranes consist of a yellowish white, opaque, ov

124 DISEASES OF THE PLEURA.

slightly semitransparent matter, varying from the consistence of t
thick pus to that of boiled white of egg, or of the buffy coat of the
blood, to which last substance, indeed, these adventitious mem-
branes bear a strong resemblance in all their physical characters.
This substance closely invests the whole inflamed portion of the
pleura, following it, when the inflammation is general, through its
whole course, as well on the lungs as on the chest, and forming a
sort of complete inner lining of it. When the inflammation is con-
fined to either the pleura pulmonalis, or costalis, the inflamed por-
tion is alone covered by the false membrane. In cases of exten-
sive inflammation, very frequently the portions of false membrane
covering the lungs and costal pleura, are united by bands of the
same, which extend from one to the other through the serous fluid
effused into the cavity. In such cases the false membrane ad-
heres but slightly to the pleura, being readily separated by the
handle of the scalpel. These membranous exudations commonly
vary in thickness from half a line to two lines; for the most part
they are of uniform thickness, though, occasionally, they are
thicker in some points, especially on the lower side of the lung
and the corresponding parts of the diaphragm. In some instances
there are partial elevations or thickenings of the membrane
throughout its whole extent, in the form of lines which cross each
other so as to exhibit a sort of irregular net-work. Sometimes
these linear elevations are so close together, as to give to the mem-
brane the appearance of being studded or granulated with small
irregular tuberosities. In both these cases., the intermediate points
remaining comparatively thin and diaphanous, when contrasted
with the elevated portions, give to the membrane an appearance
very similar to the omentum when moderately loaded with fat.
This resemblance is particularly striking when blood-vessels are
already formed in the false membrane. Sometimes, particularly
when the extravasated serum is in great quantity, the false mem-
brane is found either wholly, or in part, detached from the pleura
and floating loose in the serosity. We even find detached irregu-
lar globular masses, of considerable size, which look as if they had
nevfr been adherent to any part. This, however, seems to me
quite inconceivable; and I think it more likely that the masses In
question were formed in the angular parts of the pleura, near the
attachments of the diaphragm and roots of the lungs, and that they
have acquired their rounded shape from the motion to which they
had been subsequently subjected.

The serous effusion which almost always attends tfie formation
of false membranes, is commonly of a lemon, or light yellow co-

ACUTE PLEURISY. 126

lour, transparent, or with its transparency only slightly disturbed
by the intermixture of small fragments, or filaments, of a concrete
pus or pseudo-membranous substance. In the latter case it accu-
rately resembles unstrained whey. This resemblance is so great
that some practitioners have really fancied that Ihey had discover-
ed milk itself in the sero-purulent etfusion of puerperal peritonitis:
and, truly, such a mistake might be pardonable, did we not find
an effusion exactly similar in the inflammatory affections of all
serous membranes, and in men as well as women.

In some cases the serum is of a very deep tawny colour, ruddy,
and evidently mixed with blood. Sometimes it is quite bloody.
This colour, when very deep, seems to be caused by a secondary
inflammation that has been produced in the false membranes them-
selves, as, in such instances, we very generally find them very red,
or covered with a great number of imperfect vet very perceptible
blood-vessels. The portions of the pleura situated beneath false
membranes exhibiting this appearance, are much redder than in
the most acute recent inflammation. The effused fluid is gene-
rally without any smell in the acute pleurisy. I have found it
fetid only in a single instance, in the case of "a man who died of
pleuro-peripneumony after imperfect poisoning by opium. In this
case the serosity and false membranes had a sharp vinous odour
extremely nauseous.

The relative proportions of the effused serum and albuminous
extravasation are not at all fixed. Sometimes the serum is ex-
tremely abundant, and the membranous exudation very small, and
vice versa. Generally speaking, the more violent the inflamma-
tion, the more extensive and thick is the membranous exudation.
In weak leuco-phlegmatic subjects, on the contrary, we find a
great quantity of limpid serum, with a small portion of thin mem-
brane, often floating in it. In such cases the pleurisy seems to
pass insensibly ioto hydrothorax., as we shall see more particu-
larly hereafter. In general the limpidity of the serum is propor-
tioned to the quantity of albuminous exudation.

In some rare instances we find a pseudo-membranous exudation
uniting the contiguous surfaces of the pleura, without any serous
effusion. This would, indeed, be a very common case if we took
into our account those pleurisies which had made some progress
towards a cure, as we shall find directly that the absorption of the
fluid is the first step in the sanative process. The cases, how-
ever, to which I here advert, are those observed in persons dying
of some other disease, and who were, at the same time, affected
with a slight and partial pleurisy. Jn these cases we find a white

J26 DISEASES OF THE PLEURA,

almost colourless, semitransparent exudation, which, while recent,
readily allows the separation of the parts it unites, and remains on
the surface of each, exactly like a thick and moist paste which had
united two leaves of paper.

In cases of peripneumony, also, more especially those which are
slight and partial, we sometimes find the pleura pulmonalis in the
vicinity of the part inflamed, invested by a false membrane, with-
out there having been any attendant serous effusion. We observe
the same thing frequently in cases of phthisis, especially at the
superior lobes. Such instances of partial pleurisy, — or, as we
might name them in contradistinction to the others, dry, — are, for
the most part, mere complications with some much more serious
disease, and are often unperceived, through their whole course,
both by the physician and patient. A local sensation of heat, or
occasional slight and transient pricking pains, are the only indica-
tions of such an affection in cases of consumption.

It is the character of the false membranes produced in pleurisy
to be changed into cellular substance, or rather into a true serous
tissue like that of the pleura; and this is the natural progress of the
process when left quite undisturbed. This change is produced in
the following manner: the serous effusion which accompanied the
membranous exudation is absorbed, the compressed lung expands,
and the false membranes investing it and the costal pleura become
united into one substance. By and by, this substance becomes
divided into layers pretty thick and opaque, which are separated
by a very small portion of serosity. About this time blood-vessels
begin to make their appearance in it, the first rudiments of which
have the aspect of irregular lines of blood, much larger than the
vessels which are to take their place. The blood seems as if it
had been forced into the substance of the false membrane by a
strong injection; and we find the corresponding portions of the
pleura redder than elsewhere, and as it were spotted with blood.
After a lime, the pseudo-membranous layers become thinner and
less opaque; the lines of blood assume a cylindrical shape, and
ramify in the manner of blood-vessels, but still preserving their
augmented diameter. On minutely examining these at this stage,
we find their external coat consisting of blood scarcely yet con-
crete, and VL'ry red; within ihis there is a sort of mould, or round-
ed substance, whitish and fibrous, and formed evidently of con-
creted fibrine, perforated in its centre, already permeable to the
blood, and evidently containing it. Eventually, the layers of the
false membrane become quite transparent, and nearly as thin as
of the ordinary cellular tissue, and the blood-vessels resem

ACUTE PLEURISY. 127

ble in every respect those which ramify on the inner surface of the
pleura. It wants, however, the firmness of the natural cellular
substance, being easily torn in our attempts to examine it, and its
vessels still retain the large diameter indicative of their recent
formation; and it requires some considerable time for them to at-
tain the perfect character of the original tissues of the body. These
productions are not homogeneous;— they consist of many folds
which are united together by surfaces which are cellular, like -the
inner surface of the pleura, and which contain the vessels; while
their exterior surface is smooth, shining, and evidently exhalent,
like the outer surface of the pleura to which they adhere. I have
sometimes, though very rarely, met with portions of fat in the du-
plicates of these bodies. These accidental productions have,
for the. most part, a direction perpendicular to the surfaces where-
on they originate; that is to say, the line of their direction from
the opposite points to which they are attached, forms in general
nearly a right angle with the pleura. After having attained this
stage, these bodies, whatever may be their extent, do not, in gene-
ral, affect the health; the respiration even, except in some parti-
cular cases, does not suffer from their presence. They possess, in
fact, all the characters of the natural serous tissues, being capable
of exhalation and absorption like them, and often containing, in
cases of dropsy, a considerable quantity of effused serum. Some-
times they even inflame, and, in this case, become invested by
false membranes similar to what they themselves had originally
been. This is, however, very rare, as I have not met with more
than three or four cases of it, whilst, as we know, nothing is more
common than the adhesions we have been speaking of. It is even
worthy of remark that, in a second attack of pleurisy, the inflam-
mation, and the albuminous and serous extravasation, seem arrest-
ed in their progress by the old adhesions; so that we might almost
state it as a general principle, that the more violent has been the
attack of pleurisy in an individual, the less apprehensions may be
entertained of a second attack. In simple pleurisy we find no
sign whatever of inflammation of the pulmonary tissue, even in the
vicinity of the most inflamed portions of the pleura; only we find
the substance of the lungs, in such cases, more dense and less cre-
pitus, by means of the compression produced by the effused fluids.
If the extravasation has been very great, the lung becomes flatten-
ed and completely flaccid; it ceases to contain air, and conse-
quently to crepitate; its vessels are compressed and contain little
blood; and the bronchia, with the exception of the larger trunks
are evidently rendered smaller. The peculiar texture of the lung'

1 §^ DISEASES OF THE PLEUltA.

however, is still very perceptible, there being no trace of disorgani-
zation like that produced in peripneumony; and if air is blown
into the bronchia, the lungs become expanded more or less com-
pletely. Sometimes, however, we observe, in such cases, certain
portions of the lungs, without being more dense than natural, pos-
sessing a redness quite like that of muscle, and a compact homo-
geneous texture in which we can detect no trace of the air-cells.
When cut into, this species of degeneration presents a smooth sur-
face, without any of the granular character of lung inflamed in the
second or third degree; neither has it any of the spumous bloody
serum which is observed in lung inflamed in the first degree. To
this state of the lung 1 would willingly give the name of carnifica-
tion, which has been improperly applied by some authors to the
hepatization of the lungs, or peripneumony in the second and third
degrees. We find this morbid alteration sometimes in the central,
posterior, or inferior parts of the lungs, in cases where the extra-
vasation has been inconsiderable, while the superior parts of the
lungs are still crepitous. In other cases, we find here and there,
in the middle of a lobe quite in its natural state, portions of the
size of a filbert or almond, in this state of carnification. I consi-
der this morbid condition to be the result of a slight degree of in-
flammation which has undergone a partial and imperfect resolu-
tion.

I may here notice one symptom of pleurisy, accompanied by
effusion, as it is directly connected with the anatomical characters
of the disease: it is the enlargement of the chest. In cases of
copious effusion into the cavity of the pleura, this dilatation of the
affected side has been noticed by all writers on empyema since
the time of Hyppocrates; but I have ascertained that the same
thing takes place in the effusions of a recent pleurisy. I have of-
ten found it very distinct after two days' illness. It is, of course,
much more evident in lean than fat persons; and is very indistinct
in woman with large mammae. Oil measuring the affected side with
a piece of ribband, we find it enlarged, but never so much as it ap-
pears to the eye. An increase of half an inch on the circumfer-
ence is very obvious to the eye. In proportion as the effusion
diminishes, the dilatation of the chest insensibly disappears; and
sometimes, as we shall see more particularly hereafter, the affect-
ed side becomes narrower than before the disease.

CHRONIC PLEURISY. 129

SECTION SECOND.

Of Chronic Pleurisy.

Chronic Pleurisy does not differ essentially, in its anatomical
character, from the acute. In the chronic disease the pleura is
commonly of a deeper red; the serous effusion is more abundant
and almost always less limpid, being mixed with a great quantity
of very small albuminous flocculi. The abundance and minute-
ness of these are sometimes so considerable as to render the liquid
quite puriform, even when left undisturbed. More commonly, the
serum is of a lemon colour, although still less limpid than in the
acute disease, and thickly intermixed with .the small fragments
just mentioned, which, like coarse flour diffused through water,
fall to the bottom when at rest. In such cases, these puriform
fragments accumulate in great quantity in the most depending
parts of the thoracic cavity, and by their consistence form a link
between the sero-purulent effusion and the false membranes.
These latter never have the consistence of boiled whi'e of egg as
in the acute pleurisy. We break them with the greatest facility
in detaching them from the pleura, they are friable, between the
fingers, and sometimes their cohesion is so slight that we might
mistake them for a deposition of the thicker parts of pus. The
extraVasated fluids in chronic pleurisy are rarely so free from
smell as in the acute; sometimes they have a heavy odour, more
disagreeable than that of healthy pus.

Confining the term Chronic Pleurisy to the affection just de-
scribed, and, therefore, not even including those cases of acute
pleurisy which are chronic in respect of their length of duration,
we may say that the disease has rarely any natural tendency to-
wards resolution. In cases of extravasations which have lasted
several months, we find no mark of any step towards the conver-
sion of the false membranes iftto cellular substance. A cure,
however, is sometimes effected in another manner, as will be
shown presently.

The effusion produced by chronic pleurisy tends, most com-
monly, to become daily, more considerable. The affected side be-
comes manifestly larger. The intercostal spaces grow* broader,
and rise to a level with the ribs, and sometimes even higher

17

130 DISEASES OF THE PLEURA

The lung of the affected side, compressed towards the mediasti
num and spine, and retained in this position by the pseudo-mem-
branous exudaiion which covers it completely, is sometimes re-
duced to a thickness of little more than half an inch, even in its
middle, and, without a careful examination, might be considered
as totally destroyed. In this state the pulmonary tissue is soft,
pliant, and dense like a piece of leather, without any crepitation,
more pale than natural, occasionally greyish, and entirely without
blood. Indeed the blood-vessels are often seen flattened and
empty. The cellular texture is nevertheless still very distinct;
and sometimes, though rarely, some points are found in the stale
of canvjication above described. This case constitutes the Em-
pyema of auihors, at least of modern authors; for I apprehend no
one now considers empyema as the product of a vomica which
has burst into the cavity of the pleura. A softened tubercle may,
indeed, discharge its contents in this manner, and may thus be-
come the cause of a considerable effusion by exciting a chronic
pleurisy, but in such a crise the tuberculous matter must only be
considered in the light of an extraneous body determining inflam-
mation, and consequent effusion, by its mechanical or chemical
qualities. It is also to this species of pleivisy that we must refer
those histories of lungs entirely destroyed by suppuration which we
fiud recorded in the older writers.

Such is the nature of true chronic pleurisy; and, restricted as I
have done, it exhibits, in none of its stages, the intense fever,
power of reaction, and acute pain, that characterise an active dis-
ease. It commonly attacks subjects of a worn out constitution,
more especially such as have suffered from a tubercular affection
of the lungs or other organ. This complication with other dis-
eases, as well as the usual want of prominence of its symptoms,
both general anrl local, cause it, for the most part, to be overlook-
ed, and almost always misunderstood.

There is still another species of chronic pleurisy, viz. the acute
disease, become so, from any cause which prevents the absorp-
tion of the effused fluids and the conversion of the false mem-
branes into cellular substance. The disturbing cause in this case
is, also, generally one arising froru a weak condition of body pro-
duced by other diseases.

The acute pleurisy, after having passed into a chronic state,
may exhibit many varieties. Two of these we shall notice pre-
sently, and a third under the head of Hydrothorax. A fourth
variety is. produced by a superfluous afflux of blood taking place
to the false membranes, at the period of the development of the

CHRONIC PLEURISY. 131

new vessels in these. In this case the new-formed parts, and the
effused serum, are found deeply tinged with blood, and small clots
of pure blood are occasionally met with. This state of parts
furnishes a great obstacle to the cure of the disease, and seems to
be the cause of a peculiar modification of the adhesions, which is
to be taken notice of hereafter.

SECTION THIRD.

Contraction of the Chest consequent on certain Pleurisies.

There are some cases of Pleurisy wherein the affected side
never becomes sonorous, in the trial of percussion, although die
disease has been completely cured and the effused fluids absorbed.
Although cases of this sort are not very rare, they have not hi-
therto attracted sufficiently the attention of practitioners; and I
apprehend that the pathological character of the affection,
although noticed by several authors, has not as yet been correctly
or completely described. The subjects of this morbid alteration
are sufficiently distinguishable even by their external shape, and
by their gait. They seem always to lean towards the affected
side. This is always manifestly narrower than he opposite side,
there being frequently more than an inch of difference, when
they are both measured by means of a cord. The length of the
chest is equally diminished; the ribs are closer to one another,
the shoulder is lower, and the muscles, especially the pectoral,
are only half the size of those on the opposite side. The differ-
ence of the two sides is so remarkable, that, at first sight, we
would think it much greater than it is found to be by admeasure-
ment. The spinal column generally remains straight; sometimes,
however, it at length yields through the effect of the habitual
leaning towards the diseased side. This habit gives to the indi-
vidual the appearance of being somewhat, lame. (See Plates
VI. and VII.)

The greater number of individuals in whom I have detected
this deformity attributed it to some severe and long continued
disease of the chest, the exact character of which had never
been ascertained. I have more than once pointed out this altera-

132 DISEASES OF THE PLEURA.

tion of the form of (he chest to individuals, in whom it existed in a
great degree, who were not themselves at all aware of its existence.
All these had experienced a severe disease of long duration, the
principal site of which had seemed to be in the thorax. In several,
the disease appeared not to have been very violent. Some had bad
pleurisies, or pleuro-peripneumonies with very marked symptoms,
and which had been long in getting well. I was long aware of
this state of the chest before I had an opportunity of ascertaining
its cause by dissection. Most of these patients were short-breath-
ed, yet could not be said to have habitual dyspnoea. Cases of very
great contraction are rare; but those of a slight degree of it are
very common.

This morbid contraction of one of the thoracic cavities arises
from a somewhat irregular termination of chronic pleurisy, or of
the acute pleurisy become* chronic. In these cases the sero-puru-
len' effusion having contiuued,ior a long time, the false membranes
which invest the pleura and lungs acquire a particular hardness,
and an incipient organization, which render them incapable of being
converted into cellular substance. When the effusion is absorbed,
the lung, long compressed by it, and further bound down by a strong
false membrane completely investing it, cannot dilate itself suf-
ficiently promptly to keep pace with the progress of the absorption;
the ribs, consequently, contract, and the cavity of the chest is thus
diminished. When the fluids are completely absorbed, the costal
and pulmonary exudations come into close contact and finally unite,
so as to form only one substance. The consistence of this becomes
daily firmer, and, after a few months, acquires the consistence and
all the other characters of a fibrous or fibro-cartilaginous mem-
brane.

If we dissect carefully this species of membranous production,
we find that, although it adheres closely to the pleura of the ribs
and of the lungs, it can be detached from these almost entirely.
If we cut it transversely we find it composed of three different
layers; two exterior, which are. opaque, white, and completely
fibrous, sometimes cartilaginous and even ossified in certain points;
and one intermed iate, which is semitransparent, and resembling,
in every respect, the central and most transparent portions of the
intervertebral cartilages. This last layer is evidently the medium
of union between the two others. Although it be obviously a
posterior production, and can only have taken place after the or-
ganization of the false membranes had been far advanced, I do
not consider it as strictly the product of inflammation. I would
rather consider.it as analogous to the gelatinous and semitranspa-

CHRONIC PLEURISY. 133

rent exudation which forms the first step in the union of bone and
tendon. The ordinary thickness of these fibro-cartilaginous mem-
branes varies from two to five lines. This gradual!} lessens for
a time after their formation, and is proportioned to (he thickness
of the layers which have given rise to if. In some cases of chronic
pleurisy I am disposed to believe that there may be an albuminous
extravasation on the pleura without any observable serous effusion;
and that, in this case, there may be union of the lungs to the side
by a fibro-carlilaginous membrane (formed of this) which does
not exhibit the three distinct layers above described.

These fibro-cartilaginous membranes have been commonly de-
scribed under the name of thickenings of the pleura; and this is a
mistake very likely to be committed by those who trust to the mere
appearance of these, without further examination. On dissecting
these we can always separate them from the pleura, which is found
of its natural thickness. We must not confound these membranes
with the fibro-cartilaginous incrustations of a like nature, which
are sometimes formed on the exterior or adherent surface of the
pleura, and which I have described elsewhere. (Diet. des. Sc.
Med)

The contraction of the chest, which coincides with the period
of the absorption of the serous effusion, is frequently not to be
perceived till after several months of disease: frequently, even, the
patient has long been in a state of doubtful convealescnce before it
is at all manifest. At length, however, after a long period of ill
health, — sometimes of no less duration than two or three years, —
the patient regains perfect and often permanent health.

On examining the chests of those who had this contraction in a
very decided manner, I have uniformly found the fibro-cartilaginous
membrane above described, and I have further found the lung in
that state of compression and flaccidity, which rendered it ex-
tremely like a piece of muscle of which the fibres were so fine as
to be undistinguishable. Sometimes the compressed lung is as
red as muscle, and at other times, of a grey colour more or less
deep. This last I consider as the proper colour of lung simply
compressed, and imagine the red colour to be given by a sort of
passive congestion of blood in the part. The morbid state of
parts we have been describing seems to exclude almost the possi-
bility of a relapse; for, if this be rare in cases where the lung
and pleura are united by cellular substance, it ought to be infinitely
more so when the uniting tissue is one so very little disposed to
inflame as the fibro cartilaginous.

Although in all cases of considerable contraction I have -found

J 34 DISEASES OT THE PLEURA.

the fibro-cartlaginous membrane, I am inclined to think that there
may be a certain degree of diminution of the chest in cases tthere
a pleuritic attack has terminated slowly by means of cellular ad-
hesions only. Such adhesions, however, undoubtedly exist very
frequently without being attended by any contraction of the chest,
or, indeed, by any perceptible affection of the respiration or gene-
ral health, since we know that they are found, more or less, in
almost every adult body. It is not the adhesions, whatever be
their nature, that occasion the contraction of the chest, but the
more or less tardy development of these. The more rapid has
been the absorption of the effused fluid, in a case of pleurisy, the
less likelihood will there be of the contraction taking place. The
fact is, that 'he pulmonary tissue, like every other part of the
living body, the longer it has been subjected to compression, the
less readily will it return to its original state when the compression
is removed. A limb long compressed by a bandage will regain
its size much more slowly than one that has been bandaged for a
few hours. The consequence of this is, in the ease of the com-
pressed lungs, that as they do not yield sufficiently fast to fill the
cavity left by the absorbed fluid, the thoracic parietes must contract
proportionably in order to prevent the vacuum that must otherwise
take place.

This contraction of the chest, consequent on pleurisy, being but
little known, I shall give here a few cases of it. The first and
second afford examples of the disease after it has passed through
all its stages; the third exhibits its progress, and, also, the state of
parts anterior to its final termination; the last is a more curious
complication of symptoms.

Case 30. A woman, aged 30, had been affected with cough
for several years, but much more severely within the last four
months. She came into hospital in the last stage of consumption,
much emaciated, with hectic fever and purulent expectoration.
She died fourteen days thereafter. Upon inspecting the body
after death, the left side of the chest was found to be evidently
diminished in all its dimensions; the intercostal spaces were so
much contracted that the ribs seemed to touch each other. The
right side was of natural form and size, and appeared larger than
the other by one-half. This deformity had not been observed dur-
ing life, owing to the patient's clothing The right lung adhered
to the diaphragm and the mediastinum, in its whole extent, by
well organized cellular adhesions. This lobe contained many
tubercles in every stage. In the superior lobe there was one tu-
berculous excavation capable of containing a small pullet's egg.

CHRONIC PLEURISY. 135

The left lung was one half less than the right; it was retracted
towards the spine and ribs, so that its internal surface was turned
forwards, yet did not reach further than the origin of the cartilages,
and did not at all cover the heart: it adhered so firmly to the ribs
that it could not be separated without detaching it from its invest-
ing pleura. This adhesion was effected by the medium of a sub-
stance altogether similar, in texture, colour, and consistence, to the
fibro-cartilaginous bodies. This substance was about two lines in
thickness, and was divided into two layers, which were separated
from each other by a third, much thinner than they. This was of
a bluish grey colour and semitransparent, — qualities which form-
ed a contrast with the whiteness and opacity of the others. This
intermediate layer resembled perfectly the transparent central
portion of the intervertebral fibro-cartilages; it was less solid
than the other two, yet possessed, with them, the fibrous siructure.
The pleura pulmonalis and costalis, especially the former, were
very distinct exterior to these false membranes. The pulmonary
tissue, more flaccid and redder than natural, had lost its crepitous
feel, and was of the aspect and consistence of muscle.

Case 31. In March 1818, a man, aged 18, came into hospi-
tal, affected with recent diarrhoea and a complaint of the chest
of some standing. In the winter of 1816 he had been affected
with a violent cold, attended by severe cough, much dyspnoea,
and great pain of the left side. This side of the chest was now
evidently smaller than the right in every dimension; and the
shoulder being thereby lower, the man had the appearance of
being lame. He bent the left leg more than the right, and when
he stood upright he seemed to support himself on his left hip.
This side yielded a dull sound, on percussion, and the sound of
respiration was scarcely audible (by the stethoscope) in any part
of it: both these were otherwise on the right side. This man's
diarrhoea continued with some intervals of amelioration, but
eventually with the addition of abdominal tenderness, and he
had an attack of severe pain of the right side increased by cough
and inspiration. These symptoms, especially the diarrhoea, ex-
hausted his powers, and he died in August.

The left side of the chest was found one-third smaller than the
right, and the intercostal spaces much narrower. The lung on
this side was intimately united to the pleura of the ribs, in its
whole extent, by a false membrane one line thick in its superior
part, and two lines in its inferior part. It was white, of a con-
sistence almost equal to that of fibro- cartilage, and of a texture
somewhat similar; as fibres, both longitudinal and transverse, were

136 DISEASES OF THE PLEURA.

very visible in it, especially at its inferior part. In several
places ibis false membrane was united to the pleura by means of
cellular substance containing serum; in other places, these two
were closely united, yet still very distinguishable from each other.
The lung was flattened upon the mediastinum. Its substance was
still somewhat crepitous, but flaccid and injected with serum. It
contained many tubercles, for the most part miliary.

The right lung adhered to the costal pleura by means of a soft
false membrane, which exhibited reddish vascular points on its
surface. A still thicker layer of the same kind invested the dia-
phragm and adjoining lung. There was a little reddish serosity
in the cavity of the pleura. The tissue of the lung was crepitous,
containing a considerable quantity of serosity, and, also, several
miliary tubercles.

Case 32. A man, aged 66, in October 1817, caught a severe
cold, marked by cough, and subsequently by great pain in the
chest and hemorrhage from the lungs. This attack was followed
by hectic fever, constant cough and dyspnoea. He came into hos-
pital in March, affected with much cough, very viscid yellowish
expectoration, and hard and frequent pulse. In the left side of the
chest percussion elicited a clear sound, and the murmur of respi-
ration was distinctly heard through the stethoscope: both these
indications were considerably less distinct in the right side. The
disease seemed to decrease for several weeks in this and the follow-
ing month; but the cough and expectoration still continuing, and
his lower extremities becoming swelled, he lost ground iii the end
of May, and emaciated considerably. In the beginning of June
we first perceived the intercostal spaces on the right side to be
diminished in width: by the middle of the month the general con-
traction of this side of the chest was very distinct. This man
died towards the end of the same month.

On examining the ches' after death, it was found that the dia-
meter of the right side, both laterally and from before backwards,
was less by an inch than that of the left; and the intercostal spaces
were narrower.

The left lung was of natural size, had no adherence to the
pleura, and was crepitous throughout. It was gorged with blood,
especially on the posterior part. It contained some tubercles in
the early stages. The left lung was one-third less than the right,
and adhered intimately to the costal pleura by its whole upper
lobe as low down as the second and third ribs. This a ihesion
was effected by a well organized cellular tissue, evidently of
ancient date. The remaining pleura of the lungs and ribs, in the

CHRONIC PLEURISY. 137

whole of the lower part of the lung and the anterior portion cor-
responding with the false ribs, was also closely unitt. I; but this
adhesion, which was evidently of recent date, was effected by
means of a concrete albuminous layer, three lines in thickness, of
a yellow colour and opaque, and partially tinged with blood.
This membraniform layer could be removed in plates or folia,
which were of greater firmness the nearer they approached the
pleura, on either side, — especially the pleura pulmonalis, — on
which they had a degree of consistence nearly equal to that of
the fibro-cartilages. On the contrary, the centrical layers were
hardly of a tenacity double that of boiled while of egg. At the
point of junction of the ribs with their cartilages and on the an-
terior and exterior parts of the lung, this albuminous stratum di-
vided into two layers, one of which invested all that portion of
the lung remaining unattached to the side, and the other the cor-
responding portion of the pleura; and these two afterwards united
so as to form a shut sac or pouch. The inner surface of this sac
was nearly throughout of a bright red colour, which seemed as if
applied with a pencil, and amid which no traces of vessels could
be distinguished. This red colour did not at all enter into the
substance of the albuminous stratum, which was, throughout, of
a yellowish white, and slightly semitransparent, becoming more
white and opaque as it approached the pleura. This sac contained
about two glassfuls of a bloody but limpid serum, which com-
pressed, at this part, the lung towards the mediastinum, leaving a
space between it and the ribs of an inch and half at its greatest
width. Eight or ten pseudo-membranous bands crossed this ca-
vity, being attached, at each end, to the pleuritic layers. These
were softer and more fragile than old cellular adhesions; they were
very thin, diaphanous, and colourless, towards their middle, but
at their extremities they assumed greater firmness, and also the
opacity and colour of the layers to which they are attached.

In the top of this lung there was an external depression, cor-
responding with a fibro-cartilaginous substance internally, such as
formerly described under phthisis pulmonalis, and which I showed
to be a true cicatrization of a tuberculous cavity. In its interior
parts the lung was flaccid, not crepitous, dry, and resembling
muscular flesh. In the upper portion there were many immature
tubercles.

The pleura, in the parts corresponding to the false membranes,
was much redder than natural. The heart was sound.

The cavity of the peritoneum contained about four pints of a
-eddish serosity, partialjv limpid. The whole of the peritoneum.

18

|35 DISEASES OF HIE PLEURA.

as well on the abdominal parietes as on the mesentery and nites
tines was studded with innumerable small, grey, semitransparent
tubercles. Upon the mesentery and bowels these were quilt
transparent, and of the size of millet-seed; on the abdominal pa
rietes they were flatter, greyer, and less diaphanous. The perito-
neum was, moreover, marked in different places, by red, punctuat-
ed spots, which were either of a bright red, or almost black. In
these points, on scraping with the scalpel, a small quantity of a
semitransparent exudation", of a grey colour and mixed with dots
of blood, could be detached. This matter was very like paste,
only a little firmer. It was so thin as only to be discovered by
scraping: after its removal the peritoneum appeared somewhat les3
red. The tubercles seemed to be so intimately connected with
the peritoneum, as not to be detached by scraping: this membrane
was not sensibly thickened.

Case 33. A boy, 12 years of age, was attacked with a severe
pectoral affection, marked by violent cough, acute pain of side,
dyspnoea and fever; followed, in a few days, by considerable ha3-
moptysis, and, subsequently, by expectoration of a purulent fluid
in great quantity. The disease then took a chronic form; and, in
the course of a few months, an abscess pointed externally between
the cartilages of the seventh and eighth ribs, which, when opened,
discharged a considerable quantity of pus. Since then (now six
years) the aperture has remained fistulous, daily discharging one
or two spoonfuls of pus Occasionally, during a temporary ob-
struction of the orifice, the expectoration of this patient has be-
come augmented, and the sputa have been then always perfectly
like the pus usually evacuated from the abscess.

At this period I examined the patient. He was much emaci-
ated, but not like one wasted by consumption, the emaciation be-
ing confined rather to the bones and muscles, than to the cellular
membrane. He was extremely small for his age. The left side
of the chest was at least one third narrower than the right, and
this contraction was most, remarkable at the inferior margin and in
the antero-posterior diameter. On examining the thorax the whole
right side yielded a clear sound on percussion, but one less distinct
on the left. The respiration was quite distinct over the whole of
the sight side; it was very indistinct in the superior part of the
left sidt. and quite inaudible in the whole inferior portion. Pec-
toriloxjU/ism, also, existed in the lateral and superior part of the
same side.

From all these circumstances it is evident that in this case, in
the first instance, the maturation of one or more tuberculous masses

CHRONIC PLEURISY. 189

nad been attended by an acute pleurisy; that, although Ihe tu-
bercles, when softened, had been expectorated, yet that a commu-
nication between the remaining excavations and the pleura had
been subsequently established, which had given rise to the external
abscess. The eventual formation of a fibro-cartilaginous mem-
brane had produced the union of the lungs and pleura, and the
consequent contraction of that side of the chest. As this patient
has already lived so long with this affection, it is probable, if the
expectoration does not greatly increase, that he may survive a
long time yet. Willis relates a case similar to the above.*

SECTION FOURTH.

Of Gangrene of the Pleura, and of the false Membranes consequent
to Pleurisy.

Gangrene of the pleura is a very rare disease. It is always
of very small extent, is scarcely ever a primary affection, or a ter-
mination of the acute inflammation. Mos> commonly it is the con-
sequence of the bursting of a gangrenous abscess of the lungs into
the pleura, (see page 66) and occasionally it supervenes to chronic
pleurisy.

This disease presents the appearance of soft gangrenous spots,
of a brownish or blackish green, round or irregular, and not ex-
tending beyond the pleura. When these gangrenous patches have
been removed by the softening down of their substance, (he bor-
ders of the ulcerated part left behind, remain blackish for a iong
time. Sometimes the parts beneath the pleura are affected to a
very small depth; and almost always the cellular substance be-
comes greenish and filled with serum to some distance around »he
eschar. In some instances the intercostal muscles, the neighbour-
ing portions of the lung, and even the ribs, participate more or less
in the disease; and all exhale the gangrenous fetor.

A general inflammation of the pleura, and the consequent forma-
tion of false membranes to a great extent, and a copious effusion,
alvvays follow gangrenous affections of the pleura, if these are not
the consequence of an old pleurisy. In every case the false mem-
branes, whether old or new, put on the gangrenous character in
i greater or less degree. This is particularly observable in the

* Op, omn. I.ib. ii. Cap. xiii, Sect. 1

140 DISEASES OF THE PLEURA.

case of a gangrenous abscess bursting into the pleura. Only onc<
have I found this state of the pleuritic membranes, in a case where
the gangrenous abscesses were still without any communication
with the cavity of the pleura, anJ where the gangrene of the false
membranes seemed to be idiopathic. It sometimes happens in
chronic pleurisy that a gangrenous eschar forms on the pleura, and
permits the effused fluids to escape through the intercostal muscles,
so as to be finally evacuated, either naturally or artificially, and
that the empyema is thus cured. This species of abscess has
been long known. It is, however, very rare; M. Recamier has
only seen it twice, and I have only met with one case of it.

Besides gangrene of the pleura, nature has one other way of
evacuating, externally, the sero-purulent effusion of the chest; this
is by the formation of an abscess between the layers of the inter-
costal muscles, or between these muscles and the skin, which, burst-
ing both externally and internally, affords a passage for the dis-
charge of the contained fluids. I have met with a single case of
this kind. A cure has frequently followed the evacuation procured
by means of these kinds of abscesses. This is, however, rarely
complete; and it is more common for Ihe disease to degenerate into
an incurable fistula, which is frequently kept up by a carious state
of the neighbouring ribs.

SECTION FIFTH.

Of circumscribed Pleurisy.

It occasionally happens, particularly in chronic pleurisy, that
the effused fluid is confined to a partial space of small extent,
owing to the obliteration of the remainder of the cavity of the
pleura by former adhesion. These circumscribed, pleurisies are
observed in the three following situations chiefly: 1st, the inferior
and lateral part of the cavity of the pleura; 2nd, the space be-
tween the base of the lungs and the diaphragm; and 3rd, the
fissures between the different lobes. In these cases the effused
fluid, which is commonly puriform, is enclosed in a false mem-
brane which lines very exactly the surrounding parts.

When seated in the fissures between the lobes, the edges of
these are found closely adherent by means of cellular substance
of recent formation, while the opposing surfaces of the lobes
themselves are separated by the interposed effusion. Eayle was

CIltlONIC PLEURISY. 141

the first who described this species of partial pleurisy, which an
inattentive observer might easily mistake for an abscess of the
lung. This species is very rare, a thing which seems rather
singular, when we consider how often we find the edges of these
interlobular fissures adherent in cases of peripneumony attended
by a slight pleurisy. In such cases it would seem that the resolu-
tion of the peripneumony leaves these fissures converted into a sort
of sac, which will occasion the circumscribed effusion we have
been describing, in the event of that part of the pleura being af-
terwards attacked by inflammation.

The second variety of circumscribed pleurisy is equally rare^
and presents precisely the same anatomical characters. The third
variety is not uncommon. These partial collections of matter,
when in any considerable quantity, press forcibly on the side of
the lungs (as this is the only direction in which they can extend)
and produce a sort of cavity in these, as if there were actually a
loss of substance. If, however, on evacuating the pus, we remove
the false membrane which lines the apparent abscess, we immedi-
ately perceive that the luug is merely compressed, and that even
the pleura is uninjured.

I shall conclude this account of the several varieties of pleuritic
inflammation, with several cases which illustrate many of the
statements already made. In all of them will be found the com-
plication of air effused into the cavity of the pleura, a complication
which will be treated of more particularly, by and by, under the
name of Pneumo-Thorax.

Case 34. A man, aged 32, was seized for the first time, in May
1817, with a catarrhal affection, attended by eough, dyspnoef, &c.
which continued, with variable severity, until the beginning of
November, when he came under my care. At this time there
were considerable emaciation, hot skin, small and frequent pulse,
short and quick respiration, much cough, and considerable expec-
toration of opaque, yellow and very viscid sputa. The stethoscope
gave indication of tuberculous excavations in the lungs. The Ye
brile and inflammatory symptoms continued; and, during the
course of the following month, acute pain in different parts of the
chest supervened: at the same time, the cough became more trou
blesome, and to the yellow opaque sputa there was now super-
added a copious discharge of transparent and frothy mucus.
Percussion of the thorax vielded a much clearer sound on \h>

142 DISEASES OF THE PLEURA.

right than on the left side; while the respiratory murmur was
distinct in the latter, and not at all perceptible in the former.
The tinkling metallic sound, already alluded to (and which we
shall hereafter rind to be characteristic of the simultaneous ex-
istence of air and some liquid in the chest,) was, also, very audi-
ble on the right side. The patient lay almost constantly on the
right side, the intercostal spaces of which could now be perceived
to be wider and more prominent than natural, and the subcuta-
neous veins more obvious. All these symptoms indicated the
supervention of a pleurisy, with effusion of both air and a liquid
of some sort into the right side of the chest. Towards the end of
January the patient first perceived the fluctuation of a liquid in
his chest when he turned himself: the same thing was very dis-
tinctly heard by the bystanders when the trunk was shaken in a
sitting posture. In February the sputa amounted to about six
ounces in the twenty -four hours; they were yellow, opaque and
puriform, intermixed with bubbles of air, and swimming, as it
were, in a large proportion of a transparent and diffluent mucus,
in which there were sometimes streaks of blood. One day in
this month, he expectorated, after a fit of coughing, as much as
he usually did in the whole twenty-four hours. At this lime the
operation of empyema was performed, between the sixth and
seventh ribs, by means of a trocar only one line in diameter.
Two pounds of matter flowed in twenty minutes. This matter
was puriform, opaque, of a slightly greenish yellow colour, and
scarcely fetid. As it flowed it was intermixed with some air-
bubbles; and, on settling, it separated into two portions,— the one,
opaque and yellow, and composed of small yellowish flocculi, —
the other, thinner and transparent. The patient felt relieved in
proportion as the matter flowed, and this alleviation continued
for two days, but he Sunk on the 12th day after the operation.

On examining the body after death, we found that the succus-
sion of the trunk produced the sound of fluctuation as before. On
puncturing the thorax a gaseous fluid escaped. The right side of
the thora* was larger than the left, and contained two pints of a
serp-purulent fluid. The whole extent of the pleura, on this side,
was lined by a thick layer of coagulable lymph, the consistence
of which varied in different places, from that of soft cheese to
one nearly equal to that of cartilage: it was softer on the surface,
and more dense where it touched the pleura. It was several
lints thick on the lungs, and on the right side of the mediastinum
and diaphragm; it was thinner, softer, and more easily detached,
op the pleura of the ribs and remaining portion of the diaphragm,

CHRONIC PLEtfRlS?. 143

both of which were of an intense punctuated red colour. The
pleura of the lungs had none of this punctuated appearance, and
the layer in contact with it, which was of a cartilaginous firmness,
could not be detatched from it. The lung was compressed to-
wards the spine and posterior part of the ribs (to which it closely
adhered,) so that it hardly occupied one third part of the cavity.
The pulmonary tissue was flaccid, but still somewhat crepitous,
and permeable to the air in its posterior part. There were several
tubercles in this lung, from the size of a cherry-stone to that of a
fdbert, and almost all softened to the consistence of curd. Five
of these, of a somewhat larger size, quite softened and nearly
empty, communicated on the one side with the bronchia, and, on
the other, with the cavity of the pleura, by openings of from one
to three lines in diameter.

The left lung was of the natural size, and contained, also, a
great many tubercles in different stages of maturity: — the greater
number being small and diaphanous; — a few, quite softened but
not communicating- with the bronchia. The mucous membrane
was very red through its whole extent, and there was a small
ulcer in the posterior part of the larynx. There was a small
quantity of serum in the pericardium, and, also, in the peritoneum

Case 35. A man, aged 20, who had been unwell (he said) for
six months, and who had suffered from diarrhoea for the thre<
last, came into hospital in January, exhibiting all the usual symp-
toms of confirmed Phthisis, and, among others, that of a very dis-
tinct pectoriloquism at the superior part of the left side of the
chest. In the beginning of March a sudden alteration took place
in the symptoms: the respiration becoming more difficult, attended
with pricking pains in- the right side, the pulse getting quicker,
the skin hotter, and the face flushed. On examining the chest at
this time by percussion and the stethoscope, it was found that the
right side, which on the day before had yielded only a dull sound,
now resounded more than the other; while the respiration was very
perceptible on the left side, and not at all on the right. These
symptoms I regarded as indicating pleurisy, arising from the irrup-
tion of tuberculous matter into the cavity of the pleura, and attend-
ed both by liquid and gaseous effusion. I wished farther to ascer-
tain the effusion by the succussion of the chest, but the patient
was too weak to undergo the trial, and he died four days after tin
marked change in the symptoms.

The fluctuation of the fluid in the right cavity of the chest was
very perceptible, on succussion, after death. This side appeared,
nlso, larger than the left; when struck it emitted a clear sound:

144 DISEASES OF THE PLEURA.

and when punctured an elastic fluid escaped from it with a hissing
noise. There was found in the cavity of the pleura a considera-
ble quantity of a sero-purulent liquid, of a greenish yellow colour,
and semitransparent, notwithstanding the great portion of puriform
fragments that floated in it. The pleura was lined throughout
with an opaque albuminous exudation, of a yellowish white colour,
easily scraped off by the scalpel, and of the consistence of curdled
milk. This layer was of considerable thickness on some parts of
the ribs and diaphragm, and thinner on the lungs. The lung on
this side was compressed into one-third or one-fourth its natural
volume against the spine and mediastinum, to which last it closely
adhered. It was flabby and very imperfectly crepitous through its
whole extent, and contained hard tumours, which were evidently
tubercles. On the closest examination no opening could be dis-
covered on its surface. In the very summit of the superior lobe
there were found three tuberculous excavations; two of which, of
the size of a hazel-nut, were full of soft matter, and the third, six
times as large, and capable of containing a pullei's egg, nearly
empty. This vast cavity was lined by two membranes, the inte-
rior (that in immediate, and close contact with the pulmonary tis-
sue) of a semi-cartilaginous density, and the exterior soft, almost
entirely opaque, and easily torn. The former existed only in some
points; the latter was complete. The remainder of the lung was
filled by miliary tubercles. The left lung appeared quite sound,
only containing a few miliary tubercles.

Case 36. A man, 35 years of age, while in hospital for a
chronic affection of the knee;, was suddenly attacked, in January,
with pleuritic symptoms, viz. headach, pain in the chest aggra-
vated by respiration, frequent cough, and expectoration of white
and very copious sputa. Getting better he left the hospital in the
end of February, but returned again in the middle of March. At
this time there were decided symptoms of pleurisy with effusion
into the chest, and also of phthisis, — according to the indications
of the stethoscope: the common symptoms were — hot dry skin,
frequent pulse, quick short breathing, frequent cough, and expec-
toration (not very copious) of a frothy mucus intermixed with
sputa of a yellow colour and opaque.

The same symptoms continued, with increase of emaciation and
cough in June and July. In August, diarrhoea supervened, with
increase of cough and fetid purulent expectoration, to the amount,
for a short time, of a pound and half in the twenty-four hours.
In October, there was again copious fetid expectoration, with
dyspnoea and much cough, and inability to lie on the right side

CHRONIC PLEURISY. 145

At this time both sides yielded the same sound on percussion, but
respiration could be perceived in 'he right side only. Fluctuation
in the left side was also perceptible on sue ussion, by means of
the cylinder, but not without it. The patient said that a momen-
tary attempt to lie on the right side increased the frequency of the
cough and greatly augmented the expectoration. He was not,
however, sensible of any fluctuation in the chest. He died in the
beginning of November.

On examination after death, the left side of the thorax was
found larger than the right; the left intercostal spaces were wider
and raised to a level with the libs, while the right were sunk be-
low that level. On puncturing the thorax on the left side, an ex-
tremely fetid gas made its escape with a hissing sound. On lay-
ing it open it was found to contain about three pints of a blackish
grey liquid, extremely fetid, and having somewhat of the smell of
garlic The lungs on this side were compressed against the
spine, and were not larger than the hand. Their surface was co-
vered with a layer of a half-concrete white matter, intermixed
with a very soft black substance On it there were two openings
of the size of the finger, which terminated, interiorly, in the sub-
stance of the lungs, in culs-de-sac not communicating with the
bronchia. They were evidently the remains of tubercular exca-
vations which had discharged their contents into the cavity of the
pleura. The whole of the false membrane which invested the
pleura was black and soft, on the surface, but below this it was
firmer and whitish.

The right lung adhered to the pleura throughout by old attach-
ments, and contained, internally, a great number of miliary tuber-
cles. In its upper lobe there was an empty excavation, of the
size of a filbert, and lined by a well organized semi-cartilaginous
membrane. In the middle of the same lobe there were found
several white bands resembling ancient cicatrices. (See Book I.
Chap. I. sect 2.) Two of these united in the form of the letter
V, and contained between them a mass of tuberculous matter.*

Case 37. A man, aged 29, caught a severe catarrh from ex-
posure to much cold in the beginning of October, which he ne-
glected, as he had done a cough with which he had been affected
in the preceding spring. This catarrh, after a few weeks, was
followed by spitting of blood for several days, and, subsequently,
by a continual cough, dyspnoea and emaciation. In the begin-

* This case affords another proof of the cicatrization of tuberculous cavi-
ties, and also of their conversion into fistuls.

19

|4$ DISEASES OF THE PLEURA.

ning of February he came into hospital. At this time he was evi-
dently in a confirmed consumption — being affected with great
emaciation, frequent cough, yellovr opaque sputa, dyspnoea, diar-
rhoea, pectoriloquism. Things continued much in the same way
until the seventeenth, when the supervention of more febrile
symptoms indicated a slight peripneumony. On applying the
cylinder, it was found that respiration was not at all audible on
the anterior and lateral portions of the left side of the % chest; while
percussion gave a much distincter sound than on the right side;
and succussion of the trunk produced the characteristic noise of
fluctuation. From all these circumstances, being convinced of
the existence of both air and pus in the cavity of the pleura, and
seeing no other means of alleviating the patient, I proposed the
operation of empyema This, however, was not performed, as
he died the same day, although at the hour of the visit there did
not seem any thing indicative of so sudden a termination of his
disease.

On examining the body after death, the left side of the chest
appeared to me evidently enlarged; but this was doubted by some
of the persons present. 'On percussion it certainly yielded a
much clearer sound than the other, and succussion of the trunk
produced the noise of fluctuation.

On puncturing the thorax with a scalpel on the left side, a
nearly inodorous gas continued to escape, with a hissing noise, for
nearly a minute; and, on opening it, it was found three-fourths
empty, the lung being found only of one-third its natural size, and
compressed towards the mediastinum, but without adhering to it.
In the same cavity there was scarcely a pound of a liquid resem-
bling whey, of a whitish colour, turbid, and containing portions
of yellowish half-concrete albumen. The whole of the lung, on
this side, was covered with an irregular albuminous membrane,
which in several places greatly resembled an omentum moderately
loaded with fat. In the top of the superior lobe there were two
excavations, containing only a little soft tuberculous pus, and each
capable of containing a walnut. Both these were lined by a
double membrane, and communicated with bronchial tubes. The
whole lung was filled by tubercles in every stage. The upper
lobe of the right lung adhered to the pleura, and contained a series
of large tuberculous excavations, partly empty, and all lined by
the semi-cartilaginous membrane. -This lobe further containejji**
many immature tubercles: the other lobes were sound.

Case 38. A man, aged 22, became affected, in the beginning
of October, with a severe catarrh, which he attributed to drink-

CHRONIC PLEURISY. 147

ing cold water while hot. This was followed by a constant cough
and considerable haemoptysis. He went into an hospital at the
end of two months, and after remaining there a fortnight and be-
ing bled, his cough having become somewhat better, he left it.
Having had a fresh attack ten days thereafter, he came into the
hospital under my care. At this time he was affected with pros-
tration of strength, impeded respiration, frequent cough with vis-
cid, frothy, and somewhat adhesive expectoration, and acute pain
in the whole right side of the chest. Respiration was perfect
over the whole of the left side, but was not perceptible on the
right, except under the clavicle. Being considered as affected
with pleuro-peripneumony of the right side, he was bled and put
on proper regimen. After a continuation of this treatment the
pain of the side disappeared, and the respiration became freer,
but the patient did not recover strength, and he was, further, at-
tacked with diarrhoea. Suspecting the existence of tubercles, I
examined him with the stethoscope, and detected pectoriloquism
about the right shoulder-blade. 1 further found at this time that
the respiration continued to be very indistinct in the right side,
while percussion elicited from it a much clearer sound than from
the left. This fact, and the additional sign of the metallic tink-
ling, convinced me of the existence both of pleuritic effusion and
effused air (having a communication with the bronchia) in the
right side of the chest. This was further confirmed by the noise
of fluctuation produced by the hippocratic succussion. There
was, at this time, no appearance of oedema on the right side; the
intercostal spaces were not at all enlarged; nor did the liver ap-
pear to be at all pressed .downwards into the abdomen. However,
as the patient had lost scarcely any flesh, and his strength seemed
rather oppressed than exhausted, 1 entertained hopes of saving him
by the operation of empyema. Immediately after this determina-
tion, the patient expectorated a very great quantity of a very fetid
pus quite different from his usual sputa; and this was followed by
increased difficulty of respiration, and other symptoms indicating
a recent peripneumonic attack on the left side.

The operation was then performed, the incision being made be-
tween the fifth and sixth ribs (counting from above), about their
middle; but no matter flowed, although the passage of air by the
wound during respiration proved the penetration of the chest by
the incision. Shortly afterwards he again expectorated a large
quantity of very fetid pus, and died four hours after the operation.

On examining the body after death, the right side of the thorax

J48 DISEASES OF THE PLEURA.

appeared somewhat smaller than the left* Succussion of the
body produced the sound of fluctuation, but less distinctly than
before death On puncturing the right side of the chest, near the
junction of the third rib with its cartilage, a large quantity of ex-
tremely fetid gas made its escape; and, on making a puncture
about the middle of the fourth intercostal space, a very great
quantity of pus flowed out, very liquid, of a slightly greenish
yellow colour, and of an intolerable gangrenous fetor. The
whole of the fluid contained in this cavity of the chest amounted
to about a pint and half. The lung was much flattened to-
wards the mediastinum, being only, an inch thick at its superior
pari; it gradually enlarged downwards, and at its inferior margin
was two Inches and a half in width. The lung had thus three
sides: — the one in.ernal, attached by means of short cellular
adhesions to the mediastinum; the other anterior, of a triangular
shape, and attached by old cellular adhesions to the sterno-costal
pleura; and the third external', separated from the ribs by a space,
nearly four fingers' breadth wide, which formed the inner wall of
the excavation which had contained the effusion This excavation
(of which the ribs and diaphragm formed the remaining bounda-
ries) was completely lined by a false membrane, of a degree of
consistence intermediate between that of boiled white of egg and
car'ilage, of a pretty uniform thickness of from a line to a line and
half, and of a pearl grey colour, and semitrartsparent. It seem-
ed composed of two layers, the under being firmer than the upper.
About the middle of the fourth rib this membrane was pierced by
a small ulcer of the size of the nail, which extended to the rib,
and had all the characters of one produced by the detachment of
a gangrenous eschar. A somewhat similar ulceration, but extend-
ing only through the false membrane and subjacent pleura, was
perceptible on the external side of the compressed lung. It had
the gangrenous fetor, and was, obviously, an example of the partial
gangrene of the pleura and false membranes. On the same exterior
border of the compressed lung, at its posterior margin,there were two
more openings, which were found to communicate with two large
tuberculous excavations in the substance of the lung partly filled with
purulent matter. On blowing into the trachea, air made its escape
into the cavity of the chest, into which these fistula? opened, yet
we could not detect the exact medium of communication with the
bronchia. The substance of the lung, though flaccid, was still

* This is contrary to the usual state of things in Hydrothorax and Empy-
ema. In the present case it was the consequence of an anterior attack of
nleurisy.

CHRONIC PLEURISY. 149

crepitous, and contained some tubercles. Upon removing the
lungs it was evident that this side of the chest was much shorter
than natural. The diaphragm was found intimately adhering an-
teriorly to the seventh rib, through two-thirds of its length, the ad-
hesion sloping backwards to the ninth rib, so as to leave on the
lower and posterior pari of the chest, a species of cul-de-sac, not
more than two fingers' breadih wide. This state of parts account-
ed for the result of the operation. The incision had penetrated
through the diaphragm into the cavity of the abdomen, parallel
with the upper surface of the liver.

The left lung was of the natural size, and contained, in its up-
per lobe, a cicatrice of the kind described in Book I. Chap. I.
about an inch in length, as wide as the finger, and of the thick-
ness of two lines in its centre. Around this cicatrice the pulmo-
nary tissue was quite sound and crepitous. A little lower, and also
in the superior and posterior part of the same lobe, it was indu-
rated to the degree of hepatization, and was granular when cut
into. The remainder of the lung was crepitous, but much redder
than the right lung, and gorged with a bloody serum. It contain-
ed some small tuberculous masses like the right lung. The liver
was quite sound, and entirely concealed beneath the false ribs.
Between it and the diaphragm passed the incision made in ope-
rating.

The failure of the operation in the above case was inevitable:
the same thing would have happened if the incision had been made
three inches further back; and still more certainly had it been
made in the place of election. I am not aware that this operation
has before been frustrated by a similar obstacle. I apprehend so
close an adhesion of the diaphragm to the pleura of the ribs must
be very rare. In the present case I conceive it must be attributed
to a pleurisy long anterior to that which caused the death of the
patient. I have met with cases where the liver, ascended as high
as the'fifth rib, and where the diaphragm lay in juxta-position
with the pleura, all the way from its natural attachments to this
point, without there being any disease of the lungs or pleura. In
such cases an attack of pleurisy must have produced the exten-
sive adhesion described in the last ease.

For this and several other reasons, we ought to change the usual
place of operating for empyema. To make the present place of
operation the most depending, as it is said to be, we must have our
patient in the upright posture; but the natural posture for a person
affected with an effusion into the thorax, is that of lying on the
affected side. In this position the most depending point is the

156 DISEASES. OF THE PLEURA.

middle of the space comprised between the fourth and seventh
ribs.

On the other hand, experience proves to us — 1st, that the upper
part of the lungs adheres more frequently to the parietes of the
thorax than any other pari; 2nd, that the inferior part of these
organs adheres very frequently to the diaphragm; 3rd, that, in cases
of effusion consisting partly of albuminous concretions and sero-
purulent fluids, the thickest portions of the false membranes are
accumulated in the vicinity of the diaphiagm and adjoining parts
of the thoracic parietes; and, 4th, that the middle and lateral part
of the chest is that in which the greater portion of the effused
fluids is accumulated. For these reasons I am of opinion that the
place for performing the operation of empyema ought lo be the
middle of the space between the fourth and fifth rib, counting from
above. With regard to the'operation itself, I am of opinion that
it is one of much less severity than is usually imagined. Its
success depends less on the condition of the pleura, than on that
of the lungs; and when this viscus is not too deeply affected by
numerous tubercles, or by a large gangrenous eschar, it ought
almost always to succeed. The admission of air into the cavity
of the pleura is probably, also, less dangerous than is commonly
believed. This is, indeed, proved by the cases of wounds of the
thorax, and the history of recoveries after the operation of em-
pyema.

I have not met with any example of acute inflammation of the
pleura supervening to the operation; and I am not even sure
whether the supervention of such .an inflammation might not be
the means of a speedy and certain cure of the disease, by pro-
ducing an union between the lungs and ribs. At all events, in
cases where the severity of the symptoms presented little hope of
a cure from the operation, some benefit, and no danger, might
result from simply puncturing the chest. Perhaps, even, it might
be useful to draw off the fluids in this manner in all cafses of
chronic pleurisy, repeating, if necessary, the puncture, five or six
times. This slight operation would be attended with no incon-
venience, and. the puncture will heal up immediately. Morand,
in one of the cases already cited by me, made two punctures of
this sort, after which he performed the operation of empyema
and effected a complete cure.

HYDROTHORAX. 151

CHAP. II.

OF HYDROTHORAX.

SECTION FIRST.

Of Idiopathic Hydrothorax.

This disease is very generally considered as one of very fre-
quent occurrence, and as a common cause of death. This,
however, is far from being the case. Instances of death from
idiopathic Hydrothorax I consider to be as rare as one in two
thousand. Many diseases are often ranged under this, which
however are entirely different,— for instance— diseases of the
heart and great vessels, irregular consumptions, and even scirrhus
of the stomach and liver.

One circumstance which has more especially led to the belief
of the frequency of this disease, is the common mistake of taking
a sero-purulent effusion for it. This has arisen from the transpa-
rency of a part of these effusions. Indeed, it is only within these
few years that the nature of the pleuritic effusion has been pro-
perly known; and the mistake we have mentioned has been made
by men of great eminence at no very remote period. For exam-
ple, Morand gives under the name of dropsy of the chest, a case
of pleurisy cured by the operation of empyema *

Idiopathic hydrothorax commonly exists only on one side. Its
anatomical characters are simply an* accumulation of serum in the
cavity of the pleura; this membrane being quite healthy in other
respects; and the lung being compressed towards the mediastinum,
flaccid, and destitute of air, as in cases of pleuritic effusion.
When the effusion is very great, jhe affected side is evidently
larger than the other. This disease may exist in a very great
degree without any other symptom of dropsy in any other part of
the body.

The chief, and almost the only symptom of this disease is the im-

* Mem. de PAcad. de Chir, torn n.

152 DISEASES OF THE PLEURA.

peeled respiration: its progress, and the state of the general symp-
toms, can alone distinguish it from chronic pleurisy.

There are rases, even, where the distinction between these two
diseases is difficult in the dead body. Whatever may be thedif-
ference, both in the general symptoms and the organic lesion,
between a case of hydrothorax and an acute pleurisy; or between
a case of ascites from general debility or organic disease of the
heart or liver, and the slime disease from an attack of peritonitis;
— ror, in short, whatever may be the difference in general, between
a dropsy and an inflammation, — (here can be no doubt that these
two affections, so opposite in their extreme degrees, are neverthe-
less often very nearly allied in their slighter shades We frequent-
ly find albuminous concretions amid the serum of ascites, and
purely serous effusions in inflammatory affections of the chest.
These facts explain the admission made, by certain authors, of
inflammatory dropsies, and the fact of blood-letting being occa-
sionally beneficial in dropsy, and injurious in diseases truly inflam-
matory. This last is especially the case when the inflammation is
of a chronic kind, or originates in a cause which is not within
the control, of antiphlogistic treatment.

The causes of diseases are unfortunately, for the most part,
beyond our reach, yet we learn from daily experience, that the
particular character of these, occasions greater differences among
them (especially as regards their cure) than the nature of the dis-
ease itself. Many cases of pleurisy and peritonitis are equally
untractable by venesection, as a bubo or venereal ulcer, or as the
local inflammation of gout, or that which precedes hospital gan-
grene.

SECTION SECOND.

Of Symptomatic Hydrothorax.

Symptomatic hydrothorax is as frequent as the idiopathic is
rare. The symptomatic dropsy may accompany almost every dis-
ease, acute or chronic, general or local; its presence almost always
announces their approaching and fatal termination, and often pre-
cedes this only a few moments. It is not, perhaps, more frequent

HYDROTHORAX 153

in cases of ascites and anasarca (leucophlegmatie) than in other
diseases. It is most commonly met wiih in persons dead of acute
fever, disease of the heart, or tubercles or cancer of different or-
gans. Its symptoms, which are in every respect like those of the
idiopathic disease, do not, in general, make their appearance but
a few days, or even hours, before death. When the effusion takes
place on both sides of the chest, it produces a very painful suffo-
cation. Sometimes, however, we find a considerable effusion in
both sides, in cases where there had been no very notable dysp-
noea before death. Might not the effusion in such cases take place
in the very moment of dissolution, — or even after death? We
know that the functions of the capillary system do not cease im-
mediately after death. The quantity of serum effused varies from
a few ounces to one or two pints. It is commonly colourless or
yellowish, sometimes tawny, reddish, or even bloody.

SECTION THIRD.

Of Symptomatic Hydrothorax, depending on the production of ex-
traneous bodies in the Pleura.

There is another variety of symptomatic hydrothorax, which
arises from organic affections of the pleura. These affections are
cancerous tumours, or tubercles (such as affect the lungs) deve-
loped on its surface. The first are commonly of the variety called
medullary or soft cancer, of varying size, but rarely bigger than an
almond: they adhere strongly to the pleura, and have the usual
characters of the variety of cancer to which they belong. They
are commonly surrounded by a redness of the pleura to some dis-
tance, and this part, as well as their basis, is often intermixed with
black striae They are rarely found in great numbers.

The tubercles that form on the surface of the pleura are gene-
rally very numerous, and vary in size from that of a millet to a
hemp-seed. They are placed very close to each other, and are
often united by means of a soft semitransparent false membrane.
Near the period of their development we can sometimes scrape off
this false membrane, and with it the greater number of the tuber-
cles, which are evidently rather developed in it than in the pleura

20

154 DISEASES OF THE PLEURA.

itself. At a later period of the disease, the false membrane dis-
appears, or, at least, is united and confounded with the pleura,
which then seems thicker. In this case the tubercles adhere very
firmly to the pleura, and seem imbedded in its substance. Some-
times these tubercles are in their first stage, namely, semitranspa-
rent, greyish, or almost colourless, and sometimes in the second,
or opaque and yellow. I never met with any in the last stage, or
softened. The interstices of these tubercles are often very red,
and often contain distinct vessels. In this state the appearance of
the pleura is analogous to that of the skin in certain cases of mi-
liary eruption. We find, also, black striae intermixed with the
redness, which appear to be of the nature of melanosis.

We find also, occasionally, on the pleura, another variety of
granulations, which resemble some other cutaneous eruptions.
This consists of small, white, opaque, flattened grains, placed very
close together, and of a firm texture like that of fibrous mem-
branes. This variety is also accompanied by thickening of the
pleura. It appears to me to be the result of the imperfect organi-
zation of a false membrane, such as I have already described (page
123). These two varieties of morbid growths are very rare on
the pleura, but very frequent on the peritoneum. Bichat is the
first who noticed them, though he does not seem to have known
the Teal nature of them: they are always accompanied by hydro-
thorax. The cancerous tumours mentioned are also generally,
but not always, attended by the same disease. In all cases the
effused serum is almost always red or bloody. The bony, carti-
laginous, or fibro-cartilaginous incrustations developed in the
pleura, or rather on its external surface, scarcely ever give rise to
hydrothorax, and, in all probability, produce little or no disorder
in the functions of the part.

EFFUSION OF BLOOD. 155

CHAP. III.

OF BLOOD EFFUSED INTO THE CAVITY OF THE

PLEURA.

Penetrating wounds, or even a severe contusion of the chest,
may produce an effusion of blood into the cavity of the pleura.
The same thing takes place in certain cases of disease, and may
follow the rupture of an aortic aneurism. In some cases, also,
there is no doubt that a very copious exhalation of blood may take
place spontaneously, without any solution of continuity or external
violence. I do not here allude to those effusions which, as we
have already seen, sometimes attend the formation of blood-vessels
in the false membranes, or which confer on certain other effusions
a sanguineous tint merely; — but to a primary and idiopathic effu-
sion of blood analogous to the hemorrhages, active or passive, of
other organs. This case is doubtless very rare; yet some cases
can bear no other explanation. These various cases constitute
what has been improperly called sanguineous empyema. The
most common of these is, unquestionably, that originating in the
false membranes; and all those which I have seen become the sub-
ject of operation have been of this kind. The most dangerous spe-
cies is the spontaneous, inasmuch as, being usually the effect of a
general hemorrhagic diathesis, the removal of it, however effected,
will, in all probability, be followed by a similar effusion in some
other place. Blood effused in this manner may be absorbed as
readily as in other situations; when this does not take place
quickly, the blood is sometimes decomposed, and an aeriform fluid
is disengaged, producing particular symptoms, as we shall see
more particularly in a subsequent chapter.

J5f> DISEASES Or THE PLEURA

CHAPTER IV.

OF ACCIDENTAL PRODUCTIONS AND OTHER SOLII*
BODIES IN THE CAVITY OF THE PLEURA.

SECTION FIRST.

The pleura, like all the serous, and even mucous membranes of
the body, may be so altered in its nature as to secrete tuberculous
or cancerous matter in place of its natural fluid. This matter
may be formed in such quantity as completely to fill one of the
cavities of the chest, compressing the lungs upon the spine. This
is a very different case from that already mentioned, of the de-
velopment of tubercles on the surface of the pleura: in this latter
case the tuberculous matter is not secreted by the pleura, but
originates in the false membranes of pleurisy. Such morbid pro-
ductions as we are now considering are very rare. There is no
well described case of the kind on record; but I apprehend those
scirrhous masses mentioned by authors as filling one of the thora-
cic cavities must be of the kind in question. Boerhaave appears
to have found the medullary tumour, or soft cancer, in this situa-
tion in the person of the Marquis Saint Auban* and Haller, as
I have already observed, seems to have met with a large quantity
of the matter of melanosis in the same cavity. In two instances
I have myself discovered a considerable quantity of tuberculous
matter in this situation. In both these, the matier was in differ-
ent degrees of consistence. It was most solid at the bottom of
the cavity, and over the whole of the surface of the pleura, on
which it formed a layer of more than an inch thick; the remain-
der of the matter was quite soft, and was contained in the centre
of this sort of sac. The following case, communicated to me by
M. Cnyol, is the third instance of the same kind.

Case 39. A negro child, 6 years of age, entered the children^

•See Zimmerman, Traite de l'Experience.

ACCIDENTAL PRODUCTIONS. 157

hospital in 1807. Nothing respecting his previous history could
be ascertained. He had a deep and painful ulcer on the temple,
constant diarrhoea, frequent dry cough, unaccompanied by dysp-
noea; he had irregular fever. He died, gradually exhausted, in
less than a month.

On examination afler death, the bones in the vicinity of the
ulcer were found extensively diseased, and partly removed by
caries. On the outside of the cranium there were two tubercles,
one of the size of a large nut, and the other one half less. They
were not encysted, and were entirely composed of tuberculous
matter in the first degree of softness. One of them was contained
in a hollow on the surface of the cranium.

On opening the thorax, the right lung seemed completely trans-
formed into one tuberculous mass, but a more close inspection
showed it to be compressed by this tuberculous growth, which was
contained in, and completely filled the cavity of the pleura. This
matter was of the consistence of cheese, and exhibited no distinct
tubercles. It was about the thickness of two fingers on the ante-
rior and posterior parts of the lung, and somewhat thinner on the
side. A portion of it, of the size of a walnut, had formed a
passage outwards between the seventh and eighth ribs (which
were carious), and adhered to the skin. This portion was as
fluid as pus in its centre. Another portion united the diaphragm
to the base of the lung, and also to the ninth and tenth ribs. On
detaching this layer from the surface of the pleura, this, in place
of being smooth, was found unequal, like the surface of the cysts
of tubercles; and some very short fibres, like a fine cellular tissue,
extended from it into the morbid production. In the midst of
this mass the lung, compressed to one-fifth of its natural size, was
found in other respects sound, and did not contain the slightest
trace of tubercles. There was a small quantity of serum in the
left pleura, and also in the cavity of the peritoneum, and the liver
was not quite sound. The mesentery, and other viscera, were in
their natural condition.

Tumours of different kinds are also found developed between
the pleura of the ribs and thoracic parietes. I have met with, in
this situation, only the medullary tumour, tubercles of small size,
and cartilaginous incrustations. . Haller found, in this situation, an
immense cyst, containing a serous fluid, and compressing the lung
into the size of the hand.* M. Dupuytren found two enormous
cysts of the same kind, in the body of a young man, who died of

* Opusc. Pathol, obs. xiv.

158 DISEASES OF THE PLEURA.

suffocation, after having long laboured under a progressively in-
creasing dyspnoea. Each of these nearly filled one of the cavities
of the chest, and compressed the lungs into a small compass on
the anterior part of the cavity.* It is not improbable that these
cysts were hydatids.

SECTION SECOND.

In cases of wound, some part of the abdominal viscera has
passed into the thorax.f The same thing has followed a rupture
of the diaphragm, occasioned by a fall, by great exertions,! or by
an enormous distention of the stomach. § The same derangement
has taken place from original malformation of the diaphragm;||
and even by the natural openings in that muscle. IF On the other
hand, a hernia has heen formed by the lungs through the inter-
costal muscles. Grateloup has published a case of this kind,
which was produced by violent coughing.** Boerhaave records a
similar instance arising from the exertions during labour;ff and
Sabatier mentions another, supervening on the cicatrization of a
bayonet-wound between the fifth and sixth ribs.Jj: A fourth ex-
ample is given in Richter's Journal (Bibliotheque de Chirurgie
Allemande.)§§

* Essaia sur l'Auat. Path, par J. Cruveilhier. Paris, 1816.
\ Vide Ambros. Pare' — Leblanc — Fabric, de Hildan. Fanton.
$ Journ. de Desault, torn iii. — Richter on Herniae.
§ Haller. Disput. Chir. torn. iii.

I) Hist, de L'Acad. roy. des Scienc. 1729 & 1772 ; & Richter.
t Richter on Hernia. ** Journ. de Med. torn. 53.

ffDe Haen Prelect. inBoerhaav. ** Med. Oper. torn. 2
§§ Tom. 3

PNEUMOTHORAX. 159

CHAP V.

OF AIR IN THE CAVITY OF THE CHEST, OR
PNEUMO-THORAX.

Occasionally we find aeriform fluids in the cavity of the pleura.
These are sometimes without smell, more commonly fetid, and of
a fetor resembling that of sulphuretted hydrogen gas. These fluids
are sometimes in such quantity as very forcibly to compress the
lung, and to distend the thoracic parietes in a very sensible manner.
In this case the ribs are found more or less separated, — and the
diaphragm projecting into the cavity of the abdomen and forcing
the viscera before it.

Although this affection cannot be said to be of excessive rarity,
it has hitherto been but little noticed by medical men. All that
we find respecting it in practical writers are a few examples of
the disease very imperfectly described; and, in general, we know
it merely from the casual observations of anatomists and surgeons,
who have occasionally noticed the escape of air in opening the
chest after death, or in performing the operation of empyema.*
There exists no special memoir on this subject, to the best of my
knowledge, but an inaugural dissertation of twenty pages, by M.
Itard, at present physician to the institution for the deaf and
dumb.f The disease is named by M. Itard, Pneumo-thorax. He
details five cases of it, three of which are original, one extracted
from Selle, and the fifth furnished by M. Bayle. In all these the
aerial effusion coexisted with phthisis and chronic pleurisy. In
all of them the lungs of the affected side were compressed into a
small compass towards their roots. The fluid was more or less
fetid. The cavity of the pleura was invested by a false puriform
membrane, at least in the instances noticed with any degree of de-
tail, and contained a few spoonfuls of pus. The author of this
memoir, in conformity with the then established notions, considers

• Vide Riolan, Enchirid. Anat. lib. Hi. cap. ii.— Pouteau, (Euv. Post. t. 3
f Dissertat. sur le Pneumo-thorax, &c. Paris, 1803.

\QQ DISEASES OF THE PLEURA.

the pneumo-thorax as an affection always consequent to and de-
pending on a latent phthisis; and that its exciting cause is " the
decay of the lung by means of a chronic suppuration, together
with the partial absorption and decomposition of the pus owing to
its long stagnation in a confined cavity." We have already seen
that this consumption of the lung (pulmones assumpli, Lieutaud)
is not owing to the destruction of that viscus by suppuration, but
that the collection of purulent matter is the cause and not the
effect of the diminished size of the lungs. This fact, which I
believe M. Corvisart was the first to demonstrate in his clinical
instructions, is now considered as unquestionable by every one
well acquainted with morbid anatomy. In former pages we have
ourselves shown that the lungs may be reduced to a very small
volume by purulent or watery effusions, without containing tuber-
cles, or snowing any mark of suppuration.

All the cases of M. Itard, then, are to be considered as pneumo-
thorax consequent on a latent pleurisy, which coexisted with the
phthisis, and in which the greater part of the effused liquid had
been absorbed. It is sufficiently probable that, in these cases, the
gas was the product of decomposition of some portion of the effused
albuminous and puriform matter: the character of its smell leads
to this opinion. This species of pneumo-thorax is pretty frequent.
There are several other varieties sufficiently distinct. 1 have
several times discovered this affection coexisting with a consider-
able sero-purulent effusion of the pleura, and a communication
between this cavity and the bronchia, owing to the rupture of a
vomica, or softened tubercle, simultaneously into the bronchia and
pleura. I consider this species as the commonest of all; at least,
I have met with it most frequently. In this case it is reasonable
to believe the air contained in the cavity of the pleura to be simply
the atmospheric air conveyed thither by the bronchia. I shall
subjoin several remarkable instances of this variety.

It is possible that, in this case, the introduction of the air into
the pleura may excite inflammation of that membrane, and that,
consequently, the pleurisy may be the effect of its presence, and
not the cause, as in the instances given by M. Itard. It is, how-
ever, also possible, that a vomica may burst into this cavity
without at the same time communicating with the bronchia, and
may thus exite a pleurisy, and consequent pneumo-thorax, through
the decomposition of the pleuritic fluids. This case comes under
the head of those of M. Itard, with this difference, that the original
effusion is here considerable.

Pneumo-thorax may also be conjoined with hydrothorax. I

PNEUMO-THORAX. 161

have not met with a case of this kind, but svereal cases prove its
occurrence. It is, doubtless, true that many supposed cases of
this kind have been true pleuritic effusions, mistaken for the simple
serous exhalation; but M. Bayle gives one incontestible instance
of this sort, in a person where there was found a small portion of
serum and a great quantity of air in the pleura. (See his case

Pneumothorax also almost always occurs when a gangrenous
eschar of the lungs is dissolved and evacuated into the cavity of
the pleura. In this case gas is evolved during the chemical de-
composition of such matter; and this, together with the fluids
effused by the irritated pleura, compresses the lung, and dilates
the affected side. We have already given two examples (cases
12 and 13) of this species of pneumo thorax. Gangrene of the
pleura, also, commonly produces the same effect. A case of this
kind will be subjoined. The same effect results from the decom-
position of blood effused into this cavity. On examining the body
of a man that died after an illness of five days, Littre found in the
chest two pints of'blood, and an enormous quantity of air. This
affection may, further, be produced by rupture of the pleura of the
lungs from external violence. A case of this kind is mentioned
by Hewson * It is likewise probable that in the case of emphy-
sema of the lungs, with rupture of some of the air-cells and ex-
travasation of air under the pleura, this membrane may sometimes
be ruptured, and the disease in question be thus formed. I think
I have seen something of this kind. Finally, an aeriform fluid
may be formed in the cavity of the chest, without there being any
solution of continuity, any other effusion, or any perceptible change
of structure whatever. I have often perceived the escape of an
inodorous gas, in opening the thorax, where there was no per-
ceptible affection of the pleura. Sometimes, indeed, this mem-
brane appeared to be drier than natural, and I remember one case
in which it was, in some places, almost as dry as parchment.
Even in these cases a rupture of the pleura, so slight as to be un-
perceived, maybe imagined; but, independently of the circum-
stance that such rupture cannot well be supposed without some
external violence, we know that an idiopathic formation or secre-
tion of air can and does take place in the animal system. It is
thus that we sometimes find air, in considerable quantity, in the
pericardium, in cases where there exists no other effusion in that
cavity; we find the same, also, though more rarely, in the cavity

* Med. Obs. & Inq. vol. 3.
21

162 DISEASES OF THE PLEURA.

of the peritoneum. It would even appear that air, or an aeri-
form fluid, exists naturally, in small quantity, in the cavity of the
pleura. At least, M. Ribes assures me that he has found, in
opening the serous cavities of dogs, a small quantity of air con-
stantly to escape. This may probably, however, be merely the
natural serous exhalation in a state of vapour. The following case
will show that air introduced into the cavity of the pleura, in the
most simple and natural way — that is, by secretion — may not be
productive always of a fatal, or even very severe pleurisy.

Case 40. A man, aged 65, of a strong constitution, subject for
two years to a cough which did not prevent him from following
his business, was suddenly seized one evening with violent pains
in the abdomen and died the same night.

After death, the body, though emaciated, still retained consider-
able muscularity. The right side of the chest was evidently larger
than the left, and yielded a louder sound on percussion than even
the chest of a healthy person usually does. The left side yielded
a sound comparatively obscure through its whole extent. There
were found some diseased appearances in the brain. On penetrat-
ing by the scalpel the right cavity of the chest, an inodorous gas
escaped, and in large quantity, to judge by the force and duration
of the sound occasioned by its exit. The lung on this side was
somewhat compressed towards its roots, but still retained three-
fourths of its natural dimensions This side of the chest was
considerably dilated, and, besides the lung, might have contained
about two pints of liquid, — the quantity, no doubt, of gas that had
made its escape. The whole of the pleura was drier than usual,
and rather unctuous than humid; there were no false membranes
nor any effused fluid. The lung adhered to the costal pleura at
its superior lobe, by means of cellular layers an inch in length,
which seemed of no very ancient date. This adhesion was attach-
ed at one end to a species of cartilaginous incrustation of the size
of the palm of the hand, which adhered closely to the pleura pul-
monalis. In detaching the cellular adhesions from this fibro carti-
laginous body, there remained in the centre of the latter, a small
oval opening, about a line and half in diameter, which communi-
cated with an excavation in the lung, which could have contained
an orange. (I am not quite certain whether the oval opening,
above mentioned, existed before, or was formed by the act of
detaching the lung from its adhesions; though I am inclined to
consider it as previously existing.) The excavation was nearly
empty, containing only about a spoonful of pus. Its parietes were
immediately formed by the pulmonary tissue, except in that space
answering to the cartilaginous incrustation, where, to the extend

PNEUMOTHORAX. 163

of more than an inch square, they consisted solely of this false
membrane. There were many tubercles, in different stages, and
also numerous hard melanotic tumours in different parts of the
lung. The left lung adhered to the costal pleura in its whole
extent. It, also, contained tubercles and melanotic tumours. There
was, likewise, here a tuberculous cavity, of considerable size in
the upper lobe. There was disease in the large intestines.

Whatever may be our opinion respecting the source of the air
existing in this case, in the cavity of the pleura, the appearances
prove that air may exist there without exciting much inflammation.
The case further shows, that phthisis may pass through all its
stages without producing any violent symptom; and I am disposed
to believe, from the appearances observed, that this patient would
have been either completely, or, at least temporarily, cured of this
disease, had he not been carried off by another.

It is extremely probable, as Hewson,* and M Rullierf have sup-
posed, that pneumo-thorax offers the best chance of success for
the operation of empyema. This opinion is supported by the de-
claration of Riolan, who tells us that he saw the operation several
times performed for supposed dropsies of the chest, in which air
alone, in place of water, made its escape with a sort of explo-
sion.:}:

In many cases already detailed in this work, (see cases 14, 34,
35, 36, 37, 38,) the existence of pneumo-thorax was recognised
during the life of the patient, and the following is an additional
instance of the same kind.

Case 41. A women, aged 26, of a feeble frame, came into
hospital affected with what she called a cold of three months
standing. Within the last month only, had she lost her ap-
petite, or been unable to work at her business. She had, for se-
veral years, had the lymphatic glands in the axilla enlarged.
When this woman came into hospital she was evidently in a state
of hopeless consumption. The greater part of the chest yielded
a pretty good sound on percussion except on the left superior
part, in which situation the stethoscope gave indication of the ex-
istence of tuberculous excavations. This patient survived two
months. The day before her death, the stethoscope applied to
the left side conveyed the metallic sound, characteristic of the
existence of a cavity containing both air and liquid, and com-
municating with the bronchia (see Part II.), while respiration

* Med. Obs. f D * ct ' des Sc * mec *- Art< Empy£me

i Enchirid. Anat.

164 DISEASES OF THE PLEURA.

was scarcely perceptible in any part of it. The same side sound-
ed much better on percussion than the right, in which the
respiratory murmur was very distinct Convinced by these
symptoms of the existence of a pneumo- thorax combined with a
pleuritic effusion, I confidently expected that die Hippocratic suc-
cussion of the chest would let us hear the fluctuation of the liquid,
and I was not mistaken. The patient died the night following.

On opening the chest a great quantity of an inodorous gas
made its escape from the left side, which appeared haif empty,
the lung being compressed upwards and backwards to one-third
of its natural size. The surface of the pleura was partially
marked by a punctuated redness, and its cavity contained about
half a pint of a transparent, yellowish liquid, mixed with a few
whitish flocculi. Almost the whole of the superior lobe adhered
to the costal pleura; and, on the outer side, there was an opening
or ulceration, of the size of the nail, covered with a thick yellow
matter, and discharging bubbles of air on pressure being applied
above it. This proved to be the outlet of a short fistulous canal,
capable of admitting the finger, which communicated with a
vast internal cavity, which occupied a great portion of the lobe.
This excavation was irregular, and was lined by a very soft false
membrane. It was nearly empty, and two or three bronchial
tubes of the size of a crow-quill opened into it. In short, it re-
sembled a true tuberculous excavation — such as have been de-
scribed in Book I. Chap. I.

The right lung filled the cavity of the pleura and closely ad-
hered to it, in almost its whole extent, by a short well organized
cellular tissue. It was filled with white tubercles of the size of
a cherry-stone.

HYPERTK0PH1A. 165

BOOK THIRD.

OF THE HEART AND ITS APPENDAGES

CHAP. I.

OF DISEASES OF THE HEART.

SECTION FIRST.

Of Hypertrophic or simple enlargement of the Heart.

By Hypertrophia I mean simple increase of the muscular
substance of the heart, without a proportionate dilatation of its
cavities, or even with a diminution of Ihese. Ttiis affection is
by no means common, and appears to have escaped the notice
of M. Corvisart, as, through his whole work, he seems to con-
sider enlargement of the parietes of the heart, as being uniform-
ly accompanied by a proportionate dilatation of the cavities of that
organ.

This enlargement of the heart is always attended by a con-
siderable increase of its consistence, except when conjoined with
another affection of this organ, to be noticed presently, viz:
softening of the heart.

Hypertrophia may exist in one or both ventricles, with or with-
out a similar affection of the auricles. Most commonly the au-

166 DISEASES OP THE HEART.

rides are not affected, but occasionally they are so, while the
ventricles are sound.

When affecting the left ventricle, I have seen its parietes
more than an inch thick at the base, that is, double that of its
soui»d state. Commonly, this morbid thickening diminishes in-
sensibly from the base to the apex of the ventricle, where it is
scarcely perceptible; sometimes, however, the apex partakes in
the enlargement; as I have seen it from two to four lines thick,
which is double or quadruple the natural size. The columns
carneae of ihe ventricle and of the valves acquire a proportionate
enlargement. The septum between the two ventricles becomes
also notably thickened in the disease of the left ventricle, (which
fact seems to mark it as belonging to this rather than the other
ventricle,) but never so much so as the other parts.

The muscular substance in these cases is of a degree of con-
sistence sometimes double the natural, and is of a redder colour.
The cavity of the ventricle appears to have lost in capacity what
its parietes have gained to thickness. Sometimes I have found
this so small, in hearts twice the size of the fist of the individual,
as scarcely »o be capable of containing an almond in its shell.
The ii^ht ventricle, in such cases, is flattened along the septum,
and does not extend to the apex of the heart In extreme cases,
it seems as if it were merely included within the parietes of the
left ventricle.

In hvpertrophia of the right ventricle the appearances are some*
what different. The thickening is here more uniform, and never
so great as in 'he other: I have never found it greater than four
or five lines. It is always a little greater in the vicinity of the
tricuspid valves, and at the origin of the pulmonary artery. The
columnae carneae are much enlarged, considerably more so, in
proportion, than those in the left, in disease of that side. Simple
enlargement of the right ventricle, without dilatation, is much
rarer than that of the left. When this disease affects both ven-
tricles at the same time, the only difference from the description
just given is, that each side assists to form the apex of the heart.

DILATATION OP THE VENTRICLES 16TC

SECTION SECOND.

Of Dilatation of the Ventricles.

This disease of the heart, which has been named passive aneu-
rism by M. Corvisart, consists in dilatation of the cavities of the
ventricles, with decreased thickness of their parietes. With
these conditions there are commonly conjoined a notable degree
of softening of the muscular substance, and a colour, either more
violet, or paler, than natural. Sometimes the softness is so con-
siderable, especially in the left ventricle, that the muscular sub-
stance can be destroyed by mere pressure between the fingers;
and the parietes of the same ventricle may be so much diminish-
ed in thickness, as to be only two lines in the thickest point, and
scarcely halt a line at the apex, while the right ventricle is some-
times so completely extenuated, as to appear merely composed of
a little fat and its investing membrane. The columnar carntae,
particularly of the left ventricle, are more remote than in the na-
tural condition of the part The septum between the ventricles
loses less of its thickness and of its consistence than the rest of
the parietes.

Dilatation may be confined to one ventricle, although it more
commonly affects both at the same time. When one only is af-
fected, the apex of it extends below the other, but not in so re-
markable a degree as in the case of hypertrophia. The augmen-
tation of the cavity seems to be more in its breadth than length.
This is particularly observable when both the ventricles are dila-
ted at the same time; as, in this case, the heart assumes a rounded
shape, being nearly as wide at the apex as at the base.

SECTION THIRD.

Of Dilatation combined with Hypertrophia of the Ventricles,

This reunion, which constitutes the active aneurism of M. Cor-
visart, is extremely common; much more common than simple

168 DISEASES OP THE HEART.

dilatation, and still more so than simple thickening without dilata-
tion. This complication may exist in one or both ventricles. In
the latter case the heart acquires a prodigious size, sometimes
more than triple that of the hand of the individual. As the aug-
mentation of volume is here the effect of dilatation and thicken-
ing, the muscular substance acquires the great firmness already
described. The apex of the heart becomes blunter, but this is
rarely so great as to give to the organ the rounded form noticed
in the case of simple dilatation.

Dilatation of one ventricle is sometimes conjoined with hyper-
trophia of the other, but this is not so common as the complica-
tion in individual ventricles, i ha * met with the folk- wing va-
rieties of this complication: 1st, Hyperirophia with dilatation of
the left ventricle, and simple dilatation of the right; 2nd, Hyper-
trophia with dilatation of the left ventricle, and simple hypertro-
phia of the right; 3rd, Hyperirophia with dilatation of the right,
and simple dilatation of the left; 4th, Hyperirophia of the right,
with dilatation of the left, this last is the rarest. I do not re-
member to have met with hypertrophia of the left ventricle (with
or without dilatation) complicated with dilatation of the right.
1 would even be disposed to consider such an union as impossible.

SECTION FOURTH.

Dilatation of the Auricles.

Dilatation of the auricles is an extremely rare disease, and it
appears still more so compared with the frequency of the same
affection of the ventricles. Sometimes we find in subjects affect-
ed with hyperirophia or dilatation of the ventricles, the auricles,
also proportionably enlarged; it is, however, much more common
to find these retaining their natural size even in cases where the
ventricles are enormously enlarged. Sometimes also, but more
rarely still, the auricles are dilated when the ventricles are of the
natural size.

Before we can judge of the extent of this affection we must
have precise ideas respecting the natural proportion of the various
cavities of the heart. As far as the cavities are concerned, we
must admit that they are very nearly of equal size; but as the

DILATATION OF THE AURICLES. 169

parietes of the auricles are much thinner than those of the ven-
tricles, the former, when simply full and not distended, compose
only about one third of the whole organ, — in other words, the
size of the auricles is about one half that of the ventricles. Both
the auricles have the same capacity, although some anatomists
have considered the right larger, no doubt misled by the greater
length of its sinus, and more especially by the distended condition
in which it is commonly found after death. A similar distention,
though more rarely, takes place also in the left auricle; and this
accidental and temporary enlargement is sometimes so considera-
ble, owing to the great extensibility of the auricular structure, as
almost to equal the size of the ventricles. In order to distinguish
the real from the factitious dilatation, we have only to empty the
auricles through the vessels that enter into them, when, in the
latter case, these cavities will immediately resume their natural
size", and, in the former, they will still nearly retain their acquir-
ed volume. There is likewise another mark by which we can at
once discriminate the enlargement produced by the accumulation
of blood during the few last hours of life, from the permanent in-
crease of capacity of the auricles. In the first case, the parietes
of the auricle are greatly distended by the contained blood, and
the colour of this appears through the thinnest portions; while,
in the latter, the auricles, although very voluminous, are still ca-
pable of containing more blood, and their parietes remain opaque.

I have never met with decided dilatation of the auricles with-
out some thickening of their walls; and, on the other hand, I have
never seen thickening of their walls without an augmentation of
their capacity. I may here remark that it requires much experi-
ence to judge correctly of hypertrophia of the auricles, as, owing
to their great natural thinness, a considerable increase (say double
the natural thickness, and the increase is rarely so much) is not.
obvious to a person little accustomed to such examinations.

The most common cause of dilatation of the left auricle is the
contraction of the orifice between it and the ventricle, in conse-
quence of cartilaginous or bony induration of the mitral valve, or
of caruncles on its surface. The same causes sometimes occasion
the retraction of this valve, and consequently the permanent pa-
tency of the auriculo-ventricular orifice. In this case dilatation
and thickening may arise from the mere action of the ventricle on
the auricle. I have never seen any change in the auricles with-
out some alteration in the valves. Dilatation of the right auricle
Is most commonly the consequence of thickening of the right ven-

22

|70 DISEASES OF THE HEART.

tricle. The diseases of (he lungs which M. Corvisart reckon*
amoTig the ordinary causes of this dilatation, seem to me to pro-
duce, in general, merely the accidental distention above noticed.

SECTION FIFTH.

Partial Dilatation oj the Heart.

M. Corvisart found, in the person of a young negro who died
from suffocation, a partial dilatation of the left ventricle which was
truly aneurismaticai. " On the superior and lateral part of this
ventricle there was a tumour almost as large as the heart itself. —
The interior of this tumour contained several layers of coagulated
blood, very dense, and exactly like those found in aneurisms of the
limbs .... The cavity of this tumour communicated with the ven-
tricle by a small opening, smooth and polished."* A similar case
is cited by M. Corvisart from the Misccll. .Nat. Curios. I have
myself never met with any thing of the kind.

There is another rare species of dilatation described by Mo-
rand,! a second case of which was communicated by me to the
Soc. de la Facult de Med.} This is a dilatation formed in the
middle of one of the lips of the, mitral valve, resembling a thim-
ble, or glove-finger projecting into the auricle.

There is still one other variety of partial dilatation of the heart,
which I have several times met with, and which is probably, in a
great measure, the result of original malformation. In the natural
conformation of the heart, the right ventricle seems to consist of
two distinct parts united together, the one of which descends to-
wards the apex of the heart, while the other, almost at right angles
to the former, is directed to the leftside, and forwards towards the
pulmonary artery. The dilatation to which 1 now allude, seemed
to exist in both these divisions, while the point of union of the two
retained its natural dimensions. It is, however, more common to
find the anterior or pulmonary division of the ventricle dilated
without the other portion; and in every case of dilatation of this
ventricle, the former portion is always more dilated than the other

* Op. cit. p. 283. t H ist - de l'Acad. des Sc. 1729

i Bulletin, No. 14.

INDURATION. HI

This difference becomes still more evident when the dilatation is
conjoined with a certain degree of thickening, as, in this case,
the pulmonary portion of the ventricle frequently acquires such a
degree of -firmness that its parietes do not collapse when laid open,
a thing which hardly ever happens to the lower portion of the ven-
tricle.

SECTION SIXTH.

Induration of the Heart.

I have already observed that, in thickening of the heart, the
muscular substance possesses an unusual degree of firmness and
consistence. Corvisart has seen this so great, that the heart sound-
ed like horn when struck, and the scalpel experienced great resist-
ince in cutting it. However, the muscular substance of the heart
" retained its natural colour, and did not appear to be converted
either into the bony or cartilaginous tissue." I have never met
with this species of induration, although M. Corvisart has seve-
ral times. I consider it as the last degree of hypertrophia.

SECTION SEVENTH.

Softening of the Heart.

I have already noticed this condition of the heart. In it the
muscular substance is sometimes so soft as to be almost friable,
the fingers passing easily through the parietes of the ventricles.
Whatever may have been the patient's disease, the heart is rarely
filled with blood, and the ventricles equally collapse whatsoever
may be their varying thickness. This affection of the heart is
almost always attended by some change of colour in the organ.
Sometimes this is deeper, and even quite violet; and this is parti-
cularly the case in fevers of the kind named adynamique by Pi-
uel. More commonly, however, the softening of the heart is at-

1 72 DISEASES OF THE HEART.

tended by a striking loss of colour, so as to resemble the palest
dead leaf. This pale or yellowish tint does not always occupy the
whole thickness of the heart; sometimes it is strongly marked in
the central portions, and very little on the exterior or inferior sur-
faces. Frequently the left ventricle and interventricular septum
exhibit this appearance, while the right ventricle retains its natural
colour, and even a degree of firmness greater than natural. Again.,
we sometimes find here and there spots of the natural colour and
consistence in hearts which are, every where else, much softened
and quite yellowish. This variety of yellowish softening is par-
ticularly observable in those cases where dilatation is conjoined
with a slight degree of thickening. It is also found in simple di-
latation, although it is more, common to find this state accompa-
nied by that species of softening which is marked by an augmenta-
tion of the natural colour of the organ. There is a third variety
of softening of the heart, which will be noticed in another place,
and which is attended by a pale white colour of the muscular sub-
stance In this, the degree of softening never reaches that of fria-
bleness; often it is scarcely perceptible; but the parts are flabby,
and the parietes of the ventricles quite fall together on being
opened. This condition will be noticed under the head of in-
flammation of the pericardium, as it is peculiar to that disease. .
It would seem that the softening of the heart discovered in sub-
jects whose death has been very gradual, is an acute affection; it
is evidently still more so where it exists only partially in the sub-
stance of the organ. On the contrary, in cases where the heart
is softened and yellowish throughout, it is probable that the affec-
tion has existed for a long time. The deep-coloured softness ob-
served in subjects dead of fever, may, I think, be compared to that
adhesive softness of the Other muscles often observed in these
cases, and which is also accompanied by a degree of redness
greater than natural. This softening of the heart, as well as the
analogous gluey or fishy (gluant ou poisseux) state of the muscles,
is particularly observable in putrid fevers, particularly when these
exhibit the phenomena formerly considered as marks of putridity
— viz: livid intumescence of the face, softening of the lips, gums,
and internal membrane of the mouth, black coating on the tongue
and gums, earthy aspect of the skin, distended abdomen and very
fetid dejections. I cannot assert that this softening of the heart
exists in all kinds of continued fevers, but I have met with it con-
stantly in such cases as I have attended to. Could it accountjbr
that frequency of pulse which exists, sometimes for several weeks,
in convalescence from fevers, although the patient continues to re
gain flesh and vigour? 1

atroph\ ] 73

SECTION EIGHTH.

Atrophy of the Heart.

It is an important question whether the heart be susceptible ot"
diminution of size and power like other muscles; and, if so,
whether this affords any hope of cure, by debilitating measures, in
cases of hypertrophia. This much is certain, that, in cases where
there is much emaciation, as in Phthisis and Cancer, the heart is
generally found small. From this consideration, I have in many
cases of hypertrophia attempted the method of cure proposed by
Valsalva in aneurism! Almost all my patients got shortly tired of
the extreme severity of the regimen, and alarmed by the frequency
of the bleedings. In three cases, however, I have been so far
successful that I am led'to believe that this disease is not entirely
beyond the resources of art and nature. ' Two of these were young
women, the one VI and the other 18 years of age, both of whom
presented symptoms of hypertrophia in a high degree. The pri-
vation of one-half of their ordinary diet, and some occasional ge-
neral and local bleedings effected the gradual diminution, and,
eventually, the complete cessation of all their symptoms. The
youngest has now been cured four years, and has long ago return-
ed to her usual regimen. The other still follows the prescribed
regimen, and is now quite reconciled to the diminished quantity of
food. Blood-letting has not been found necessary for the last
year, and the general symptoms of the disease have disappeared,
although the unnatural thickness of the parietes of the heart is still
recognisable by the stethoscope. The third case is still more con*
elusive, as I have been enabled to ascertain the state of the heart
after death. I shall therefore state it more particularly.

Case 42. A woman, 50 years of age, had been affected for
twelve years with all the symptoms of disease of the heart, in a
very high degree, viz* strong and frequent palpitations, habitual
dyspnoea, breathlessness on using the least exercise, sudden start-
ings from sleep, almost constant oedema of the lower extremities,
and lividity of the cheeks, nose, and lips. These symptoms had
increased during the last year, so that she could scarcely move
iron] her chair without the feeling of suffocation. In this state I
recommended the treatment of Valsalva, which she agreed to. I

174 DISEASES OF THE HEART.

immediately reduced her aliments to one-fourth of her former al-
lowance, and bled her once a fortnight, either from the arm or by
leeches. This mode of treatment gave immediate relief; and in
the course of six months all the symptoms had disappeared; and,
with the exception of debility (which however was not greater
than it had been previously), she enjoyed a better state of health
than for many years before. The respiration was now free, and
the palpitations, oedema, startings, and lividity of the face had
quite disappeared. After this I recommended the bleedings to be
decreased in frequency, and I dispensed with them altogether at
the end of a year. She also returned gradually to her old regi-
men, only that now a much smaller quantity of food satisfied her
appetite. She lived two years in a state of perfect health, when
she was suddenly carried off by an epidemic cholera. Upon ex-
amining the body after death I found the heart considerably less
than the closed hand of the individual; being only about the usual
size of that of a child 12 years old, although this woman was five
feet three inches in height. The exterior of the heart resembled,
in appearance, a withered apple, the wrinkles running longitudi-
nally. The ventricular parietes were flaccid, but without any no-
table softening, and of the natural thickness. I am well aware
that nothing can be deduced from a single case, but I have thought
the above relation might be useful by stimulating others to prose-
cute this snbiect more at length.

SECTION NINTH.

Fatty Degeneration of the Heart.

In medical writings we find many examples of the heart being
overloaded with fat in a surprising manner, and to which change
of structure various symptoms, and even the sudden death of the
individuals, were attributed. M. Corvisart thinks that an enor-
mous accumulation of fat around the heart may, in fact, produce
such effects, although he has met with no similar, or other perma-
nent derangement, in persons whose hearts were found to be much
loaded in this manner. I have also met with a great many case*

PATTY DEGENERATION. 175

of hearts, overloaded in this manner, in subjects dead of various
diseases. In these the fat was deposited between the muscular
substance of the heart and the investing pericardium, and chiefly
at the union of the auricles and ventricles, at the origin of the
great vessels, and along the tract of the coronary arteries, also
along the two edges and at the apex of the heart. 'Sometimes the
posterior face of the right ventricle is covered by this deposition
in its whole extent; a circumstance which rarely has place on the
surface of the left ventricle.

The fatter the heart is, the thinner, in general, are its parietes.
Sometimes these are extremely thin, especially at the apex of the
yentricles^and the posterior side of the right ventricle. On examin-
ing ventricles affected in this manner, they present the usual ap-
pearance internally; but on cutting into them from without, the
scalpel seems to reach the cavity without encountering almost any
muscular substance, the columnae carneae appearing merely as if
bound together by the internal lining membrane. In these cases
the fat does not appear to be the product of degeneration of the
muscular fibres, as these can be separated by dissection. Some-
times, indeed, portions of fat penetrate deeply between the mus-
cular fibres; but, even in this case, the distinction between the
two tissues is still very marked, and they are confounded by no
mutual gradation of colour or consistence. It would seem proba-
ble from this, that, from pressure or some unknown aberration of
the powers of nutrition, the muscular substance has wasted in pro-
portion as the investing fat has increased. It would seem reason-
able to expect rupture of the heart from an affection of this kind;
such an instance, however, has never occurred to me. Very com-
monly we find, in such subjects, a large quantity of fat in the' lower
part of the mediastinum, particularly between the pericardium
and pleura. This fat, much reddened by its small vessels, and
covered by its pleura, assumes the figure of a cock's comb and is
firm. The fat surrounding the heart, on the contrary, is almost
always of a pale yellow colour. I have not observed, any more
than M. Corvisart, any symptoms that could directly denote the
existence of an accumulation of this sort. I apprehend it must
exist in a very great degree before it gave rise to any serious com-
plaint. This is not, therefore, the condition I wish to denote by
the name of Fatty degeneration of the Heart. This latter is an
actual transformation of the muscular substance into a substance
possessing most of the chemical and physical properties of fat. It
is precisely similar to the fatty degeneration of the muscles ob-

170 DISEASES OF THE HE AIM.

served by Haller * and Vicq-d'Azyr.f I have only met with it
♦n a small portion of the heart at one time, and only towards the
apex. In these portions the natural red colour is superseded by a
pale yellow like that of a dead leaf. This change of structure
appears to proceed from without inwards. Near the internal sur-
face of the ventricles, the muscular texture is still very distin-
guishable; more externally, it is less so; and still nearer the sur-
face it becomes gradually confounded, both in colour and consist-
ence, with the natural fat of the apex of the heart. In such cases,
however, even the portions that still retain most of the muscular
character, when compressed between two pieces of paper, still
grease these very much. This character distinguishes this spe-
cies of degeneration from simple softening of the viscus. I have
never found rupture of the heart attributable to this change, any
more than to the morbid accumulation of fat. It is denoted by no
symptoms with which I am acquainted.

SECTION TENTH.

Cartilaginous or Bony induration of the muscular substance oj tin-
Heart.

I have never met with ossification of the muscular substance
of the heart, and only a small number of examples of this are
on record. M. Corvisart found, in the case of a man who died
of hypertrophia of the left ventricle, the whole apex of the heart,
and more partially the columnar carnea:, converted into cartilage
(op cit.).

Haller (Opusc. Pathol.) found, in a child, whose heart was
of the natural size, the inferior part of the right ventricle, tKe
most muscular parts of the left auricle, and the sigmoid valves of
the aorta and pulmonary artery, in a state of ossification. M.
Renauldin has published, in the Journal de Med. for 1816, a
very interesting case of the same kind. The patient was a man
33 years of age, much addicted to study, and subject to violent
palpitations on the slightest motion. " On applying the hand to

* Opusc. Pathol. t Tom. v.

CARDITIS. 177

the region of the heart a sort of motion of the ribs was felt, and
even the slightest pressure produced very acute pain, which lasted
long after the pressure was discontinued. On examining the
body after death the heart was found extremely hard and heavy.
On attempting to cut the left ventricle great resistance was found,
owing to the total conversion of the muscular fibre into a sort of
petrifaction, having in some places a sandy character, in others a
resemblance to saline crystallization. The grains of this species
of sand were very contiguous to each other, and became larger
towards the interior of the ventricle. They were continuous
with the columnar carneae, which were themselves converted
into a similar substance, but still ratained their original form, only
much enlarged. Some of these sabulous concretions were of the
size of the point of the little finger, and resembled small stalac-
tites shooting in different directions. The ventricle was thicken-
ed. The right ventricle and great arterial trunks were sound.
The temporal and maxillary arteries, and also a part of both the
radial arteries, were ossified." We frequently find on the interior
surface of the ventricles, especially the left, cartilaginous scales
continuous with the lining membrane, and apparently deposited
between it and the muscular substance of the heart. These are
generally small. I have never found them ossified.

SECTION ELEVENTH.

Of Carditis.

Inflammation of the heart is a rare affection, and is, conse-
quently, very imperfectly known both in a practical and patholo-
gical view. There are two varieties of it, the general, or that
affecting the whole heart; and the partial, or that confined to a
small extent of it. There 'perhaps does not exist on record a
satisfactory case of general inflammation of the heart, either
acute or chronic. The greater number of cases so called, and
particularly those given by M. Corvisart, are evidently instances
of Pericarditis attended by that degree of discoloration of the
heart which we shall find frequently to accompany that affection.
Nothing proves that the paleness of the heart in such cases is the

93

176 DISEASES OF THE HEART.

consequence of* inflammation. This affection generally increases
both the redness and density of the parts which it occupies; —
but the discoloration in the cases alluded to is conjoined, in gene-
ral, with a perceptible softening of the heart. It is further obser-
vable that, in these cases, the pericardium was filled with pus,
while not a particle was found in the substance of the heart itself:
now, pus must be considered as the most unequivocal indication
of inflammation. The only case which I have met with of
general inflammation of the heart possessing this unequivocal
mirk, is noticed by Meckel in the Mem. de l'Acad. de Berlin.
But this case is described with so* little precision, as merely to
prove the possibility of the fact, and affords no help towards a
general description of the disease.

Instances of partial inflammation of the heart, characterized by
the presence of an abscess or ulcer in its parietes, are much more
common. Bonetus has recorded a good many such cases in his
Sepulchretiim. I have only met with one instance of the kind.
In this (in a child twelve years old) the abscess was situated in
the parietes of the left ventricle, and might have contained a fil-
bert: it was complicated with pericarditis. In another case, of
a man of 60 years old, I found an albuminous exudation, of the
consistence of boiled white of egg, and of the colour of pus, de-
posited among the muscular fibres of the left ventricle. The
patient had presented symptoms of an acute inflammation of some
of the thoracic viscera, without precisely indicating its site.
Orihopncea, and a feeling of inexpressible anguish, had been the
chief symptoms.

Ulcers of the heart have been still more frequently observed
than abscess; they have been met with in its external and internal
surface.* All the cases, however, recorded under this name are
not quite correctly designated. In the Sepulchretum we frequently
find a case of pericarditis, attended with a rough and uneven
pseudo-membranous exudation, mistaken for an ulcer of the exte-
rior surface of the heart. This has been noticed by Morgagni
(Epist 20 and 25). That true ulcers of this surface, however,
have been observed, is beyond doubt. A case of this kind is
described by Olaus-Borrichius in the following words: u Cordis
exterior caro, profunde exesa, in lacinias et villos cameos putres-
centes abierat;"f and similar cases are recorded by Peyerj: and
Graetz.§ Ulcers on the internal surfaces of the heart are perhaps

* Morgagni, Epist. xxv.

f SepwlcWt. Lib. II. obs. 86. ±Ibid. sect. II. obs! 21

§Disput. de Hydr. pericard. sect. 2.

CARDITIS. 170

more common than on the external; or, at least, there are on re-
cord a greater number of incontestible examples of the former.
Bonetus, Morgagni and Senac have collected a great many of these.
I have myself only met with one case of this kind. The ulcer
was on the internal surface of the left ventricle, and was an inch
long by half an inch wide, and was more than four lines deep in
its centre. This patient had laboured under hypertrophia of the
left ventricle, which had been recognised before death: this was
occasioned by rupture of the ventricle. This terrible and, fortu-
nately, very rare accident, is almost always the result of ulcera-
tion of the ventricular parietes. Morand has collected several
cases of this kind in the Mem. de l'Acad. des Sciences for the
year 1732, and Morgagni has described a similar instance —
(Epist. 27).

Rupture of the heart from violent exertion, without previous
ulceration, is much rarer still; and the number of incontestible
examples of this is very small. Several cases, recorded as such,
are so imperfectly described, as to leave a doubt whether the al-
leged rupture might not have been rather the consequence of the
incisions of an inexpert dissector. The best authenticated exam-
ples of this kind of rupture are those given by Haller (Elem.
Physiol.), and Morgagni (Epist. 27).

It is surprising that the great thinness of the parietes of the
ventricles, in the cases of accumulation of fat, does not give rise
to rupture, more especially towards the apex and posterior part of
the right ventricle. This is, however, so far from being the case,
that ruptures of the right ventricle are much rarer than those of
the left, and that, in this last, the rupture, when it occurs, is very
rarely towards the apex.

M. Corvisart has given, for the first time, examples of another
species of rupture of the heart, of a less certainly dangerous na-
ture; — that, namely, of the tendons and fleshy pillars of the
valves.*

In the three cases related by him the rupture appears to have
been the consequence of violent efforts in lifting great weights, &c.
A sudden and very intense feeling of suffocation was the immediate
result of this accident, which terminated in exhibiting all the
usual symptoms of disease of the heart. I shall have occasion
to notice in a subsequent section a case of the same kind, only
produced, apparently, by ulceration of the tendons.

* Corvisart on the Heart, obs. 33, 40, and 41 .

130 DISEASES OF THE HEART.

SECTION TWELFTH.

Of Cartilaginous and Bony Induration of the Valves of the Heart.

The mitral and sigmoid valves of the aorta are subject to be-
come the site of cartilaginous or bony productions, which increase
their thickness, alter their shape, and obstruct, sometimes almost
totally, the orifices in which they are placed. The tricuspid and
sigmoid valves of the pulmonary artery are much less subject to
these alterations, although they are not quite exempt from them,
as Bichat thought. Morgagni found (Epist. 37), in the case of
an old woman, both these partially indurated. He likewise
found, in a young woman, the sigmoid valves of the pulmonary
artery agglutinated by means of a cartilaginous induration, partly
ossified, so as considerably to diminish the diameter of the artery.
M Corvisart has twice met with a cartilaginous induration of the
base of the tricuspid valve, and I have myself sometimes observ-
ed slight cartilaginous incrustations, both at the base, and on the
points of this valve. 1 am not, however, aware that any one has
found these indurated portions completely ossified; nor do I believe
that the induration has ever been so considerable as to occasion a
serious state of disease. For these reasons J shall confine my re-
marks to the valves of the left ventricle.

The cartilaginous induration of the mitral valve is sometimes
confined to the fibrous bands found in its base. In this case it has
the appearance of a very smooth, though unequal roll, lessening
the orifice in which it is situated. This sometimes has the con-
sistence of perfect cartilage, sometimes only that of imperfect car-
tilage. Similar incrustations sometimes are met with in other parts
of these valves. The bony indurations present the same charac-
ters as to situation and inequality of thickness. Though formed in the
interior of the valve, they often projectfrom it quite uncovered. These
ossifications are never perfect bone; they are whiter and more
opaque, more fragile, and evidently contain a greater proportion of
phosphat of lime. On this account they have been frequently
named stones or calculi. In fact, they frequently bear a striking
resemblance to small pieces of stone, of very irregular surface, re-
cently broken. When they are situated in the floating extremities

INDURATION OF THE VALVES. 181

of the valve, these are sometimes united together, so as to reduce
the orifice to a mere slit, which will, sometimes, scarcely admit
the blade of a knife or a goost quill. M. Corvisart found the
orifice between the auricle and ventricle reduced to a channel three
lines wide, and bent like the canalis caroticus, from the thicken-
ing of the ossified mitral valve Sometimes, though rarely, the
tendinous cords of the mitral valve are affected in (he same
manner; and M. Corvisart in one case found the whole of one
of its pillars ossified.*

The ossification of the sigmoid valves of the aorta may com-
mence, like that of the mitral, in their base or their loose edges,
— and much more frequently in one of these situations than in the-
intermediate portion. When in the loose extremity, the ossifica-
tion seems most frequently to originate in the small tubercles
known by the name of the Corpora Sesamoidea.

When the ossification is confined to the floating edge of the
valves, or when the base though ossified is little thickened, the
valve may still perform its functions, provided the middle portion
of it be still sound. But when the ossification is extensive, the
valves grow together, and get incurvated, either towards their
concave or convex side, so as to acquire the appearance of cer-
tain shells. In this state they are immoveable, being either fixed
on the side of the aorta, or in the orifice of the ventriele. Very
frequently, of the three valves one is bent in a direction opposite
that of the two others. In one case, M Corvisart found all the
three valves ossified in their closed position so as to leave merely
an extremely small slit for the passage of the blood. The evil
of this was partly obviated by one of the valves, although ossi-
fied and very thick, still retaining, at its base, sufficient mobility
to allow an increase of one or two lines to the orifice during the
action of the heart.

♦ Op. cit. p. 212, 214.

182 DISEASES OF THE HEART

SECTION THIRTEENTH.

Of Accidental or Extraneous Productions in the Heart.

Of all the organs of 'the body the heart is perhaps the least
liable to these productions, if we except ossifications. Twice
only have I found tubercles in its muscular substance, and not
once melanosis, medullary sarcoma, on any oiher species of can-
cer. M. Recamier, however, informs me that he has found the
heart partially converted into a scirrhous matter resembling lard,
in a person who also had cancers in the lungs. In the Sepul-
chretum we find several examples of tumours in the heart, which
appear to have been cancerous. Columbus found two hard
tumours of the size of an egg in the parietes of the left ven-
tricle* Morgagni' relates a case where there were numerous
small tubercles on the external surface of the right auricle, in a
subject which exhibited similar, but larger, tumours in the medi-
astinum, lungs, lymphatic glands, and cellular substance of the
thorax and abdomen (Epist 78).

Encysted serous tumours are equally rare in this viscus. When
they do occur they are most commonly found between the muscu-
lar substance and investing pericardium. Examples have been
recorded by Baillou, Houlier, Cordaeus, Rolfinckius, Thebesius,
Fanton, Valsalva, Morgagni, and Dupuytren. The latter found
cysts of this kind in the parietes of the right auricle, projecting
inwardly, and distending it to a size equal to the whole of the
other parts of the heart. Morgagni describes a tumour, which
was eviden'ly a hydatid, implanted on the surface of the left
ventricle (Epist 21), and which appears to have been that
variety named by Rudolphi Cysticercus finnus.

* De re Anat. lib. xv.

POLYPT. 130

SECTION FOURTEENTH.

Of Polypi of the Heart.

It was formerly customary to attribute to the polypous concre-
tions of the heart observed after death, the symptoms which truly
depend on the enlargement of that organ. The incorrectness of (his
opinion is proved by the fact, that these concretions are very fre-
quently found in persons who have never exhibited any symptom
of disease of the heart: in truth, they are met with in three-
fourths of dead bodies. It is equally erroneous to believe, with
some modern authors, that polypi never begin to form until the
moment of death. Many facts prove that these concretions can
be formed during life. The phenomena of aneurisms alone
prove this. Haller found the carotid artery and internal jugular
vein quite obstructed by very firm concrete fibrine in one case;
and the inferior vena cava in another* Vinckler,f Stancari and
Bonaroli have met with similar cases. |

I have myself observed, in a consumptive subject, an oblitera-
tion of the inferior cava for the space of four fingers' breadth.
This obstruction was produced by a whitish fibrinous concretion
which filled the whole caliber of the vein. The exterior layers
of this concretion were like the buffy coat of the blood, only
much firmer, and adhered strongly to the inner coat of the vein;
the inner portions were, on the contrary, of a yellowish colour,
more completely opaque, and of a friable character like certain
kinds of cheese. In another case I found a similar obstruction in
the carotid artery; and, in a third, I observed the whole of the
vessels of the pia mater, in a circumscribed space about the size
of the palm of the hand, injected with a similar concretion. None
of these individuals had exhibited any symptoms indicative of such
an affection, nor did there exist in any of them any obstacles to the
course of the blood which might account for them: we must,
therefore, attribute them to spontaneous coagulation of the blood,
and reasoning, a priori, therefore, nothing is more probable than

* Opusc. Pathol, obs. 23, 24.

t Dissert, de Vasor. lithias. * Morgagni, Epist. 64.

184 DISEASES OF THE HEART.

that the blood may coagulate during life, in the heart also; at leas?
at the very close of life, when the circulation is performed only
in an irregular and imperfect manner. M. Corvisart was there-
fore correct in distinguishing polypi into such as are of a formation
posterior to death, and such as have been produced while the in-
dividual was still alive. These two kinds are easily distinguished
from each other The former, or those of recent formation, ex-
hibit merely a slight layer of whitish opaque fibrine partially en-
veloping the coagula of blood contained in the heart and large
vessels. This fibrinous or buffy layer never completely surrounds
the coagula, and does not adhere to the parietes of the heart or
vessel in which it is contained. Sometimes this layer is thicker,
and, in this case, especially if the subject is dropsical, it is semi-
transparent and tremulous like jelly.

On the other hand, the polypi of more ancient formation are of
a much firmer consistence, and adhere more or less strongly to the
parietes of the heart. In the ventricles and auricular sinuses, this
adhesion is partly caused, no doubt, by the intertexture of the con-
cretion with the columnae carneae; but, even here, the principal
part of the attachment is independent of any mechanical structure
of the parts. These concretions are of a more distinctly fibrinous
texture than are the recent formations or the buffy coat of the
blood, and they are, further, of a pale flesh or slight violet colour;
while the more recent are, as already mentioned, of a white or
yellowish colour.

These ancient concretions are found most frequently in the
sinus of the right auricle, and in the right ventricle. When in
the former, they completely obstruct its cavity, but in the ventricle
they only double in thickness its parietes (thereby lessening its
cavity) and obstruct the descent of the tricuspid valve. In this
case, one may remove all the loose coagulated blood without injur-
ing the concretion; it is even possible that this might be mistaken
for the natural boundaries of the cavity.

The columnae carneae to which these concretions are attached,
are commonly perceptibly flattened; a circumstance which, of itself,
would prove their formation to be anterior to deaih. M. Corvisart
was the first, as far as I know, to observe this flattening of the co-
lumnae: in the case noticed by him they were quite effaced. I
have not met with any case so strongly marked as this; but it is by
no means rare to find cases wherein the thing is very perceptible.
There is still a third species of concretion, evidently more an-
cient than those just described, — of a formation, perhaps, several
months anterior to the patient's death. These are found adhering

EXCRESCENCES ON THE VALVES. 185

10 the parietes of the heart, sometimes so firmly as only to be de-
tached by scraping with the scalpel. Theit consistence is less
than that of those just noticed; being not at all fibrinous, and re-
sembling rather a dry friable paste or a fat and somewhat soft
cheese. They have lost the semitransparency of recently com
creted fibrine, and resemble in evefy respect those layers of de*
composed fibrine met with in false aneurisms. I have only met
with concretions of this kind in the auricles.

SECTION FIFTEENTH.

Of Excrescences on the Valves and internal Parietes of the Heart'

There are two very distinct varieties of this affection. The
first has been described by M. Corvisart under the name of Ex-
crescences of the Valves; the other, which does not appear to have
been hitherto described, I shall notice under the name of globular
excrescence. The first kind might very well be named warty ex-
crescence, inasmuch as they are extremely like warts, especially
those of venereal origin on the parts of generation. Like these,
the excrescences in the heart sometimes resemble small cherries,
in their form and tuberous surface; at other times they are elon-
gated into the form of a small cylinder or cord, and, occasionally,
they are so short and so crowded together, as merely to give to
the parts on which they are situated a rough or rugged surface;
more frequently, however, they are either isolated or ranged in a
single line along the loose, or the attached border of the valves.
I have never observed any longer than three lines. The colour
of these excrescences is sometimes whitish like that of the valves,
and hardly so opaque; more commonly they are either wholly or
in part tinged with a reddish or light violet colour. Their tex-
ture is fleshy, like venereal warts, only of somewhat less firm con»
sistence. They adhere immediately to the subjacent parts; some-
times so strongly as to be only separable by incision; more com-
monly they are easily removed by scraping. The venereal origin
of these excrescences, entertained by M. Corvisart, appears to me
very improbable, when we consider their rarity and the frequency
of venereal complaints, and when we meet with them, as we do,
in individuals who, in all probability, never had this disease

24

188 DISEASES OP THE HEART.

Whatever may be the remote cause of these bodies, the manner
of their formation seems to me more explicable. In dissecting the
more voluminous excrescences, it has always appeared to me that
their texture has borne a strong resemblance to that of the more
compact poljpous concretions. Frequently we observe in their
centre a violet or sanguineous tint; and sometimes I have even
found a very small, but distinct, coagulum of blood. From these
circumstances I am led to believe, that these excrescences are
merely polypi organized by the same process which transforms the
false albuminous membranes into true adventitious membranes, or
into cellular substance.

In like manner as M Corvisart, I have only met with these
excrescences in the following situations, viz. the mitral, tricuspid,
and sigmoid valves, and (much more rarely) the interior of the
auricles, especially the left. In general they are more common in
the left than the right side of the heart. I may here remark that
the view of the fromation of these excrescences, given above,
proves that they are not likely to occur but in subjects already
affected with some serious disease of the heart or large vessels; a
circumstance, as we shall find, in another place, which must render
their diagnosis very difficult. [In the following notice of a case of
this affection, I shall, as in many of the former cases, omit several
of the symptoms with the intention of again noticing them in
another part of this work.]

Case 43. A man, aged 35, at the period of his coming into
hospital, had been affected for five months with great dyspnoea
and violent palpitations on making any considerable exertion,
starlings from sleep, and occasional spitting of blood. For a few
days past he had laboured under a severe diarrhoea. His counte-
nance was tranquil, with some colour, the pulse small, hard, and
regular, and the respiration oppressed. The action of the heart
was not quite regular, but there was no distention of the jugular
veins. This patient died on the third day

The pericardium contained half a pint of serum. The heart
Was double the size of the patient's fist. The right ventricle was
very large, its parietes being at least four lines thick, and its co-
lumnar very large. The tricuspid valves, and the sigmoid of th*
pulmonary artery, were of a deep violet red colour. The right
auricle was sound. The left ventricle was one-third larger than
natural, and its walls were six lines thick, and its coltimnae very
thick. One of the tendons affixed to the edge of the mitral valve
was ruptured about its middle. This rupture appeared to have
been the consequence of progressive wasting of its middle part; and

EXCRESCENCES ON THE VALVES. 18"*

^ne of the other tendons of the same valve was unequally exten-
uated, but still whole. The whole floating border of the mitral
valve was covered with small excrescences such as I have describ-
ed, varying in size, form, and consistence Altogether they gave
to the valve a thickened and fringed appearance. The sigmoid
valves of the aorta, and the lining membrane of this artery,
were extremely red, and exhibited in this respect a striking con-
trast with the inner membrane of the ventricle. The whole inner
surface, and indeed the whole parietes, of the left auricle, were of
the same red colour; and, above the opening of the left pulmonary
veins, and about two lines from the auriculo-ventricular opening,
there was about an inch square coated with a congeries of excres-
cences similar to those on the mitral valve, and very firmly attach-
ed. The muscular substance of the heart was of moderate firmness.
The pleura contained about a pint of serum on each side. The
lungs were sound.

The globular excrescences have a quite different appearance
from those just described, resembling little balls or cysts, of a
spherical or oval shape, and of a size from that of a pea to a
pigeon's egg.

The exterior surface of these is equal, smooth, and of a yellow-
ish white colour, and the thickness of their parietes is very
uniform, being never more than half a line. The substance com-
posing their parietes is opaque and very similar to that of ancient
polypi, its consistence being firmer than boiled white of egg The
inner surface of these parietes (the cyst) is not so smooth as the
exterior, and it appears to be composed of a softer substance,
which occasionally has the appearance of passing gradually into
the matter contained within it. This matter may exist in three
different states, all of which may be found in the same subject, but
in different cysts. These are, 1st, a liquid resembling half-coa-
gulated blood, only turbid as if intermixed with some insoluble
powder, and sometimes containing a few clots of perfectly coagu-
lated blood; 2nd, a more opaque matter, of a pale violet colour,
of a pultaceous consistence, and very like the lees of wine; and
3rd, yellowish, opaque fluid, like thick pus or thin paste. I have
only met with cysts of this kind in the ventricles and auricular
sinuses. They are found as frequently in the right as left side of
the heart, generally near the apex of the ventricles, and always
adherent to the walls of the cavity. They are attached by means
of a pedicle, which is often so slightly connected with the co-
lumnae carneae as to be detached from them without being rup-
tured This pedicle, although forming part of the excrescence,
resembles the common polypi more than the other portions, and

188 DISEASES OF THE HEART

seems as if it wore of more recent formation and less perfectly
organized. I have never found these bodies more organized than
I have described, and I have considered those containing clots of
blood as the newest, those containing a fluid like the lees of wine
as next in order, and those containing a puriform matter as thr
most ancient I have met with these excrescences in subjects dead
of different diseases, but all of whom had remained in a dying
state (agonie) for several days or even weeks.

The only case that I have met with in medical writings, which
seems to me to agree -with the above description, is recorded in
the JVRscei Natur. Curios. The affection, nevertheless, docs not
appear to be extremely rare, as I have met with several case?
of it.

SECTION SIXTEENTH.

Of the Red Colour of the internal Membrane of the Heart and
large Vessels.

In examining dead bodies we frequently find the inside of the
aorta and pulmonary artery uniformly reddened, as if stained by
the blood they contained. This colouring is of two kinds, — either
bordering on scarlet, or violet. The scarlet colour has its seat
exclusively in the inner membrane, as, when this is removed,
the tunic beneath is found of the natural colour. This colour is
quite uniform, as if painted, without any trace of vascularity,
only sometimes more intense in one place than another. Some-
times this stain diminishes progressively from the origin of the
aorta, but frequently it terminates quite abruptly with irregular
edges. Sometimes in the middle of a very red portion we find
a circumscribed spot retaining the natural white colour, like the
whiteness produced by pressure with the finger on an erysipelatous
skin. The origin and arch of the aorta are the situations most
commonly reddened, and, with them, the sigmoid and mitral
valves. When the pulmonary artery is affected, its valves, as
well as the tricuspid, are commonly in the same state. The
Jining membrane of the ventricles and auricles is frequently
colourless when the valves are deeply stained; not unfrequently.

REDNESS OF INTERNAL MEMBRANE, 180

riowever, the auricle participates in the affection, but scarcely ever
the ventricles. This redness is attended by no sensible thick-
ening of the part, and it entirely disappears after a few hours
maceration.

M. Corvisart has slightly noticed this affection; and has avowed
his ignorance of its nature and cause. Franck, who has observed
it through the whole tract of the arteries, considered it as the
cause of a particular and uniformly fatal fever. My own obser-
vations are far from leading to the same result, although I confess
myself ignorant of the nature of this affection The most natural
idea respecting it is, that it is the result of inflammation. But
mere redness, without thickening of parts, does not sufficiently
characterise this state; while the abrupt termination, and exact
circumscription presented by the redness in certain cases, seem
not easily to accord with the nature of inflammation. On the
other hand, it may, indeed, be said, that, in the serous and mu-
cous membranes, this sort of redness by stains is more character-
istic of inflammation than the mere sanguineous infarction of the
capillaries, which might take place either at, or after, death. The
following is an example of this affection.

Case 44. A young woman, fresh-coloured and plump, came
into hospital complaining only of intense headach, of three days'
duration. At the end of two days the disease assumed the ap-
pearance of acute hydrocephalus, the pulse being very slow, very
regular and of moderate strength. The cerebral symptoms increas-
ing rapidly, this patient died at the end of ten days from the in-
vasion of the disease, after the application of the usual measures,
and particularly the employment of a great number of general and
local bleedings indicated by the violence of the headach. For
two days before death, the pulse became more frequent, but not
stronger, nor more irregular. On examining the body, besides
the hydrocephalus, there were found tubercles in the lungs, large
tuberculous ulcerations in the intestines, extensive emphysema in
several portions of the mucous coat of the intestines, unequivocal
marks of confirmed lues, and, finally, a very intense redness of all
the valves of the heart, the aorta, and particularly of the pulmo-
nary artery.

One of my pupils informs me that he found in an aorta intensely
reddened, some small purulent collections, resembling miliary
pustules, situated between the internal and middle coats. This,
however, must have been the consequence of disease of the mid-
dle coat itself, as we can hardly suppose that inflammation of the
.internal coat would terminate, in suppuration of its adherent sur

J 90 DISEASES OP THE HEART.

face. I do not, however, mean to deny the possibility of the in-
flammation of blood-vessels. On the contrary, I think it proba-
ble that the affection we have been describing is of this nature;
and 1 would be disposed to consider the various concretions of
blood already mentioned, for example, those which produce obli-
teration of veins, and the warty excrescence, as the result of in-
flammation.

The second species of redness of the large vessels has a quite
different appearance, being, in place of a bright red, of a violet
hue. It is also usually extended at the same time to the aorta,
pulmonary artery, valves, auricles and ventricles. This variety
is not so exactly confined to the lining membrane, as we find the
muscular substance of the auricles and ventricles, and even the
fibrinous coat of the aorta and pulmonary artery, participating in it,
at least partially. I have found this variety of colouring in sub-
jects dead of putrid fevers, emphysema of the lungs, and disease
of the heart. All these individuals had remained long in a mori-
bund condition, with suffocation; and I have thought that the vio-
let tint was deep in proportion to the intensity and duration of the
latter symptom. From this circumstance 1 am disposed to con-
sider this condition of the vessels as the effect of deranged circu-
lation and congestion of the blood in the capillaries; being ana-
logous to the livid hue of the cheeks, &c. observable in persons
dead of disease of the heart. It is, in fact, an effect of death, or
at most produced in articulo mortis.

I would here beg to observe, that it is often difficult to distin-
guish mere congestion of the capillaries from actual inflammation.
The distinction, however, is of great importance, both in morbid
anatomy and practical medicine, the more so, as both these affec-
tions may exist simultaneously. In proof of this I may refer to
the controversy that has for some time existed respecting the con-
dition of the mucous membrane of the intestines in fever.

I am far from denying the influence of irritation, ulceration,
aphthae, and consequent inflammation of the intestinal tunics in
continued fevers; and, although they have been more or less notic-
ed and appreciated in all ages, M. Broussais has truly benefited
his profession by calling the attention of practitioners more par-
ticularly to them, and by showing the injurious error of former
periods in withholding the employment of general and local bleed-
ings in fevers. But we should fall into as great, although an op-
posite, error, if we concluded that all continued fevers depended
on the intestinal irritation that accompanied them, and that every
kind of redness observable in them after death indicates a dis-

REDNESS OP INTERNAL MEMBRANE. 191

order requiring venesection for its treatment. The mucous
membrane of the stomach and bowels is naturally pale only in
persons of pale skins; its degree of colour may be judged of by
that of the lips, mouth, anus and vulva, in different individuals.
No one will set down the livid gums of a dropsical or scorbutic
patient, or the swelling and blueness of his hands and feet, to in-
flammation, or think of treating these affections by blood-letting.
Now, in many cases, I conceive, the redness of the mucous coat
of the intestines has much more relation to this passive congestion
than to inflammation. If, then, such appearances (as is most pro-
bable) only took place in such subjects, at the same time as the
lividity of the face and of the dependent parts of the body — that
is to say, some days or hours before death; it would be absurd to
look to such condition of parts for the cause of the fever, — more
especially, as we often find, in such cases, traces of as great or
greater disorder in almost every texture of the body. For ex-
ample: — the skin is dry and harsh; the lips, gums, and lining
membrane of the mouth are swollen, soft and chopped; the mem-
branes of the brain are gorged with blood and containing serum;
the lungs are charged with a sero-sanguinolent fluid; the mucous
membrane of the bronchia is swollen and of a violet hue; the
heart is flaccid, livid and soft; the blood fluid and imperfectly co-
agulable; the lining membrane of the arteries or veins livid as if
stained by blood; the muscles fishy (poisseux); the spleen enlarg-
ed; the capillaries of almost every organ, and of the surface, gorg-
ed with blood; and, lastly, the intestines are in the same state, and
their lining membrane livid, ulcerated and thickened in diverse
places. — Now, to which of these affections shall we attribute the
disease? All are posterior — often many days — to the fever. Is
it not, therefore, more rational to consider, that none of these
local lesions are the cause, but that, as in small-pox and measles,
some unknown cause, acting generally on the system, has produc-
ed both the fever and the local affections — whether active or pas*
sive — which accompany or follow ,it?

In the very case where there exist simultaneously aphtha? and
exulcerations in the intestinal tunics, and redness, lividity, and
capillary congestion of the mucous membrane, we ought to con-
clude, from analogy, that the two former states are the result of
inflammation, active or passive, — and the three latter the result of
debility of the circulation in the capillaries; that the first may re
quire venesection, but that this very means, carried to too grea!
lengths, may give rise to, or increase the last, by increasing tin
general debility. The haematemesis and bloody fluxes which oc

152 DISEASES OF THE HEART.

cur sometimes in continued fevers ought rather, in my opinion, to
be attributed to purely passive congestions of the capillaries, than
to inflammation. In the instances just mentioned we find the
whole of the intestinal tunics in the affected part tinged with
blood, and softened, without any notable increase of thickness of
the part; while inflammation of every mucous membrane uni-
formly increases both the thickness and density of the part. We
may farther add the fine observation of Bichat, that, of any mor-
bid affection, inflammation has the least tendency to propagate
itself by contiguity, especially in membranous parts Peritonitis
and dysentery leave untouched the muscular coat of the intestine,
but the lividity consequent on fatal fevers often extends to the
whole three tunics.

SECTION SEVENTEENTH.

Of Malformation of the Heart.

There exist two varieties of unnatural communication between
the cavities of the heart, viz. the perforation of the septum of
the ventricles, and the continued patency of the foramen of Bo-
tallus. The first variety is very rare, there being not more than
five or six instances of it on record. In all these the unnatural
aperture was smooth, evidently very ancient, if not congenital.
The continued patency of the foramen of Botallus is much more
common. Sometimes this is produced by the imperfect union of
the two plates of the foetal valve, so that a probe, or even a fe-
male sound, can be passed obliquely from one auricle to the other.
This condition of parts is not very rare, and does not appear to be
productive of any kind of inconvenience. In other cases we find
the foramen continue constantly open so as to admit the finger.
I have myself seen it sufficiently large to receive the thumb. It
is commonly believed that this species of malformation is always
congenital; but from some cases which I have met with, I am
disposed to believe that such a perforation may be produced b)
an accident; or, at least, when such a condition of parts exists as
tbove described, that a blow, fall, or violent exertion, may cause
the dilatation of the oblique opening, and its progressive enlarge
went The history of several cases on record, especially of some

DISPLACEMENT. 193

of M. Corvisart's, would seem to countenance this opinion, since,
in several of these, the individuals had enjoyed good health, with-
out any symptom of diseased heart, until they had experienced
some of the accidental causes above mentioned.

I do not know that any of these unnatural communications
have existed without consequent thickening and dilatation of
either the whole, or part of the heart, especially the right side.
The symptoms of the latter affection are, consequently, combined
with those of the former. These are principally the four follow-
ing: 1, a great sensibility to the impression of cold; 2, frequent
faintings; 3, the respiration more constantly impeded than in most
other diseases of the heart; and 4, a violet or blueish colour of
the skin much more extensive than in any other disease, and,
sometimes, even general. This last symptom has been named by
several authors the blue jaundice, or the blue disease. On the
other hand, all the above mentioned symptoms have been found
to exist in subjects who had no other malformation than the con-
tinued patency of the foramen of Botallus; and still more so in
those cases where the pulmonary artery was found to originate in
the left ventricle, and the aorta in the right, or where the latter
has opened at once into both ventricles. In some diseases of the
lungs, especially emphysema, the blue colour of the skin is some-
times quite as intense and as extensive as in the case of malfor-
mation of the heart. On the other hand, the foramen of Botallus
has been found dilated very considerably, without there being
present any degree of lividity except on the face and extremities.
The case of dilatation noticed by myself, above mentioned, was
of this sort.

SECTION EIGHTEENTH.

Of Displacement of the Heart.

The heart, although retained in its place by the diaphragm,
large. vessels, and peculiar structure of the mediastinum, and, still
more, by the constant state of plenitude of the chest, may, never-
theless, in certain pases, be thrown to the right or left by a solid,
liquid, or aeriform effusion into either sac of the pleura, by exten-

25

194 DISEASES OF THE HEART.

sire tumours in the lungs, and, as we have already seen (page 8Gj.
by emphysema of this organ. In like manner, a tumour in the
superior mediastinum, or a large aneurism of the arch of the aorta,
may press it downwards, so that that part of the diaphragm on
which it reposes shall project into the abdomen. Sometimes even
this depression has taken place without any visible cause, in which
case the affection has been named by some authors prolapsus of
the heart.

These various kinds of displacement produce no perceptible in-
convenience when they exist in a slight degree; when more mark-
ed, they may produce bad effects; but in this case, they are them-
selves consequences of lesions much more serious.

SECTION NINETEENTH.

Changes produced by Diseases of the Heart in the texture of other

Organs.

On examining the bodies of persons who have fallen victims to
organic affections of the heart, besides the organic lesion and the
serous effusions which almost always accompany it, we find all
the marks of congestion of blood in the internal capillaries. The
mucous membranes, especially those of the stomach and intes-
tines, are of a red or violet tint; and the liver, lungs, and capilla-
ries situated beneath the serous mucous and cutaneous tissues, are
gorged with blood. The augmented colour of the mucous mem-
branes varies much in degree and extent. Sometimes it is ob-
served only here and there, under the form of small points or
specks, disseminated over the surface of the membrane: at other
times it occupies the whole extent of the surface, and has the ap-
pearance of being attended by some swelling of the part. These
two latter appearances are sometimes so considerable, that, if we
looked to them merely, without examining the condition of the
heart, and without reference to the history of the patient, (who
had been found capable of taking into his stomach wine and other
stimulant matters without experiencing any pain, even up to the
period of his death,) we might be tempted to believe that the fatal
disease had been a violent inflammation of the stomach and bowels.

CAUSES. 195

In fact, the degree of redness of these membranes observed after
diseases of the heart, is often much more intense and extensive
than is found after true inflammation of these parts, as, for exam-
ple, in dysentery; a fact, among many others, sufficiently proving
the insufficiency of mere redness to characterise inflammation of
the mucous membrane of the intestines.

Lancisi and Senac, after Hildanus, consider gangrene of the
limbs as a consequence of disease of the heart and large vessels.
The late M. Giraud was of the same opinion, and, since his time,
many practitioners have considered the gangrene of old persons as
usually caused by ossification of the arteries. M. Corvisarl justly
doubts whether, in such cases, there is any thing else but mere
coincidence of independent diseases; and I think that the single
circumstance of the rarity of the spontaneous gangrene of the limbs,
compared with the frequency of disease of the heart and ossifica-
tion of the arteries, is sufficient to render the thing quite improba-
ble. This is equally the case with the notion of Testa, that oph-
thalmia, and sometimes the loss of the eye, maybe ranged among
the consequences of diseases of the heart.*

SECTION TWENTIETH.

Of the Causes of Diseases of the Heart.

The causes of diseases of the heart are, like the diseases them-
selves, various in their nature. Ossifications are the result of
some aberration of the process of assimilation which is not easily
understood. I have already stated my opinion respecting the ori-
gin of the excrescences on the valves. The dilatation and thick-
ening of the ventricles, diseases of much greater frequency, also
may arise from numerous causes; but these are in general more
easily traced to their effects than the former. All diseases which
give rise to severe and long-continued dyspnoea produced, almost
necessarily, hypertrophia or dilatation of the heart, through the
constant efforts the organ is called on to perform, in order to propel
the blood into the lungs against the resistance opposed to it by the

• Delle Malattie del Cuore, Bologna, 1810

196 DISEASES OF THE HEART.

cause of dyspnoea. It is in this manner that phthisis pulmonalis,
empyema, chronic peripneumony, and emphysema of the lungs,
act in producing disease of the heart; and that those kinds of ex-
ercise which require great exertion, and thereby impede respira-
tion, come to be the most common remote causes of these com
plaints.

On the other hand, it is found that diseases of the heart, on the
same principle of mutual influence, give rise to several diseases of
the lungs They are thus among the most frequent causes of
oedema of the lungs and haemoptysis. When, however, diseases
of the heart are found to coexist with chronic pleurisy, phthisis,
emphysema, and, in general, with chronic disease of the lungs, it
will usually be found, on close examination, that the latter are the
primary diseases. It follows from these, and other facts noticed
under the head of Emphysema and Pulmonary Catarrh, that a
neglected Cold is frequently the original cause of the most severe
diseases of the heart.

To all these causes must be added the congenital disproportion
between the size of the heart and the diameter of the aorta. M.
Corvisart has, perhaps, gone too far in asserting that there can be
no dilatation of the heart without the previous existence of a dis-
proportion of this kind, or of a contraction, or some similar ob-
struction to the circulation, at a greater or less distance from the
heart; it is, however, true, that it is very common to find an aorta
of small diameter in cases of hypertrophia or dilatation of the
heart. Still, this is not always the case, and however rational
such a cause may be, we can readily conceive many others. We
know that the energetic and reiterated action of all muscles notably
increases their size, as in the case of those of the right arm of the
fencer, the shoulder of the porter, and the hands of most artisans.
On the same principle we must admit that even nervous palpita-
tions, or such as originate from moral causes, may, by frequent
recurrence, produce a true enlargement of the heart.

There is yet another congenital cause of disease of the heart,
which appears to me to be of greater frequency than the small
caliber of the aorta, above mentioned, — I allude to a disproportion-
ate thickness of one or both sides of the heart. I am satisfied
that in a great many persons the parietes of one or both sides of
the heart are either too thick or too thin from birth. In such cases
there can be no doubt that the usual exciting causes will be more
apt to produce formal disease of the heart than in individuals in
whom this disproportion does not exist.

J»ERlCAKDin« 191

CHAP. II

DISEASES OF THE PERICARDIUM.

SECTION FIRST.

Of Pericarditis, or Inflammation of the Pericardium.

Pericarditis is inflammation of the serous membrane which
lines the fibrous sac of the pericardium, the heart and largr
vessels. It may be either acute or chronic. This inflammation,
like that of all membranes of the same kind, is marked by red-
ness, more or less deep, a concrete albuminous exhalation and a
sero-purulent effusion. The redness is almost always but slight
in the acute disease. When it exists, it is for the most part only
partially. It is most commonly punctuated, and looks as if the
surface of the membrane was covered, here and therewith little
specks of blood very close to each other. I have never perceived
that this redness was accompanied by any thickening of the part,
In some cases, wherein, to judge by the thickness of the false
membranes, the inflammation appears to have been very great, no
redness whatever can be discovered on the serous membrane, on
removal of the membranous exudation This concrete albumi-
nous exudation commonly invests the whole surface of the peri-
cardium, as well on the heart and large vessels, as on the sac. It
rarely presents the appearance of an equable membranous layer,
like the false membranes of pleurisy; on the contrary, its surface
is most frequently marked by a great 'number of rough and irre-
gular prominences. Sometimes the knobbed appearance of this
exudation is very like what would result from the sudden separa-
tion of two pieces of slab joined by a pretty thick layer of butter;
at other times, it is more like the internal surface of the second
stomach of the calf, aft observation made, in one case, by M
Corvisart. In certain cases this aspect of the false membrane
has given rise to a singular error, having, been mistaken for a

198 DISEASES OF THE PERICARDIUM.

variolous eruption in subjects dead of the small-pox. The con-
sistence of this exudation is usually greater than that of the false
membranes of pleurisy; it is also thicker, and more firmly adhe-
rent to the subjacent parts; its colour is, however, the same, being
of a pale yellow analogous to that of pus.

The serum effused in inflammation of the pericardium is limpid,
of a pale yellow colour, or slightly brownish. It contains few
fragments of semi-concrete albumen; at least, it very rarely con-
tains enough of these to give it a milky and turbid character.
The quantity of this effusion is usually considerable in the com-
mencement of the disease, often as much as a pound. M. Corvi-
sart found it, in one case, to amount to four pounds. It would
seem that the quantity of effused serum diminishes quickly, as
soon as the violence of the inflammation begins to subside; as we
usually find the proportion of serum and of albuminous exudation
nearly equal, while in pleurisy and peritonitis the serum is com-
monly from twenty to fifty times greater than that of the extra-
vasated lymph. Very commonly even, in very violent cases, we
find no effused serum, and only a thick and highly concrete albu-
men filling the whole caviiy of the pericardium, and uniting the
heart and large vessels to the exterior or loose portion of this
membrane. In this case we may suppose that the effused serum
has been quickly absorbed, and the two layers of false membrane
cemented together; although it is not impossible that, in some
cases, th^more solid exudation may be the only one. We have
seen that the same thing occasionally takes place in certain partial
and sub- acute inflammations of the pleura; and several observa-
tions have led me to believe that the cartilaginous patches that
sometimes are met with on the exterior of the lungs (see page 51
and page 132) are produced in the same manner.

When the disease terminates favourably, the pseudy-mem-
branous exudation, after a certain time, is converted into cellular
substance, or rajher into laminae of the same nature as the serous
membranes; that is to say, the laminae are double, the exterior
surface being exhalent, and the interior cellular, or adherent, and
containing the vessels distributed to the part. Sometimes these
laminae are long, sometimes so short that the pericardium seems
intimately adherent to the heart.

Before the conversion of false membranes into cellular tissue
was well understood, the adhesion of theDericardium to the heart
was regarded by divers authors as a cause of various and serious
complaints. Lancisi and Vieussens considered it as constantly
causing palpitation; Meckel, as rendering the pulse habitually

PERICARDITIS. 199

small; and Senac, as productive of frequent faintings. Even M.
Corvisart himself has fallen into some mistakes on this head.
He admits three species of adhesions, — all of which I have just
described as mere varieties or stages of the same affection.
These are, 1st, a demi-concrete albuminous adhesion, -which is
the only one recognised by him as the consequence of pericar-
ditis; 2nd, the very intimate or close cellular adhesion, deemed an
effect of gouty or rheumatic affections; and 3rd, the extended or
long cellular adhesion, the cause of which is not assigned by
him* M. Corvisart is further of opinion that no person can live,
and preserve a good state of health, who is affected with a com-
plete and close adhesion of the pericardium to the heart, or of
the lungs to the pleura.

I have, however, met with many cases where this condition of
parts was found after death, in which no disorder of the respira-
tion or circulation existed during life. A case adduced by M.
Corvisart in support of his opinion (op. cit. p. 34) appears to
me rather conclusive against it, inasmuch as the appearances on
dissection showed sufficient lesions in other organs to account for
the symptoms referred by him to the adhesions between the heart
and pericardium.

. Sometimes, though rarely, the inflammation is confined to a
part only — sometimes a very small part — of the pericardium
These partial inflammations are in proportion to the general, in
point of frequency, hardly as one to ten. Their anatomical
characters are precisely the same, only that the albuminous
exudation is in them confined to the inflamed part. The serous
effusion is sometimes as abundant as in the general disease; more
commonly, however it is less. The inflammation in this case
almost always terminates in being cured, by the transformation
of the pseudo-membranous exudation into long serous laminae;
scarcely ever are these partial inflammations followed by the in-
timate adhesion of the parts.

We frequently find on the surface of the heart opaque white
patches, sometimes as large .as the palm of the hand, more com-
monly one half or one third this size, and often very small.
They are nearly of the thickness of the nail, and have a degree
of consistence equal to that of the membranes composed of con-
densed cellular substance, as, for instance, the exterior membrane
of the lymphatic glands. They adhere so closely to the parts on
which they lie, that it is difficult to ascertain, even by dissection,

* See Treatise on the Heart, &c, by M, Corvisart,

200 DISEASES OF THE PERICARDIUM.

whether they are situated above or beneatij the fine membrane
covering the heart and great vessels. M. Corvisart is of opinion
that they are beneath it. I have, however, ascertained the in-
correctness of this opinion, as I have several times been able to
remove the patches, leaving the serous membrane of the pericar-
dium still untouched.

Are these patches the effect of- partial pericarditis and the con-
sequent conversion of the effused lymph into a condensed mem-
branous cellular tissue? M. Corvisart considers them as produc-
ed without previous inflammation, and seated, as 1 have already
said, beneath the serous surface of the pericardium. Both these
notions are, I think, inadmissible, inasmuch as there exists no
example of an albuminous exudation on the adherent surface of
a serous membrane, and as facts without number prove that
pseudo-membranous exudations are always the produce of in-
flammation.

I have lately met with a case which appears to me to throw
some light on the question of the origin of these spots. In a
man dead of peripneumony, I found a thin false membrane, very
firm and of a yellowish colour, investing the right auricle and a
portion of the ventricle of the same side, all the rest of the peri-
cardium being quite free, only containing in its cavity two or
three ounces of a transparent and slightly yellow serum. Some
parts of the false membrane, particularly on the auricle, were of
a whiter colour and firmer than the rest, and exhibited an appear-
ance almost the same as the white patches above described.

Chronic pericarditis is always general, occupying the whole
internal surface of the serous membrane. This is commonly
much redder than in the acute disease. The redness is formed
by the close approximation of minute points, which look as if
applied with a pencil. Rarely the chronic disease is accompanied
by a pseudo-membranous exudation; and when this exists, it is
thin, soft, friable, and entirely resembling a layer of very thick
pus. In every case there exists a more or less copious effusion
of a turbid, milky fluid, sometimes, having quite a puriform
character. I am led to believe that the close adhesion of the
pericardium to the heart, is commonly the consequence of the
absorption of this fluid, and that the adhesion by the long laminae
is the product of the acute disease. In one case I found a close
and general adhesion of the pericardium to. the heart and large
vessels, by m< ans of a false fibro-cartilaginous membrane, in
every respect like those of the pleura.

From one case, cited by M. Corvisart, I am led to believe, that

HYDRO-PERICARDIUM. 201

there may occasionally arise, subsequently to chronic inflammation
of the pericardium, a tuberculous eruption similar to those fre-
quently formed in the false membranes of the pleura and perito-
neum. " The portion of the pericardium," he says, " which in-
vests the heart, was of a greyish colour, thickened, unequal,
wrinkled, crisp, and containing granulations of which the summit
seemed ulcerated." I am the rather led to consider these granu-
lations as tubercles, because in the same subject " both lungs,
although crepitous, were granular throughout." (Op. cit. obs.
vii.)

In many cases of pericarditis, especially in the chronic disease,
the muscular substance of the heart has lost its colour and become
whitish. '1 his loss of colour is sometimes attended by a notable
degree of softening, and, at other times, the consistence is natural.
Most writers have regarded this loss of colour as a mark of the in-
flammation of the heart itself, and most of the examples recorded
of Carditis are merely cases of inflammation of the pericardium
accompanied by this loss of colour. A great number of those col-
lected by M. Corvisart are of this kind. For my own part 1 am
disposed to doubt the correctness of the opinion that refers this loss
of colour to inflammation. We can never be sure of the exist-
ence of inflammation in a muscular organ unless we And a deposi-
tion of pus among its fibres.

SECTION SECOND.

\

Of Hydro-pericardium, or Water in the Pericardium.

It is extremely common to find a greater or less quantity of se-
rum in the pericardium; most frequently this does not exceed a
few ounces, and can rarely be considered as idiopathic. Most
commonly it can only be regarded as taking place in articulo mor-
tis. When there exists a general dropsical diathesis, we occa-
sionally find some water in the pericardium, but, in general, it con-
tains less than the other serous cavities. In the idiopathic hydro-
pericardium, on the contrary, the pericardium is commonly the
only membrane which contains serous effusion.

The effused serum is sometimes colourless, but more commonly

26

202 DISEASES OF THE PERICARDIUM.

it is yellowish, brownish or reddish, although still perfectly limpid,
and wiibout any admixture of flakes of lymph: rarely it is sangui-
nolent. II is variable in amount. Most frequently it does not
exceed one or I wo pounds, but it has been found in much greater
quan»ily than this. M. Corvisart records an instance wherein
eight pounds were found. This effusion is attended by no change
in the heart or its coverings. Some authors have, indeed, stated
the heart to have been macerated (macere) in such cases; but 1
am disposed to consider such statements as the result of imperfect
observation and incorrect description. Very frequently before
opening a pericardium partially filled with serum, I haye distinctly
observed an accumulation of air in the caviy. I have seen this
occupy a space the size of the fist, and when as large as this, a
distinct hissing sound is perceived in puncturing the pericardium.
In place of this continuous mass of air, we more commonly ob-
serve a great quantity of small air-bubbles on the surface of the
liquid. I am inclined to think that I have found air in the peri-
cardium in cases where there was no serum, but I am not quite-
assured of the correctness of my observation. At all events, this
case of simple Pneumo- Pericardium is extremely rare, while the
other variety, just described, is by no means so.

SECTION THIRD.

Of Accidental Productions in the Pericardium.

Various species of accidental productions have been found be-
tween the pericardium properly so called, and the pleura; also,
between it and the internal and serous membrane; and, lastly, be-
tween the serous membrane and the heart. In the Sepulchretum
of Bonetus and other collections of cases, we find examples of
what appear to be tubercles, cancerous tumours, or cysts, in the
different situations just mentioned. But the imperfect knowledge
of membranes before the time of Bichat, and the general confusion
of all accidental productions under the names of Scirrhus, Carci-
noma, Atheroma, &c renders it impossible to ascertain precisely
either the nature or site of such morbid growths. I have already
noticed the fatty productions, in the form of a cock's comb, deve-

ACCIDENTAL PRODUCTIONS. 203

loped occasionally between the pleura and fibrous membrane of
the pericardium. Twice or thrice I have found tubercles in the
same situation, in subjects which exhibited a great number of these
bodies in the lungs and elsewhere. I have also seen a tubercle
situated at the point of the origin of the pulmonary artery and be-
neath the serous membrane of the pericardium.

Once only have I met with an instance of ossification between
the layers of the pericardium. As this case was remarkable both
for its extent and the effects produced by it, I shall here briefly de-
tail it.

Case 45. A man, aged 65 years, had led an intemperate life,
but had, nevertheless, enjoyed good health until his fiftieth year.
At this lime he appears to have had an attack of pleurisy of short
duration, but which was followed by cedema of the lower extre-
mities and subsequently by anasarca of other parts, and by dysp-
noea and breathlessness on ascending an elevation, or using any
degree of exercise. When he came into hospital, in the end of
spring, the dropsical symptoms continued and the lips were swollen
and violet. The pulsations of the heart were unequal, irregular,
and very distinct, though perceptible over a very small extent of
the chest. The pulse was feeble, small, soft, unequal, intermit-
tent and irregular. There was no cough, but copious expectora-
tion. The thorax sounded well superiorly, but badly on the lower
parts.

The patient could lie in any posture; slept well, even without
having his head raised, and had no sudden startings from sleep. —
He died in the course of a few months, the dropsical swellings
and dyspnoea having much increased. The brain, lungs, and ab-
dominal viscera were found in a sound state. The heart was en-
larged, and adhered throughout to the pericardium, by means of
very close cellular attachments. On first touching it, it seemed to
be quite inclosed in a bony case, situated beneath the fibrous
membrane of the pericardium; but on further examination this in-
crustation was found to be incomplete. Around the base of the
ventricles there was a zone or band, partly bony and partly carti-
laginous, of from one to two fingers' breadth, of unequal thickness,
flattened, yet somewhat rough on its surface. This band projected
into the angle between the ventricles and auricles, and extended
along the interventricular septum on both sides, to near the apex
of the heart. The whole of this production was contained be-
tween the fibrous membrane of the pericardium and the serous
membrane which lines it internally. The auricles were enlarged

204 DISEASES OF THE AORTA.

so that each might have contained a large egg. One of the mitral
valves contained an ossified point of the size and shape of a
French bean.

CHAPTER III.

OF ANEURISM OF THE AORTA.*

In the following observations I shall adhere to the ancient dis-
tinction of true and false Aneurisms, — the former comprehending
dilatation without rupture of any of the arterial coats, the latter
with rupture of some of these.

True aneurism of the ascending portion and arch of the aorta
is very common. The dilatation usually extends from the origin
of the artery to the point where it begins to descend. This dila-
tation rarely proceeds so far as to produce very serious symptoms,
the extreme point of dilatation of the artery not being wider than
from two to three fingers' breadth. The convexity of the arch
and anterior part of the artery appear to yield more than the
other parts of the vessel. When the dilatation exists in the de-
scending aorta, it assumes the form of an ovoid tumour, gradually
terminating, at-each extremity, in the undilated artery. It is not
uncommon to find several dilatations of this kind in the same
artery. Sometimes we find the whole tract of the aorta dilated
to double its natural size.

Dilatation in the arch of the aorta, in the degree above describ-
ed, is very common; but this is not usually named aneurism unless
it arrives at a considerably greater extent. These sometimes are
very large. M Corvisart records one double the size of the heart,
and I have seen them of the size of the head of a full-grown foetus. '
When the true aneurism acquires a certain size, the inner coat
often is ruptured and a false aneurism ensues. The true aneurism
is commonly accompanied with a morbid degeneration of the in-
ternal tunic of the artery. It exhibits spots of a bright red, slight
cracks, and a great number of small ossified points. These fattei
are usually considered as contained in the substance of the inner

* This chapter is more abridged than the others.— Tram

ANEURISM. 205

coat, but they are, in truth, situated between it and the middle
coat.

The false aneurism of the aorta, consequent to the true, is rarer
than the simple dilatation of that artery; but it is much more com-
mon than that greater degree of simple dilatation which alone
usually claims the name of aneurism.

The false aneurism is most common in the ascending, and the
true in the descending aorta I have never met with any other
species of false aneurism in the ascending aorta, or its arch, but
that consequent to the true, or simple dilatation of the part. In
tjje descending aorta, however, false aneurism often takes place
without any previous dilatation. The opinion at present current in
the Parisian schools, viz. that in aneurism the internal coat re-
mains entire and protrudes, in the form of a hernia, through the
ruptured fibrinous tunic, is more untenable, as a general position,
than that of Scarpa, who maintains the rupture of the two inter-
nal tunics in every case of the disease. Both these opinions are
true in certain cases, but not in all.

Aneurisms of the aorta produce various effects on the adjacent
organs, according to their volume and position. Simple dilatation,
when in a moderate degree, hardly produces any effect, but the
most inconsiderable false aneurisms may give rise to very serious
disorder. The first and most common of these effects is compres-
sion acting on the heart and lungs. When the aneurism is in con-
tact with the lungs, it most commonly merely compresses them; some-
times, however, the substance of these organs gives way, and the
aneurism, when it bursts, pours its blood directly into the air-cells.
Frequently the aneurism compresses the trachea, or one of the two
bronchial trunks, flattens, and eventually destroys a part of them,
and death ensues by a species of haemoptysis from the rupture of
the tumour. The same thing occasionally happens with the oeso-
phagus, but not so frequently. I have only met with three instan-
ces of death from this cause. The ordinary effect of these aneu-
risms on the heart, is to displace it more or less, downwards or to
one side. Sometimes the aneurism bursts into the pericardium
(see Morgagni and Scarpa); but I have never met with an exam-
ple of this. A case is on record of an aneurism of this kind burst-
ing into the pulmonary artery * The left cavity of the pleura is,
bv far, the most frequent situation for the rupture of these aneu-
risms. I have met with one case where the aneurism compressed
and destroyed the thoracic duct; and M. Corvisart notices a fatal

f Bulletin de la Faculte" de Med. 1819.

206 DISEASES OF THE AORTA.

case of compression of the superior vena cava from the same
cause The most remarkable local effects of aneurisms of the
aor'a, are those on the vertebral column. They often destroy this
to a very great depth. This destruction is entirely the work of in-
terstitial absorption, there never being any mark of caries. On
the side next the vertebrae the sac is completely destroyed, and
the circulating blood is bounded by the naked bone.

Aneurisms of the ascending aorta destroy, in like manner, the
sternum by their pressure, so that they are at length covered
merely by the skin. I have met with two or three tumours of this
sort so large that they could not be completely covered by both
hands. The aneurisms of the arch of the aorta, and of the arteria
innominata, sometimes project, in like manner, at the top of the
sternum or above it, or under the cartilages of the first false ribs
of ihe right side. It is not always the largest aneurisms that most
readily make their way externally. Sometimes those of the size
of an egg produce this effect, whilst, occasionally, those of the size
of ihe head of a full-grown foetus remain quite covered and are
even compressed by the sternum.

END OF PART FIRS!

PART SECOND.

DIAGNOSIS.

ON THE

DIAGNOSIS

DISEASES OF THE CHEST,

INTRODUCTION.

However dangerous diseases of the chest may be, they are,
nevertheless, more frequently curable than any other severe inter-
nal affection. For this reason medical men, in all ages, have
been desirous of obtaining a correct diagnosis of them. Hitherto,
however, their efforts have been attended by little success, — a
circumstance which must necessarily result from their having con-
fined their attention to the observation and study of the deranged
functions only. From the continued operation of the same cause,
we must even now confess, with Baglivi, that the diagnosis of the
diseases of this cavity is more obscure than that of those of any
other internal organ. Diseases of the brain, not in themselves
numerous, are distinguished, for the most part, by constant and
striking symptoms; the soft and yielding parietes of the abdomen
allow us to examine, through the medium of touch, the organs of
that cavity; and thus to judge, in some measure, of the size, posi-
tion, and degree of sensibility of these, and, also, of the extraneous
bodies that may be formed in them. On the other hand, the dis^

.27

aiO DISEASES OF THE CHEST.

cases of the thoracic viscera are very numerous and diversities,
and yet have almost all the same class of symptoms. Of these
the most common and prominent are cough, dyspnoea, and, in
some, expectoration. These, of course, vary in different diseases;
but their variations are by no means of that determinate kind
which can enable us to consider them as certain indications of
known variations in the diseases. The consequence is, that the
most skilful physician who trusts to the pulse and general symp-
toms, 4s often deceived in regard to the most common and best
known complaints of this cavity. Nay, I will go so far as to as-
sert, and without fear of contradiction from those who have been
long accustomed to morbid dissections, — that, before the discovery
of Avenbrugger, one half of the acute cases of peripneumony and
pleurisy, and. almost all the chronic pleurisies, were mistaken by
practitioners; and that, in such instances as the superior tact of a
physician enabled him to suspect the true nature of the disease,
his eonviction was rarely sufficiently strong to prompt and justify
the application of very powerful remedies. The percussion of the
chest, according to the method of Avenbrugger, is one of the most
valuable discoveries ever made in medicine. By means of it, se-
veral diseases, which had hitherto been cognisable by general and
equivocal signs only, are brought within the immediate sphere of
our perceptions, and their diagnosis, consequently, rendered both
easy and certain.

We must still admit, however, that the method of percussion
is far from being complete, or generally available. It frequently
affords no indication in phthisis; and in no case does it enable us
to distinguish this disease from chronic peripneumony. Even in
peripneumony it fails us in a great measure when the inflamma-
tion is confined to the centre of the lung, or when both lungs are
equally affected, and only in a slight degree. It does not enable
us to distinguish the disease just mentioned from pleurisy, hydro-
thorax, or any other effusion into the cavity of the chest. It
completely fails us, or rather certainly misleads us, in the disease
called Pneumo- Thorax. It gives no indication of the diseases of
the heart unlil this organ is greatly enlarged; and it is often before
this takes place that the disease proves fatal. It affords no assist-
ance in aneurisms of the aorta and large vessels, until the nature
of the disease is appreciable by the sight, or by the touch. In
many other respects, also, the indications afforded by percussion
3re rendered equivocal by peculiarities of formation, by the nice-
ties required in its performance, and by the circumstances under
which it is performed. It is more particularly in diseases of the

DIAGNOSIS. 211

heart that we regret the insufficiency of this method, and wish
for something more precise. The general symptoms of disease
in this organ greatly resemble those produced by many nervous
complaints, and by the diseases of other organs. The results
afforded by the application of the hand to the part, with the view
of judging from the tactual sensations communicated, have been
found of some use, in doubtful cases; but, as a general method,
this is by far loo vague and uncertain to be of much benefit.

In these cases some physicians have attempted to gain further
information by tile application of the ear to the precordial region;
and, doubtless, such a proceeding will increase the certainty of the
diagnosis. Even this, however, is very insufficient; and there
are, besides, many reasons why it cannot be followed, as a general
guide, in practice. Nevertheless, I had been in the habit of using
this method for a long time, in obscure cases, and where it was
practicable; and it was the employment of it which led me to the
discovery of one much better.

In 1816, I was consulted by a young woman labouring under
general symptoms of diseased heart, and in whose case percussion
and the application of the hand were of little avail on account of
the great degree of fatness. The other method just mentioned
being rendered inadmissible by the age and sex of the patient, I
happened to recollect a simple and well-known fact in acoustics,
and fancied, at the same time, that it might be turned to some use
on the present occasion. The fact I allude to is the augmented
impression of sound when conveyed through certain solid bodies,
— as when we hear the scratch of a pin at one end of a piece of
wood, on applying our ear to the other. Immediately, on this
suggestion, I rolled a quire of paper into a sort of cylinder and
applied one end of it to the region of the heart and the other to
my ear, and was not a little surprised and pleased, to find that I
could thereby perceive the action of the heart in a manner much
more clear and distinct than I had ever been able to do by the
immediate application of the ear. From this moment I imagined
that the circumstance might furnish means for enabling us to
ascertain the character, not only of the action of the heart, but of
every species of sound produced by the motion of all the thoracic
viscera. With this conviction, I forthwith commenced at the
Hospital Necker a series of observations, which has been continu-
ed to the present time. The result has been, that I have been
enabled to discover a set of new signs of diseases of the chest,
for the most part certain, simple, and prominent, and calculated,
perhaps, to render the diagnosis of the diseases of the lungs.

212 DISEASES OF THE CHEST.

heart and pleura, as decided and circumstantial, as the indications
furnished to the surgeon by the introduction of the finger or sound,
in the complaints wherein these are used.

In prosecuting my enquiries I made trial of instruments of
various composition and construction. — The general result ha9
been that bodies of a moderate density, such as paper, wood, or
Indian cane, are best suited for the conveyance of the sound, and
consequently for my purpose. This result is perhaps contrary to
a law of physics; — it has, nevertheless, appeared to me one which
is invariable.

I shall now describe the instrument which I use at present, and
which has appeared to me preferable to all others. It consists
simply of a cylinder of wood, perforated in its centre longitudinal-
ly, by a bore three lines in diameter, and formed so as to come .
apart in the middle, for the benefit of being more easily carried.
One extremity of the cylinder is hollowed out into the form of a
funnel to the depth of an inch and half, which cavity can be ob-
literated at pleasure by a piece of wood so constructed as to fit it
exactly, with the exception of the central bore which is continued
through it, so as to render the instrument in all cases, a pervious
tube. The complete instrument, — that is, with the funnel-shaped
plug infixed, — is used in exploring the signs obtained through the
medium of the voice and the action of the heart; the other modi-
fication, or with the stopper removed, is for examining the sounds
communicated by respiration (See Plate VIII.) This instru-
ment I commonly designate simply the Cylinder, sometimes the
Stethoscope.

In speaking of the different modes of exploration I shall notice
the particular positions of the patient, and also of the physician,
most favourable to correct observation At present I shall only
observe that, on all occasions, the cylinder should be held in the
manner of a pen, and that the hand of the observer should be
placed very close to the body of the patient to insure the correct
applica:ion of the instrument.

Tiie end of the instrument which is applied to the patient, —
that, namely, which contains the stopper or plug, — ought to be
slightly concave to insure its greater stability in application; and
when there is much emaciation, it is sometimes necessary to insert
between the ribs a piece of lint or cotton, or a leaf of paper, on
which the instrument is to be placed, as, otherwise, the results
might be affected by (he imperfect application of the cylinder.
The same precaution is necessary in the examination of the cir-
culation in cases where the sternum, at its lower extremity, is

DIAGNOSIS. 213

drawn backwards, as frequently happens with shoemakers, and
some other artisans.

Some of the indications afforded by the stethoscope, or mediate
auscultation, are very easily acquired, so that it is sufficient to have
heard them once to recognise them ever after: such are those
which denote ulcers in 'he lungs, hypertrophia of the heart when
existing in a great degree, fistulous communication between the
bronchia and cavity of the pleura, &c. There are others, however,
which require much study and practice for their effectual acquisi-
tion.

The employment of this new method must not make us forget
that of Avcnbrugger; on the contrary, the latter acquires quite a
fresh degree of value through the simultaneous employment of the
former, and becomes applicable in many cases, wherein its solitary
employment is either useless or hurtful. It is by this combination
of the two methods that we obtain certain indications of emphy-
sema of the lungs, pneumo-thorax, and of the existence of liquid
extravasations in the cavity of the pleura. The same remark
may be extended to some other means, of more partial applica-
tion, such, for example, as the Hippucratic succussion, the mensu-
rationof the thorax, and immediate auscultation; all of which me-
thods, often useless in themselves, become of great value when
combined with the results procured through the medium of the
stethoscope.

In conclusion, I would beg to observe, that it is only in an hos-
pital that we can acquire, completely and certainly, the practice
and habit of this new art of observation; inasmuch as it is neces-
sary to have occasionally verified, by means of examination after-
death, the diagnostics established by means of the cylinder, in
order that we may acquire confidence in the instrument and in
our own observation, and that we may be convinced, by ocular
demonstration, of the correctness of the indications obtained. It
will be sufficient, however, to study any one disease in two or three
subjects, to enable us to recognise it with certainty; and the dis-
eases of the lungs and heart are so common, that a very brief at-
tendance on an hospital will put it in the power of any one to ob-
tain all the knowledge necessary for his guidance in this important
class of affections There are three classes of application of this
instrument, viz. as regards the Voice — the Respiration — and the
Circulation; all of which I shall here briefly notice as observable
in the healthy subject; referring for the varieties of these, as
modified by disease, and for the diagnostic indications afforded
by them, to the individual affections to be noticed hereafter.

2 14 DISEASES OF THE CHEST.

I. The Voice. When a person in health speaks or sings
his voice excites in the whole parietes of the ihorax a sort of vi-
bration, which is easily perceived on applying the hand to the
' chest. This phenomenon is no longer observable when, through
disease, the lungs have ceased to be permeable to the air, or art
ren.oved from the contact of the parietes of the chest by an effus-
ed fluid. This sign is of inferior value, since a great many causes
occasion varieties in the intensity of the vibration, or completely
destroy it. For instance, it is little sensible in fat persons, in those
whose integuments are considerably flaccid, and in those who have
a sharp and weak voice. Anasarca of the chest completely de-
stroys it, even when the lungs are quite sound. Jn any case it is
only very perceptible at the anterior and superior part of the chest,
on the sides, and in the middle of the back. From these and
other causes we can derive little practical benefit from attending
to this particular circumstance.

On making use of the cylinder with the view of further investi-
gating this phenomenon, I soon found, as indeed might have been
expected, that it conveyed the peculiar vibration much less dis-
tinctly lhan the bare hand. I also ascertained that the degree of
intensity of the vibration varied in different points of the thorax.
The places where it is most distinct are the axilla, the back — be-
tween the spine and the edge of the scapula, and on the anterior
and superior part of the chest near the angle formed by the union
of the clavicle with the sternum. When we apply the cylinder
to these points, the voice appears stronger and nearer to us; in the
others, on the contrary, particularly in the inferior and posterior
parts of the thorax, it seems weaker and more remote.

II. Respiration. On applying the cylinder, with its funnel-
shaped cavity open, to the breast of a healthy person, we hear,
during inspiration and expiration, a slight but extremely distinct
murmur, answering to the entrance of the air into, and its expul-
sion from, the air-cells of the lungs. This murmur may be com-
pared to that produced by a pair of bellows whose valve makes no
noise, or, still better, to that emitted by a person in a deep and
placid sleep, who makes now and then ar profound inspiration. We
perceive this sound almost equally distinct in every part of the
chest, but more particularly in those points where the lungs, in
their dilatation, approach nearest to the thoracic parietes, as, for
instance, the anterior-superior, the lateral, and the posterior-inferior
regions. The hollow of the axilla, and the space between the
clavicle and superior edge of the trapezius muscle, exhibit the
phenomenon in its greatest intensity. It is equally perceptible on

DIAGNOSIS. 215

the larynx, on the exposed or cervical portion of the trachea, and,
in many persons, through the whole tract of this canal to the hot-
torn of the sternum; but on the trachea, and in some degree at
the root of the bronchia, the respiratory murmur has a peculiar
character, which evidently indicates the transmission of the air
through a larger space than the air-ciells. In this position, also,
it often seems as if the patient, in inspiring, inhales the air through
the tube of the stethoscope, and expels it by ihe same, during ex-
piration.

To judge correctly of the state of respiration by this method,
we must not rely on the results of the first moments of examina-
tion. The sort of buzzing sensation often caused by the first ap-
plication of the instrument, the fear, restraint, and agitation of the
patient, which mechanically lessen the force of respiration, the
frequently inconvenient posture of the observer, and the great sen-
sation occasionally produced by the action of the heart, — are all
causes which may at first prevent us from correctly appreciating,
or even from hearing at all, the sound of inspiration and expira-
tion. We must, therefore, allow some seconds to pass before we
attempt to form an opinion.

I need hardly observe that there must be no noise whatever in
the vicinity of the patient. The intervention of clothing, even
when of considerable thickness, does not sensibly diminish the
sound of respiration; but we must be careful that there is no
friction between this and the instrument, as this circumstance,
especially if the clothes are of silk, or of a fine hard stuff, may
mislead us by exciting a sensation analogous to that produced by
respiration. Fatness, even when excessive, and anasarca of the
chest, seem to have no notable effect in diminishing the peculiar
sound. The sound is more distinct in proportion as the respiration
is more frequent. A very deep inspiration made very slowly will
sometimes be scarcely audible, while an imperfect inspiration,
such, for instance, as hardly at all elevates the chest, — provided it
be made quickly, may produce a very loud sound. On this ac-
count, when examining a patient, more especially if we have had
but slight practice with the instrument, we should desire the res-
piration to be performed rather quickly. This is, however, a very
unnecessary precaution in most diseases of the chest, as the fre-
quent presence of dyspnoea necessarily renders the respiration
quick. The same is true of fever, and the agitation caused by
nervous affections.

Many other causes, and especially the age of the individual, alter
the intensity of the sound. In children, respiration is very sono

216 DISEASES OF THE CHEST.

rous, even noisy, and can be heard easily even through very thick
clothing. In them the close and forcible application of the
instrument, to prevent the friction of the garment, is unnecessary,
as any noise (hat might arise from this cause is lost in the intensity
o( the other. The respiration of children differs, also, from that
of adults in other respects besides its intensity. It is impossible
to describe this peculiarity, but it will easily be understood by com-
parative trials. It appears as if, in children, we could distinctly
hear the dilatation of all the air-cells to their full extent; whilst,
in adults, these seem as if, from their stiffness, they could only
bear a partial dilatation This difference of sound is much less
marked in expiration than inspiration. The dilatation of the chest
in inspiration is also greater in the child, and both these peculiari-
ties are more remarkable as the child is young: the} continue, in
a greater or less degree, to the period of puberty or a little beyond
it.

The sound produced by respiration varies, also, very much in
its intensity in different adults. In some men it is scarcely per-
ceptible unless they make a very deep inspiration, and even then,
although sufficiently distinct, it is not one half so audible as in the
majority of persons. These individuals have generally a rather
slow respiration, and are little subjeet to dyspnoea, or breaihless-
ness, from any cause. Others, however, have the respiratiou
very sensible even during a common inspiration, without being, on
this account, at all more subject to shortness of breath than the
former. Some few individuals, again, preserve through life a slate
of respiration resembling that of children, and which 1 shall there-
fore denominate puerile, in whatever age it may be perceptible.
Such persons are almost all women, or men of a nervous tempera-
ment, and they preserve, in some other respects, the character of
childhood. Some of these cannot be said to have any ..ciual
disease of the lungs, but they soon get out of breath, even though
lean, by exercise, and are very liable to catch cold. Others of
this class are affected with a chronic catarrh, attended by dyspnoea,
a condition constituting one of those cases to which the name of
Asthma is usually given. With these exceptions, an adult cannot,
by any effort, give to his respiration the sonorous character of
childhood; but in' some morbid states, the respiration spontane-
ously acquires it, without being, at the time, performed more
forcibly than usual. This is particularly the case when one whoie
lung, or a considerable portion of both lungs, is r^nJerci imper-
meable to air through disease, especially acute disease. ):> 'he
sound portion of the lungs, in these cases, the respiration is per-

DIAGNOSIS. 2H

seclly similar to lhat of children. The same thing is observable
throughout the whole extent of the lungs in some cases of fever,
and in certain nervous diseases

At first we are tempted to believe that the superior intensity of
the respiratory murmur in children may be owing to the tenuity of
the muscles covering the chest, and to the superior suppleness of
the tissue of the lungs. But the first cause must have scarcely
any effect in this way, since we find that, even in the fattest chil-
dren, and in those most thickly clothed, the respiration is much
more distinct than in the leanest adult examined uncovered ;
whilst, of the adults who possess the puerile respiration, many are
very robust and full of flesh. Neither does the quieter respira-
tion of the adult depend on any induration or loss of pliability
in the pulmonary tissue, since it sometimes accidentally returns to
the character it had in infancy. I am rather disposed to believe
that the difference of result depends on the fact of children re-
quiring a greater proportion of air than adults ; whether this ne-
cessity arises from the greater activity of their circulation, or from
some difference in the chemical composition of the blood.

The respiration which is most audible to the ear, is not that
which produces the greatest noise in the interior of the chest. I
do not here allude to that species of respiration which is accom-
panied with a rattling or hissing, or any other unnatural sound,
but to that kind of respiration which is simply loud, and which is
so frequent in dyspnoea. This noise is merely the aggravation of
the natural sound made by many persons in sleep, and is caused by
the mode in which the air impinges upon the parts in the fauces.
We can imitate it at will. I am acquainted with an asthmatic
patient, whose habitual respiration can be heard at the distance of
twenty feet, and whose respiration, as heard in the interior of the
chest, is, nevertheless, weaker than in the majority of men. The
same remark applies to the noise (snoring) emitted by many
healthy persons during sleep; and, also, to the imitative sounds of
jugglers and ventriloquists, — all of which are produced in the
throat and posterior nares, and are quite unconnected with the
sound of respiration in the interior of the chest.

When we can distinctly perceive, and with a uniform intensity,
the respiratory murmur in every part of the chest, we may be
assured that there exists neither effusion into the cavity of the
pleura, nor any species of engorgement in the substance of the
lungs. On the other hand, when we find the respiration is not to
be distinguished in any particular point, we may safely conclude
the corresponding portion of the lungs within is become imperme-
able to the air from some cause or other. This sign is as easy to

2S

218 " DISEASES OF THE CHEST.

be perceived as ihe presence or absence of the sound, in the per-
cussion of Avenbrugger, and affords precisely the same indica-
tions. With the exception of some peculiar cases, in which the
simultaneous employment of the two different methods gives us
signs which are completely pathognomic, — we may state it as a
general fact, that the absence of the sound on percussion coincides
uniformly with the absence of respiration, as ascertained by tli 1
stethoscope.

As appertaining to the action of respiration, although not ob-
servable in the perfectly healthy conditon of this function, I shall
here briefly allude to a phenomenon which will be more particu-
larly described hereafter. It is the peculiar sound conveyed by
the cylinder, when the air, during respiration, is transmitted
through fluid matter of any kind in the lungs or bronchia. From
its resemblance, both in its origin and character, to what is usually
called the rattles in dying persons, and from want of a better
word, I have adopted this term 1o denote it whenever it occurs.
Its character and varieties will be described hereafter.

Ill The Circulation. In the introductory chapter to the
Diagnosis of the diseases of the heart, I shall detail, at consider-
able length, the results obtained by the cylinder, both in the
healthy and disordered condition of that organ. At present I al-
lude to them merely; and chiefly for the sake of uniformity.

The alternate contractions of the auricles and ventricles of the
heart give rise to sounds very distinct, and of different kinds, so
as to enable us to study the actions of that organ even more ex-
actly than by the dissection of living bodies. The truth of this
seemingly paradoxical assertion rests on the fact, of the ear judg-
ing much more correctly of the intervals of sound, than the eye of
the intervals of motions corresponding to these.

In ordinary circumstances the stethoscope, applied between the
cartilages of the fifth and sixth ribs, at the end of the sternum, or,
indeed, in any point where the pulsation of the heart is percepti-
ble,— conveys to the ear a distinct sound. This, in the healthy
body, is double, and each beat of the arterial pulse corresponds to
this double sound, in other words, to two sounds. One of these
is clear and rapid, and somewhat resembles the sound produced
by the valve of a pair of bellows: this corresponds to the systole
of the auricles. The other is more dull and prolonged, coincid-
ing with the beat of the pulse and with the shock or impulse com-
municated to the parietes by the motion of the heart:— it indi-
cates the contraction of the ventricles. The sounds heard at the
end of the sternum are produced by the action of the right side

PHTHISIS PULMONALIS. 219

of the heart; those between the cartilages of the ribs by the left
cavities. In the state of health the sound produced by the con-
tractions of each side is the same.

PHTHISIS PULMONALIS.

(Part I. Page 33.)

In following up my observations on the comparative resonance
of the voice in several subjects, both healthy and diseased, I was
struck by the discovery of a phenomenon entirely new to me. In
the case of a woman, affected with a slight bilious fever, and a
recent cough having the character of a pulmonary catarrh, on ap-
plying the cylinder below the middle of the right clavicle, while
she was speaking, her voice seemed to come directly from the
chest, and to reach the ear through the central canal of the instru-
ment. This peculiar phenomenon was confined to a space about an
inch square, and was not discoverable in any other part of (he chest.
Being ignorant of the cause of this singularity, I examined, with
the view to its elucidation, the greater number of the patients in
the hospital, and I found it in about twenty. Almost all these
were consumptive cases in an advanced stage of the disease. In
some the existence of tubercles was still doubtful, though there
was reason to suspect them. Two or three, like the woman
above mentioned, had no symptom of this disease, and the degree
of robustness of these seemed to put all fears of it out of the ques-
tion. Notwithstanding this I began immediately to suspect that
this phenomenon might be occasioned by tuberculous excavations
in the lungs. The observation of the same thing in patients who
had no other symptom of phthisis, did not appear to me conclu-
sive against the correctness of my suspicion, because I knew it to
be by no means unusual to find in the lungs of persons dead of
some acute disease, and who had never shown any sign of con-
sumption, tubercles not only softened but excavated, and forming
the very case denominated ulceration of the lungs. The subse-
quent death, in the hospital, of the greater number of the indivi-
duals who had exhibited this phenomenon, enabled me to ascer-
tain the correctness of my supposition: in every case I found ex-

220 DIAGNOSIS.

cavations in the lungs, of various sizes, the consequence of thu
dissolution of tubercles, and all communicating with the bronchia
by openings of different diameters.

1 found this peculiar phenomenon (which I have denominated
Pectoriloquism) to be more perceptible according to the proximity
of the excavation to the superficies of the lungs; and that it was
most striking when these adhered to the pleura in such a manner
as to render the thoracic parietes almost a part of the walls of the
ulcerous excavation, — a case of very frequent occurrence.

This circumstance naturally led me to think, that pectoriloquism
is occasioned by the superior vibration produced by the voice, in
parts having a compara'.ively more solid, and wider extent of sur-
face; and 1 imagined that, if this were so, the same effect ought to
result from the application of the cylinder to the larynx or trachea
of a person in health. My conjecture proved correct. There is
a perfect identity of effect beiween pectoriloquism and the sound
of the voice as heard through the tube resting on the larynx; and
this experiment offers an excellent mean for giving us an exact no-
tion of the phenomenon, when we have not the proper subjects for
observation. Pectoriloquism becomes more striking when we close
the other ear by the hand. We then perceive, in the most evident
manner, that the whole articulate voice of the patient passes by
the cylinder.

In the early stage of Phthisis, neither percussion of the chest,
nor auscultation in any of its forms, affords any means of, detecting
the disease in ordinary circumstances. When, as sometimes hap-
pens, especially in the superior lobes, the tubercles are congregat-
ed in great numbers in one spot, so as to form masses of consider-
able size, — in this case the respiration is inaudible, and percussion
elicits a dull sound. This, however, must be considered as a very
rare case.

As long as the expectoration retains either of the characters as-
cribed to the first stage of the disease (see page 56), it is useless
to look for the phenomenon of pectoriloquism, for the tubercles
being still unsoftened, it cannot exist. But when the expectora-
tion assumes the characters of the second stage (page 57, 58), if
we have recourse to the stethoscope at this period, we shall dis-
cover incipient pectoriloquism. This will daily become more evi-
dent; and sometimes, even at the end of a few hours, will be com-
plete. This is especially the case where the yellow purulent ex-
pectoration has existed in great quantity from the very moment oi
its first appearance.

In upwards of two hundred instances of consumptive subjects.

PHTHISIS PULMONALIS. 221

whose bodies I have examined after having ascertained, during
life, the condition of their lungs as indicated by the cylinder, I
have not met with a single instance in which ulcerous excavations
did not exist in those points of the lung over which the phenome-
non of pectoriloquism had shown itself distinctly; and as in most
of these cases I had ascertained the existence of this in several
points at once, I have, in fact, several hundred of positive obser-
vations on this point, and not a single negative one.

On the other hand, I have not met with one case of pulmonary
excavations .communicating with the bronchia, in any subject
whose chest I had completely examined, and during several days,
without finding pectoriloquism. This deception, however, it is
evident, may readily occur if we are satisfied with a single exam-
ination of a patient, or if ive confine our examination to one point
of the chest; because, as I have already remarked, the sputa con-
tained in the excavations may obstruct, for a time, the communi-
cation with the bronchia, and thus suspend pectoriloquism for se-
veral hours. On this account, when we have reason to suspect an
attack of consumption, and do not find this phenomenon on our
first trial, we ought to suspend our judgment until similar observa-
tions, repeated at different times, have confirmed or overturned the
first indication. If, after repeated trials, we cannot discover pec-
toriloquism, we must infer either that the tubercles are still im-
mature, or, if softened, that they do not as yet communicate with
the bronchia, or, lastly, that the disease is not phthisis.

Although the superior lobes of the lungs are the most common
seat of tuberculous cavities, still we must not content ourselves
with examining these only, in cases where we do not at first dis-
cover pectoriloquism. It sometimes, though rarely, happens that
excavations exist in the centre of the lungs, in their anterior, mid-
dle, or lateral parts, or even in their inferior edge, while the supe-
rior lobes are uninjured.

In two or three cases only, in subjects which I had thoroughly,
though but for a few times, examined, and in which there was no
pectoriloquism, have I found on dissection excavations of greater
or less extent. In one case of this sort 1 discovered a cavity large
enough to contain a middling sized apple. But in this, and other
similar cases, the cavities were almost completely filled by soft
tuberculous matter, and communicated with the bronchia only by
one or two openings at their inferior and posterior parts, of so nar-
row a caliber as almost to preclude the escape of the pus by them.
Sometimes, also, in cases wherein pectoriloquism had been dis-
tinct, in addition to the excavations which afforded this sign, I

222 DEAGNOSIS.

have discovered, on dissection, other cavities, generally small,
though sometimes large enough to contain an almond, which had
no communication whatever with the bronchia. These were ge-
nerally rilled with tuberculous matter softened to the consistence
of pus. Cases of this sort, it is obvious, are merely exceptions
which confirm a general rule; since we know that pectoriloquism
cannot show itself but in cases where there is a communication
between the bronchia and a cavity, at least empty in part.

I have detected pectoriloquism in subjects in whom, at the time,
no other characteristic symptom of phihisis was present; as was,
indeed, the case with the first patient in whom 1 recognised it.
In cases of this sort, whose progress 1 have been enabled to trace,
I have observed the gradual development of phthisical symptoms
until they reached that point when their nature could be misun-
derstood by no one. From all this, I think we are entitled to con-
clude, that pectoriloquism is a - true pathognomonic sign ol phthisis,
and that it announces the presence of ibis disease sometimes in an
unequivocal manner, long before any other symptom leads us to
suspect its existence. 1 may add, that it is the only sign that can
be regarded as certain.

Cough, dyspnoea, puriform sputa, hectic fever, haemoptysis,
emaciation, — in short, the complete reunion of symptoms of
which the frightful picture has been so faithfully delineated by
Aretaeus, — may exist in cases, which we see, nevertheless, reco-
ver, contrary to all expectation.* We have already shown that
some of these cases may probably be truly cases of phthisis; but
there can be no doubt that others are examples of organic affec-
tions simulated by nervous or mere junctional disorder.

On the other hand, we frequently observe in cases of true
tubercular phthisis, that almost all the usual symptoms of this
disease are wanting. Sometimes there is no cough whatever, or
it is suspended for monlhs together; and hectic fever is, in like
manner, scarcely perceptible, or altogether absent, for as long a
period. Even emaciation, which has given its name to the dis-
ease, is sometimes very trifling; and death may be occasioned by
the mere effect of the tubercular disorganization before it be per-
ceptible. In many cases, again, a colliquative diarrhoea and
hectic fever are the only symptoms, and, consequently, render the
nature of the disease very equivocal

In this respect, then, the indications of the stethoscope will
supply one of the desiderata of medical science, and will help

* See M. Bayle's cases, 48, 49, 50, 51, 52, 53, 54.

PHTHISIS PULMONALIS. 223

us to distinguish the cases which are quite beyond the resources
of nature and art, from those which still leave us room to hope,
We have already examined (Part I. page 42) the question how
far the presence of pectoriloquism ought to be considered as de-
noting the existence of an inevitable cause of death.*

It is in the superior lobes that tubercles generally begin to show
themselves, and consequently, it is in the parts of the chest an-
swering to these that pectoriloquism is most frequently found, —
namely, the interior and superior part., the axilla, the space be-
tween the clavicle and trapezius muscle, and on the upper flat
par;s of the scapula, — /his bone and its muscles having no other
effect over the phenomenon than to render the sound duller.

Pectoriloquism is certain or uncertain. It is certain when it
possesses the characters described in page 219, and wheresoever
we find it with these, even although momentarily, we may be
assured that there exists, in the corresponding parts of the lung,
an unnatural excavation communicating with the bronchia.

Pectoriloquism is uncertain when the patient's, voice appears
somewhat more acute and slightly altered like that of ventrilo-
quists, or when it resounds under the cylinder with more than its
natural strength, without seeming to traverse the tube. We have
a perfect notion of the uncertain pectoriloquism on applying the
cylinder between the inner edge of the scapula and the spine,
opposite the origin of the bronchia, in a healthy person that is
lean and has an acute voice. This phenomenon naturally exists
in this point in such subjects, and, indeed, more or less in all
persons, for reasons already stated. In thin narrow-chested
children, these points even give sometimes perfect pectorilo-
quism.

For this reason, we must, in many cases, draw no conclusion
from uncertain pectoriloquism, when it exists only in the point
just mentioned, in the axilla, or near the junction of the clavicle and
sternum We must even extend the same remark to the whole
superior and anterior portion of the chest, when the pectoriloquism
is very imperfect and exists equally in both sides. When, how-
ever, we find uncertain pectoriloquism in places below the third
or fourth rib, or on one side only, there is strong presumption of

* We shall see, in another place, that there is an analogous phenomenon
[Haegophonism] which may sometimes be confounded with pectoriloquism,
but which by no means affords the same indications; and there is one case
of actual and perfect pectoriloquism, where the cause of the phenomenon
is of a much less serious kind than consumption. [Dilatation of the Bron
•hia.l

224 DIAGNOSIS.

the existence of an excavation; and if the same phenomenon
does not exist in the points above mentioned, the presumption
amounts to a certainty; and we must conclude, either that the
tuberculous cavity is seated very profoundly in the lungs, or that
it is stilt filled, in a great measure, by imperfectly softened mat-
ter.. If in any point of the chest, the sound of the voice is much
stronger than in the opposite side, more especially if it is so in-
tense as to seem stronger and nearer than the natural voice heard
by the ear, the indication is as certain as if the voice traversed
the tube, and we reckon, in such case, the pectoriloquism imper-
fect, not uncertain. Pectoriloquism is more distinct in propor-
tion as the voice of the person is sharp. This is most frequently
the case with women and children. It is, therefore, in them we
must be most on our guard against that variety of the phenomenon
which I have named uncertain. In persons, on the other hand,
with a very deepvoice, pectoriloquism is often uncertain when
there exist excavations in the state most favourable for its pro-
duction. In such cases, the voice, much agitated, and as it were
trembling, does not enter the tube, but resounds at its extremity
with a force double or triple that natural to it. The patient
seems to speak through a speaking trumpet, quite close to the ob-
server, and not, as in the case of perfect pectoriloquism, through
a tube into his ear. This variety of the phenomenon, especially
if it exists on one side of the chest only, affords an indication no
less certain than perfect pectoriloquism. This is more particular-
ly the case, if we stop the other ear, and find a very great differ-
ence of sound between the place in question, and the other parts
of the chest.

When the pulmonary excavations are extremely large we find
distinct pectoriloquism changed into this variety, even in persons
not possessing a deep toned voice. This fact enable us, in some
cases, to trace the progress of the increase and development
of tubercles. In cases of the most perfect pectoriloquism, some-
times the voice, in place of passing uninterruptedly through the
cylinder, is intermittent. This circumstance does not, in any
respect, affect the indication. Sometimes perfect pectoriloquism
ceases for a time, evidently (as we learn from the accompanying
rattle) by the obstruction of the excavations, or their openings,
by the accumulation of the sputa. On this account we must
never pronounce a patient to be nonpectoriloquous from a single
trial.

Commonly, in cases of pectoriloquism, the voice, as heard
ihrough the tube, is somewhat smothered like that of ventrilo-

PHTHISIS PULMONALIS. 225

quists. Like theirs, also, the articulation of some words is very
distinct, and of others very obscure and dull. Sometimes it is
weaker than the natural voice, but commonly it is louder. Some-
times it seems as conveyed by a trumpet; and at others, as if
spoken directly in the ear, without any intermedium, and so loud
as to be very disagreeable. Sometimes it resounds as if convey-
ed by a brass tube, and is accompanied by a very characteristic
sort of bleating (chevroltement), which will be described hereaf-
ter under the name of Hcegophonism.* This must not be con-
founded with pectoriloquism properly so called. Sometimes every
word is followed by a sort of tinkling, like that of a small bell
or glass, which dies away in the tube at a variable altitude. I
shall more particularly notice hereafter this sound also, which I
have named metallic tinkling (tinlement metalliqne). In some
cases each word is accompanied by a sound resembling the forci-
ble expiration of the breath in blowing out a candle; and we can
hardly believe that some one is not blowing strongly into our ear
through the tube of the cylinder.

The most complete extinction of the voice does not affect pec-
toriloquism; it being often very distinct in persous whose voice
cannot be heard at the distance of three or four feet. A moderate-
sized and regular-shaped excavation appears to give rise to .the
phenomenon more decidedly than a very large or irregular one.

We may form some idea of the nature of the contents of an ex-
cavation from the particular characters of the pectoriloquism.
When the cavities are quite empty, the voice is heard clear and
without any extraneous sound. When, on the contrary, they con-
tain a certain portion of soft matter, the voice is accompanied by
a sort of guggling noise which renders the articulation less dis-
tinct.

In the last stage of Phthisis, that is to say, after the formation
of tuberculous excavations, the auscultation of the respiration also
affords some useful indications. In these cases the sound of res-
piration continues very audible over the site of the excavations;
but instead of being attended by the usual crepitous noise, it here
resembles simply the sound of wind, as of a pair of bellows, or
like that observed on applying the cylinder to the trachea, but still
more distinct. In these circumstances percussion on the parts of-
ten elicits a dull sound, owing to the engorgement surrounding the
excavation; and these two circumstances, — namely, — the existence
of a spot yielding very forcibly the sound of respiration without

* See Diagnosis of Pleurisy.
29

226 DIAGNOSIS.

crepitus, in the centre of a portion of the chest which sounds
badly, — may be considered as pathognomonic of this state of parts.
In certain cases, the sound of respiration over the site of tubercu-
lous cavities is accompanied by the sensation as if the patient in
inspiration inhaled the air from the tube of the stethoscope and
exhaled it during expiration. This is observable on applying
the instrument to the trachea and larynx of a person in health.

One species of that variety of respiration, also, which 1 have
denominated the rattle, affords some signs almost as characteristic
of the disease as pectoriloquism itself. The species here meant
is that which I have named the mucous or guggling rattle. It is
produced in the present case by the transmission of air through
softened tuberculous matter; in many other cases it arises from the
accumulation of sputa or blood in the bronchia or trachea: it is the
dead rattles of the vulgar. This is the only species of the rattle
that can be heard by the unassisted ear, and it can be so only when
its seat is in the trachea or larger bronchial tubes. The cylinder
enables us to hear it when it exists in any part of the lungs.

The mucous rattle points out the existence of tuberculous exca-
vations when it is found exactly circumscribed and confined to par-
ticular parts of the chest. It sometimes precedes evident pecto-
riloquism by several days or even weeks. Both simple respiration
and cough produce this species of rattle in tuberculous excavations
half-filled with softened tuberculous matter. When this is very
liquid we often can distinctly recognise the fluctuation of a liquid,
in place of the rattle. The noise in such cases is sometimes ex-
ceedingly like that produced by the escape of water from a bottle
held with its mouth directly downwards. Sometimes, but very
rarely, the patient himself is sensible of the motion occasioned by
the passage of the air in the excavation, which he commonly ex-
presses by saying that he feels the matter expectorated come from
that particular point.

In exploring the phenomena of pectoriloquism, if the patient is
in bed we ought to make him lie on his back, and at both sides of
the bed successively, while we examine the anterior parts of the
chest. In examining the lateral parts of the chest, and the axilla,
we must make the patient to lean from us; and while examining
the upper part of the shoulder he must lean towards us. In examin-
ing the back, we seat him in his bed with his back towards us, his

PERIPNEUMONY. 227

body a little bent forwards and his arms crossed. If the patient
is seated in a chair, it is best to kneel on one knee while examining
the anterior parts of the chest. In every case it is advisable to
make him turn his face away from us while examining him.

PERIPNEUMONY.

(Part I. Page 59.)

Peripneumony is one of the longest known diseases: its diag-
nostic symptoms are not, however, on this account, unequivocal.
Impeded respiration, deep pain in the side affected, incapacity of
lying on the opposite one, fever, cough, viscid sputa, sometimes
mixed with blood, the urine of a deep red, — are the principal
symptoms assigned to this disease by authors. There is, however,
not one of these but may be absent in the most violent cases,
while, on the other hand, they are almost all common to many
other diseases.

In a great many cases of peripneumony there is no pain.
Dyspnoea is, in like manner, sometimes very slight, and is fre-
quently unperceived by the patient when it is visible to the medi-
cal attendants. Some patients cannot lie on the affected side,
though the contrary is much more commonly the case. The
cough is sometimes slight and infrequent; and in the chronic va-
riety of the disease especially, (whether this is the original affec-
tion or succeeds the acute stage,) it is sometimes so very incon-
siderable as scarcely to deserve* the name, and its existence is
denied by the patient. Even fever, the invariable attendant of
inflammatory affections, at least at their origin, is sometimes to-
tally wanting in this disease after the few first days.

The only one of the general symptoms that can certainly be
depended on is the tenacious sputa noticed in the First Part (page
63). But even this is not always well-marked; and, indeed,
seldom is so after the first days of the disease.

.From all this it follows, that the physicians, who confine them-
selves, in diseases of the chest, to the examination of general
symptoms, must often mistake chronic peripneumony, and even

22b DIAGNOSIS.

sometimes the acute disease; particularly if they do not see the
paiient till after the first days of the complaint, or in those cases
where the peiipneumonic affection supervenes in the course of
another disease

The percussion of the chest, according to the method of Aven-
brugger, is a much surer means of ascertaining this disease, in
all its stages, than the examination of the external symptoms only.
The little time and trouble required by.it, and the certainly of its
results, would exclude the necessity of any other mode of explo-
ration,, if it were applicable in all cases; but we have already
seen (j>age 210) that this is not the case.

The exploration by the cylinder has not this disadvantage: it
indicates the pulmonary inflammation in every possible case, and
points out, moreover, the degree of if, with much greater preci-
sion than percussion. In the first degree of peripneumony, the
respiratory murmur is still heard in the part affected, whether
percussion affords any sensible alteration of sound or not; and it is,
further, accompanied by that species of rattle to which I give the
name of crepitous rattle, affd which is the pathognomonic sign of
this first degree of peripneumony. This species of rattle resem-
bles the crepitation of solid salts in a heated vessel, or it may be
said to be very analogous to the noise emitted by the healthy lungs
when compressed in the hand, — only stronger. The only other
diseases in which this species of rattle is found, are oedema of the
lungs and haemoptysis. The second and third varieties of perip-
neumony are distinguished by the total absence of the respiratory
murmur. On the patient making a deep inspiration we see and
feel the motion of the thoracic parietes, but we hear no sound
whatever. Sometimes, however, in place of the natural sound of
respiration we hear the mucous rattle. This is particularly the
case when a pulmonary catarrh is conjoined with the peripneu-
mony, or when the viscid mucous sputa of the early stage are
changed, towards its latter stage, into a thicker and more opaque
expectoration.* We commonly observe, also, in all the varieties
of the disease, but especially in the two first, that the respiration
acquires the character which we have named puerile (page 216)
in the parts of the lung which have remained sound.

When peripneumony terminates favourably, the cylinder be-
comes a sure measure of the progress of the cure. Before per-
cussion can inform us of any diminution of the pulmonary engorge-
ment, the cylinder enables us to distinguish a slight murmur

* For an account of this species of Rattle see Page 226

PERIPNEUMONY. 229

during expiration. This is first observable in one point, and
always in the superior portion of the side affected, gaining ground
daily, both in degree and extent, until the period of complete
resolution If in this state the patient makes a deep inspiration,
we often can perceive, towards its termination, a sort of crepita-
tion like that produced by blowing air into the cellular substance
of meat, as practised in the shambles, or like the sudden disten-
tion of a dry bladder. The percussion of the chest gives a much
tardier indication of the resolution of the inflammation; and,
moreover, does not point out the progressive amendment, like
the cylinder. This is a matter of great importance both in a
moral and therapeutic point of view, and cannot be properly met
by attention to the general symptoms merely. It often happens
that persons affected with peiipneumony, after the use of anti-
phlogWtics, appear almost cured for a few days: the fever and pain
go off, the cough becomes less frequent, and the expectoration
trifling; the strength and appetite return; but we learn by the
cylinder and percussion that the pulmonary engorgement remains
quite undiminished. Accordingly, in such cases, we find that
after a deceitful convalescence of a few days, or even weeks, the
strength again fails, and a fresh inflammation, or merely general
exhaustion, with cerebral congestion and dyspnoea, carries off the
patient. In a still more numerous class of cases, peripneumony
retains the character of an acute disease only during four or five
days, while the organic lesion of the lung is not completely re-
moved till after several weeks.

There are many other cases wherein the method of auscultation
is applicable, when that of percussion fails. The following are a
few of the circumstances which render percussion either partially
or generally useless as a diagnostic: 1st, it is inapplicable to that
portion of the thorax occupied by the liver, and also, in a great
degree, to the opposite portion containing the distended stomach-
2nd, it is useless in many cases of great fatness; 3rd, in most
rickety subjects; 4th, in some few cases it is rendered useless by
some unknown peculiarity of constitution; 5th, by the artificial
application of a blister to the part; and 6th, when both lungs are
inflamed in corresponding points, or when they are violently af-
fected, and throughout a great extent. In this last case death al-
most always supervenes before the pulmonary engorgement be so
far advanced as to be indicated by any peculiarity of sound on per-
cussion.

In this case the cylinder is of great use. Besides the species
of slight crepitus that accompanies respiration in the first degree

2S0 DIAGNOSIS.

of peripneumony, and the comparative intensity of the natural
respiratory murmur in the sound portions of the lungs, this instru-
ment furnishes another symptom quite characteristic in the pre-
sent case. It is this — although the respiration is still heard in the
inflamed parts, we perceive that it is in force very much less than
it ought to be, considering its frequency, and the great degree of
enlargement of the thorax in inspiration which then conspicuously
exists. In these cases the cylinder is of the greatest advantage,
inasmuch as the double peripneumony (that is, of both lungs) is one
of the most insidious diseases, and may be easily confounded with
an attack of asthma or nervous dyspnoea, especially when it super-
venes, as it frequently does, during a fever or disease of the heart.
In such a case, an opportune bleeding (which is rarely indicated
by the general symptoms) will often save the patient.

To conclude, — in every case, even where percussion is employ-
ed with most advantage, auscultation affords indications more con-
vincing still. Nevertheless, the method by percussion ought never
to be omitted in peripneumony. In this case I may observe that
the method of auscultation is more simple, requiring only two pre-
cautions — namely, to cause the patient to breathe a little more fre-
quently, and to keep the cylinder exactly applied on the chest.

GANGRENE OF THE LUNGS.

(Part I. Page 64.)

The general symptoms of this affection have been already no-
ticed in Part First (page 66). When the disease has produced ex-
cavations in the substance of the lung, these give rise to pectorilo-
quism equally with those of phthisis. When these cavities com-
municate at the same time with the bronchia and cavity of the
pleura, and have thereby excited an attack of pleurisy accompa-
nied by pneumo-thorax, (see page 141), the modification of the
respiratory sound, denominated the metallic tinkling, is further ob-
servable,

HEMOPTYSIS. 231

HAEMOPTYSIS.

(Part I. Page 69.)

The principal symptoms of this disease are the following: —
great oppression, cough attended by much irritation of th*e larynx,
and sometimes by very acute pain in the chest; — expectoration of
bright and frothy blood, quite pure or merely intermixed with sa-
liva, or some bronchial or guttural mucus; — pulse frequent, full,
and with a particular kind of vibration, even when soft and weak,
as it frequently is after a day or two. Of all these symptoms the
spitting of blood is the most constant and most severe. This is
commonly very copious, returning by fits, with cough, oppression,
anxiety, intense redness or extreme paleness of face, and coldness
of the extremities. When the hemorrhage is very great it comes
on sometimes with a very moderate degree of cough, and is ac-
companied by a convulsive elevation of the diaphragm like that
which takes place in vomiting. This accounts for the expression
— vomiting of blood, which is used by most persons who have suf-
fered a violent haemoptysis.

The haetnoptysical engorgement is usually of too small extent to
be recognisable by percussion; and, besides, it frequently has its
seat in those portions of the lung which are beyond the reach of
this means of diagnosis.

The stethoscope affords two signs indicative of this affection,
viz: 1st, the absence of respiration in a portion of the lung of small
extent, and 2nd, a mucous rattle. In that variety of the disease
where the blood is furnished by the bronchial membrane, there is
the latter indication without the former. Should this distinction
be not very clear (as will be the case when the engorgement is of
small extent), it will always be wise to act as if the affection were
certainly the more severe of the two.

232 DIAGNOSIS.

PULMONARY CATARRH.

(Part I. Page 70.)

V

In the First Part I have stated that the general symptoms of pul-
monary catarrh, especially cough and expectoration, afford no cer-
tain means of discriminating it from other diseases of the lungs.
Mediate auscultation, however, either by itself, or conjointly with
percussion, furnishes us with several certain indications, as well of
its existence, as its severity. The chief of these is furnished by
that modification of the respiratory sound which I have named the
rattle; and I shall take this opportunity of describing this pheno-
menon more particularly than I have hitherto done. The pecu-
liar sounds classed under this denomination are very various; and
although they are, in general, very striking in their characters, it
is, nevertheless, very difficult to communicate a correct notion of
them to such as have never heard them. However, from what I
have already said respecting them, and what I shall now say, I
hope any one will be able to distinguish the different kinds on
trial, as they can be much more easily recognised than described.

There are four principal kinds of this phenomenon: 1st, the
humid or crepitous; 2nd, the mucous or guggling; 3rd, the dry
sonorous; and 4th, the dry sibilous or hissing rattle. The two
first of these have been already described (pages 226 and 228).

The dry sonorous rattle is more variable in its character than
the two former. In this the sound, more or less deep, is some-
times extremely loud, resembling, at different times, the snoring
of a person asleep, the bass note of a musical instrument, or the
cooing of the wood-pigeon. This last sound is sometimes so
exactly imitated that one is tempted to think one of these birds
is concealed about the patient's bed. This variety is usually very
partial in its extent. I have often found its site in pulmonary
fistulae, at other times in the bronchial tubes preternaturally dila-
ted. We must not confound this species of rattle with common
snoring, which, as we have already shown, has its seat in the
fauces, and is quite inaudible in the chest.

PULMONARY CATARRH. 233

It is not easy to determine the cause of this phenomenon. The
character of the sound does not indicate the presence of any liquid,
and the examination, after death, of persons exhibiting it, con-
firms the indication. I am led by my dissections to believe that
it is produced by the partial obstruction or narrowing of a part
of the tract of a bronchial tube; whether this takes place from
the pressure of a tumour, or of a portion of the lung condensed
by inflammation, or by the obstruction produced by a portion of
tenacious mucus, or by the partial thickening of the internal coat'
of a bronchial ramification.

The dry sibilous or hissing rattle is also varied in its character.
Sometimes it is like a prolonged whisper of various intonation;
sometimes it is very momentary, and resembles the chirping of
birds, the sound emitted by suddenly separating two portions of
smooth oiled stone, or by the motion of a small valve. These
different kinds often exist together in different parts of the lungs,
or successively in the same part.

The peculiar nature of the sound, and the appearances on dis-
section, prove the sibilous rattle to be owing to minute portions of
very viscid mucus obstructing, more or less completely, the small
bronchial ramifications.

Besides the peculiar sound indicated by the various species of
rattle, there is also to be noticed a slight sense of vibration com-
municated to the cylinder when the seat of the phenomenon hap-
pens to be in the point immediately beneath it, but not otherwise.
When this vibratory sensation can be discovered in no point of
the chest, we may'conclude the rattle has its seat in the central
parts of the lungs. Some of the species of rattle, especially the
mucous and crepitous, cannot be distinguished at the distance of
one or two inches from their site. The other kinds may frequently
be distinguished through the whole extent of the chest, and,
thus, are often combined with the others. The different varieties
of this phenomenon frequently convey to the ear a sensation, as if
it was accompanied by the successive formation and rupture of
bubbles of various sizes, like those made by children from soapy
water. Many of the various images suggested by the different
sensations are very distinct, and may be described as permanent
varieties of the phenomenon. I shall not, however, enter upon
this at present.

The indications afforded in disease, by the exploration of the
various species of rattle, are less numerous, and of much less
importance than those furnished by the voice, and by respiration
in its simple state

30

234 DIAGNOSIS.

The above observations respecting the rattle apply to this ptie
nomenon as observed in the chest, and as tHe cause exists in the
ramificaitons of the bronchia. The same thing is observable over
the trachea in certain cases, as in catarrh and haemoptysis. This
is the only species that can be heard with the naked ear; but the
cylinder detects it often when inaudible to the ear.

In the commencement of pulmonary catarrh, when there merely
exists a slight coryza, almost without cough, and accompanied
6nly by a sligh' irritation in the throat, the cylinder announces a
rattle which is often very loud. This is usually of a sonorous
but dull character, and sometimes hissing. Its site is indicated
by the sort of vibratory sensation formerly noticed. When very
loud, we can hear it at a distance from its site; but here it is more
feeble, and unaccompanied by the vibratory movement.

I am led to believe that the rattle is more grave and sonorous,
in'proportion as the mucous membrane is much swollen, and the
secretion of mucus is small. In proportion as the disease ad-
vances and* the mucous secretion increases, the rattle gradually
assumes the character of guggling or mucous formerly described.

When the pulmonary catarrh is partial, as is usually the case,
the rattle is confined to the part affected. The danger of the
disease, and the severity of the general symptoms, are always
proportioned to the extent of the local affection. When the rat-
tle is heard over the whole of one lung, or in the greater part of
both, the case is always severe. If the disease is acute, it is then
attended by a violent fever; if chronic, there are orthopnea and
prostration of strength, — and these symptoms are more severe in
proportion as the patient is advanced in life. When the rattle
extends over the whole of both lungs (which is only the case
when there is violent fever), the disease is almost always fatal,
except when the patient is very young.

One of 'he" most remarkable phenomena in the pulmonary ca-
tarrh, is the occasional suspension of respiration in the affected part.
This circumstance, which may be considered as pathognomonic
of the disease, often supervenes all at once, and passes off in the
same manner, after coughing or expectoration. Its cause is ob-
viously the obstruction of a bronchial tube by the contained mu-
cus. In such cases, sometimes the respiration is not entirely lost^
but only so far lessened as to be barely audible.

This suspension of respiration must not mislead the observer to
confound this with other diseases. In the present affection, per-
cussion of the chest produces a distinct sound, — a circumstance
suthcient to distinguish it from peripneumony, and pleurisy with

PULMONARY CATARRH. 235

effusion into the chest. In pneumothorax and emphysema of the
lungs, the same absence of the sound of respiration and the dis-
tinct sound on percussion exist, as in these cases of catarrh. But
in the former disease (pneumo- thorax), all the other symptoms are
so different, that there can be no risk of confounding the two
affections. In the latter disease (emphysema), the very same in-
dications are furnished by auscultation and percussion, as in the
pulmonary catarrh; but, in this case, sure means of discrimina-
tion are furnished by the general symptoms. Pulmonary catarrh,
of sufficient severity to produce suspension of respiration in a
large part of the chest, is a severe acute disease, accompanied by
fever, strong and frequent cough, and copious expectoration;
while emphysema is a chronic affection, whose almost only symp-
tom is the impeded respiration.

Chronic Catarrh. In the former part of this work (page 77)
I have adverted to the difficulty of distinguishing this disease
from phthisis pulmonalis. In fact the most perfect similitude
exists between the two diseases, in as far as regards the expec-
toration, the emaciation, and all the other general symptoms.

Percussion gives no assistance in the diagnosis; since, in most
cases, the chest sounds quite well in consumptive patients. The
indications afforded by the stethoscope are much more to be de-
pended on. In such cases, if, upon properly examining a pa-
tient, (viz. at different times, and for a certain length of time,)
we find neither pectoriloquism, nor the guggling produced by
softened tubercles (see page 226); nor the tracheal respiration of
tuberculous excavations (see page 225); nor the permanent ab-
sence of respiration in certain places (from tuberculous engorge-
ments of some extent, see page 220); — and if the respiration is
perceptible over the whole chest, we have a strong presumption
that the disease is merely chronic catarrh; and if the same re-
sults uniformly present themselves after an attendance of some
time (say two or three months), our presumption is converted
into certainty.

With regard to the diagnosis of the different varieties of
catarrh, I shall only here observe, that in chronic catarrh the
rattle is rarely continuous, and si ill more rarely general over the
chest; and that, further, the sound of respiration is scarcely ever
suspended as in the acute disease.

In the pituitous catarrh the rattle is usually extremely sibilous
and sonorous, frequently resembling the chirping of birds, the
sound of a bass string, and sometimes the cooing of the wood-
pigeon in a slight degree.

236 DIAGNOSIS.

The pathognomonic signs of the Dry Catarrh are the same as
those of emphysema of the lungs (see Emphysema), a disease
which its existence for a short time necessarily produces.

Often in cases of chronic catarrh the respiration acquires the
character of puerile. In such cases the dyspnoea is greater than
usual, and the disease is usually called Asthma. In many cases,
however, of dyspnoea, which might properly be called nervous
(nervous asthma), I have observed the respiration quite natural; in
others, I have observed it with the puerile character.

DILATATION OF THE BRONCHIA.

(Part I. Page 79.)

From the time that I had ascertained the dependence of the
phenomenon of pectoriloquism on the reverberation of the voice,
in an excavation situated amid the pulmonary tissue, and that the
same thing was observable on the larynx and trachea, I had no
doubt but the lesion in question would give the same result.
Owing to the infrequency of this affection of the lungs, I have
only as yet verified my conjecture in a single case. A woman,
aged 50, died of a disease unconnected with the thoracic viscera.
She had been for several years affected with an habitual expec-
toration, and had before her death exhibited the phenomenon of
pectoriloquism, in a very evident manner, about the third rib on
the right side. On examination, we found in the part of lung
corresponding to this point, two bronchial tubes dilated to three
times their natural size, and one of them terminating in a cul-de-
sac sufficient to contain a small filbert.

We may regard it as certain, that, in the case of partial or gen-
eral dilatation of the bronchia, pectoriloquism will be found to
correspond to the extent of the organic affection. I am also
confident that in such case, the character of the voice, and the
sound of respiration, will be such as to indicate that the pheno-
menon does not arise from an ulcerous cavity; but as I have not
yet had an opportunity of verifying this conjecture, I shall not
here dwell upon the subject.

EMPHYSEMA OF THE LUNGS. 237

EMPHYSEMA OF THE LUNGS.

(Part I. Page 82.)

The general symptoms of this affection are rather equivocal.
Dyspnoea being its most striking feature, it is one of the diseases
usually confounded under the name of asthma. In it the respira-
tion is habitually impeded, but is aggravated by occasional pa-
roxysms which are quite irregular in their return and duration.
Like dyspnoea from any other cause, it is further increased by the
usual causes, such as indigestion, mental emotion, elevated situa-
tion, violent exercise, especially that of mounting, &c. It is
unaccompanied by any fever, and the pulse is, for the most part,
regular. When the affection exists in a high degree, the skin
assumes a dirty aspect, with a bluish tint in some places, especial-
ly the lips. In all the cases I have seen there was a slight de-
gree of habitual cough, with a very slight mucous expectoration.
The complaint often exists from childhood, and does not seem
materially to abridge the duration of life. Like other dyspnoeas
it frequently, in the end, gives rise to hypertrophia or dilatation
of the heart.

When this disease occupies only one side, or exists much more
in one lung than the other, this side is evidently enlarged, and the
intercostal spaces wider. It also yields a more distinct sound on
percussion. When both sides are equally affected, the chest
yields a very distinct sound throughout, and presents a more round-
ed outline, both before and behind, than is natural in the sound
state of that cavity.

The pathognomonic sign of this disease is furnished by a com-
parison of the indications derived from percussion and ausculta-
tion. The respiratory murmur is inaudible over the greater part
of the chest, and is very feeble in the parts where it is audible:
at the same time a very distinct sound is produced by percussion.
If the disease is not very severe, the sound of the respiration is
still audible, but in a much less degree than the sound on percus-
sion would lead us to expect. There is also heard, in the affect-
ed parts, an occasional slight sibilous rattle.

238 DIAGNOSIS.

This single circumstance — of the absence of the noise of res-
piration in a chest, which sounds well on percussion, — is sufficient
to distinguish emphysema of the lungs from any other disease of
the chest except pulmonary catarrh and pneumo-thorax. We
have already made some remarks on the distinction between the
former disease and empysema; and may repeat, that the general
symptoms are sufficient to enable any one to discriminate them.
The means of distinguishing emphysema from pneumo-thorax will
be noticed under the account of the latter disease.

It is difficult to account for the absence of the sound of respi-
ration, in a disease which consists essentially in dilatation of the
air-cells, and in which, consequently, there exists more air than is
usual in the lungs. The fact is, probably, accounted for by the
temporary obstruction of the bronchia by the increased mucous
secretion which usually accompanies this disease, and by the par-
tial compression of the air-cells by those dilated. This supposi-
tion is corroborated by the fact, that persons affected with this dis-
ease have their breath much oppressed, in the first instance, when
they chance to catch cold; while the respiration improves imme-
diately after the expectoration commences, and even becomes
better than before the catarrhal affection.

(EDEMA OF THE LUNGS.

(Part I. Page 92.)

The symptoms of this affection are extremely equivocal. Imped-
ed respiration, slight cough, and a watery expectoration are the
only signs of it. Percussion affords no useful indication. The
stethoscope furnishes two means of diagnosis, but even these are
less satisfactory than in most other diseases of the lungs. These
are, 1st, the much less degree of distinctness of the respiratory
murmur than might be expected from 1 he efforts used in this action,
and from the great dilatation of the chest with which it is accom-
panied; and, 2nd, a slight crepitous rattle like that in the first
degree of peripneumony, but fainter. Indeed, the cylinder is not

ACCIDENTAL PRODUCTIONS. 239

sufficient of itself, without reference to the general symptoms, to
distinguish the last mentioned disease from oedema.

There is another case in which it is almost impossible to ascertain
the existence of oedema of the lungs, and that is, where it is
complicated with emphysema of that organ. The indications of
the stethoscope will, in this case, merely point to the emphysema;
while, should the patient die, the examination of the body is likely
to lead us into an error on the other side, the emphysematous con-
dition of the lung being obscured by the serous infiltration of the
air-cells*

The same difficulty of ascertaining the true character of the lung
exists, in a still greater degree, in the case of peripneumony super-
vening to the emphysema.

With regard to this last complication, I may here remark,
though somewhat out of place, that, on the living subject, the
cylinder and percussion in the first degree of peripneumonic affec-
tion, will only recognise the emphysema; and, in the second or
third varieties, will only recognise the peripneumonic affection.
This is true of the complication when seen only after it is formed;
if the patient had been seen previously to the supervention of the
peripneumony, percussion of the chest would have demonstrated
the existence of the emphysema and the invasion of the peripneu-
mony.

ACCIDENTAL PRODUCTIONS

(Part I. Page 99.)

Whatever be the nature of these bodies, the symptoms attend-
ing them are almost always the same, and consist, for the most
part, only of a degree of dyspnoea proportioned to the sjze of
tumour; and cough, varying in degree and in the extent and nature
of the accompanying expectoration The most deleterious pro-
ductions, even, such as the medullary tumour, sometimes attain a
considerable size, and produce death by suffocation without pre-

* In this case we must pass a ligature round a portion of the lung and
dry it, when the true character of the part will be evident.

-240 DIAGNOSIS.

viously giving rise to marked derangement of functions.- Tubercles,
more than any of the others, produce general effects on the system.
Yet, even in the case of them, these effects rarely supervene until
long after their formation, and, indeed, not until after the period
of their solution.

When an accidental production has attained- a large size, for
example that of an egg, the cylinder will indicate its presence by
the absence of respiration in the part. But when the tumours are
small, and the lung sound in the intervals, the respiration, as
indicated by the cylinder, is not at all affected. 1 have often ob-
served the respiration equally distinct on both sides of the chest,
in persons in whom it was found, after death, that one lung was
sound, or merely containing a few very small tubercles; and the
other filled with tubercles; from the size of a millet-seed to that
of a filbert, and in such quantity as to give to this lung double or
triple the weight of a healthy one. When, in such cases, the
intermediate portions of lung are engorged with any species of
matter, respiration of course ceases in them; and percussion yields
a dull sound.

In the case of cyst noticed in page 101, and in the hydatid
described in case 27, page 103, the cylinder must have detected
their existence, and in the latter perhaps, might have led to, and
justified the performance of, an operation for the relief of the
patient. At all events the employment of the cylinder must afford
more chance of ascertaining the character of such affections, than
any other means we yet possess.

Osseous Concretions. The cylinder gives no assistance in as-
certaining the existence of these.

Melanosis. When melanotic tumours soften so as to leave a
cavity, they will give rise to pectoriloquism; and when this matter
impregnates a portion of the lung, to the extent noticed in page
111, the cylinder will indicate the impermeability of the lung to
air, but will not enable us to discriminate the affection from perip-
neumony.

Medullary Tumour. During the greater part of the existence
of this species of tumour in the lungs, there is no sensible degree
of fever, and death arrives without any perceptible alteration of
the pulse. Emaciation may be very long in taking place, but it
always does s.o, and is rapid in its progress, towards the termi-
nation of the disease. The cylinder will point out their presence.
as that of other tumours, when they are of a certain size.

PLEURISY. 241

PLEURISY

(Part I. Page 122.)

A well-marked acute pleurisy is, for the most part, easily re-
cognised. The stitch in the side, dyspnoea, fever, and dry cough,
or cough accompanied only by glairy and almost colourless sputa,
are often sufficient to afford a moral assurance of its existence,
and to do away all necessity of other more precise means of diag-
nosis. But it is not uncommon to meet with pleurisies, even acute,
in which many of these symptoms are wanting; whilst many chro-
nic pleurisies are often so indistinctly characterised, and accom-
panied by so many functional anomalies, that it is frequently not
till after several weeks, or even months, that the true nature of
the disease comes to be suspected.

Percussion points out the disease with much more certainty.
As soon as the effusion takes place, the resonance of the chest
fails over the whole of its site. This failure, indeed, may arise
equally from peripneumony: but the nature of the general symp-
toms, more particularly the character of the expectoration, and
the absence or presence of the stitch of the side, will tend to fix
the distinction.

Mediate auscultation furnishes us with much more certain
means of discriminating these two diseases, and enables us to as-
certain with precision, not merely the existence of the effusion,
but its quantity. The signs by which the cylinder effects this,
are, 1st, the total absence, or great diminution, of the respiratory
murmur; and, 2nd, the appearance, disappearance, and return of
the sound which I have named Hwgophonism.

When, as is often the case, the pleuritic effusion is very copious
from its very commencement, the sound of respiration is then
totally absent through the whole of the side affected, except in a
space of three fingers' breadth along the vertebral column. This
complete disappearance of respiration after the existence of disease
for a few hours, is quite pathognomonic of pleurisy with copious
effusion.

In peripneumony, the disappearance of the respiration is gra

31

242 DIAGNOSIS.

dual, and is perceived to be unequal in different parts of the chest,
being often not lost in the upper part till after some days or weeks;
it is, further, preceded for twenty-four or thirty-six hours by a
crepitous rattle (see page 228) quite characteristic In pleurisy,
on the contrary, the loss of the respiratory murmur is sudden,
equable, uniform, and so complete, that.no effort of inspiration
can render it perceptible. The continuance of the respiration
along the spinal column is an equally constant sign. This exists
equally in the chronic disease, attended with the most copious ef-
fusion. It is explained by the compression of the lungs back-
wards towards their roots.*

These copious and sudden effusions occur chiefly in old persons,
or in adults of weak and cachectic habits. The sudden cessation
of the respiration in such cases, must, therefore, be considered as
affording a very bad prognostic; as we may be assured that the
conversion of the false membranes into cellular substance, and
the absorption of the effusion, will take place either not at all, or
imperfectly, and the disease will soon pass into the chronic state.
In children, and persons of strong constitution, the effusion
scarcely ever takes place so rapidly and suddenly; and the respi-
ration does not finally disappear till after one or more days. When
the effusion is considerable the respiration becomes puerile in the
sound side.

When the effusion begins to diminish, by absorption, this is first
observable by the augmented intensity of the respiratory murmur
along the side of the spine, where it had never quite disappeared.
Shortly after, it is perceptible in the anterior superior part of the
chest, and top of the shoulder, and in a few days it returns in the
other parts of the chest. Wherever there are adhesions between
the lungs and pleura, of any considerable extent, the respiration
continues audible over them in a greater or less degree throughout
the whole period of the effusion; and the commencement of the
absorption is perceived by the augmented intensity of sound in
these places.

The return of the respiratory sound is much more slow in
pleurisy than peripneumony. Sometimes it is weeks, and even
months, after'tbe reappearance of it near the clavicle, before it is
perceptible in the inferior parts of the chest; and, often, for

* In some rare cases the respiration continues to be audible immediately
under the clavicle, owing' to close adhesions existing in that part, between
the lungs and pleura.

PLEURISY, 24S

months after the convalescence of a patient, it is only one-half so
distinct in the affected side as in the sound one.

To these signs 1 have to add another, already noticed, and
which appears quite characteristic of this disease when accom-
panied by a middling degree of effusion: — I mean Hxgophonism,
or Caprine Pectoriloquism This phenomenon has a great analo-
gy to pectoriloquism, and I for a long time confounded it with the
latter, considering it as a modification depending on some pecu-
liarity of shape or situation of the tuberculous excavations. It is,
however, quite distinct from pectoriloquism, and depends on quite
a different cause, as has just been stated. Haegophonism resem-
bles pectoriloquism in consisting, like it, of a strong resonance of
the voice under the cylinder. Very rarely, however, in haego-
phonism does the voice seem to enter the tube, and scarcely ever
does it completely traverse it, as in perfect pectoriloquism. The
voice seems, further, to be more acute, and as it were argentine,
than the natural voice of the individual, and exhibits the illusion
as if some one were speaking within the cavity of the chest. It
has, moreover, another character so constant as to lead me to
derive from it the appellation of the phenomenon, — I mean a
trembling or bleating sound like the voice of a goat, a character
which becomes the more striking as the key of it approaches that
of this animal's voice. It also sometimes resembles the sound of
the human voice transmitted through a cleft reed, or the nasal
intonations of the juggler speaking in the character of Punch.
This species of bleating is most commonly combined with the ar-
ticulation of the words, as heard within the chest; sometimes it
seems to be contemporaneous with the articulation, but not arising
from the same point; and sometimes it seems rather to succeed,
than accompany the pronunciation of the words.*

I am of opinion that this phenomenon only exists in cases of
pleurisy (acute or chronic) attended by a pretty large effusion into
the pleura; or in cases of other liquids effused in the same pro-
portion. It has uniformly appeared to me that haegophonism has
decreased gradually with the absorption of the effused fluid. In
acute pleurisies I have found it sometimes to continue only a few
days; while, in the chronic disease, I have known it to continue,
with variable intensity, for several months. I have further ob-

* To hear this sound properly we must apply the cylinder strongly to the
patient's chest, and place the ear gently on the other end. If the latter is
forcibly applied, the bleating sound is diminished one half, and the phenn
menon approaches nearer to common pectoriloquism

244 DIAGNOSIS.

served that when the effusion has become very abundant, — espe-
cially when so great as to cause evident dilatation of the chest, —
this phenomenon has ceased; and I have never met with it in old
cases of Empyema, in which the lungs were compressed towards
the mediastinum. In cases where it was absent, it has sometimes
appeared, on the absorption (as it seemed to me) of a certain por-
tion of the effusion.

Haegophonism further differs from pectoriloquism in being ex-
tended over a considerable space. Most commonly it is perceived,
at the same time, in the whole space between the scapula and
spine, around the inferior angle of the former bone, and in a zone
three fingers broad, stretching from the middle of the scapula to
the sternum. I consider this phenomenon to be owing to the na-
tural resonance of the voice in the bronchial tubes rendered more
distinct by the compression of the pulmonary tissue, and by its
transmission through the medium of a thin layer of fluid. The
respiration is always very perceptible in the points where haegopho-
nism exists.

1 think there are only two cases of Pleurisy in which this
phenomenon will not be observed: These are, (1) where a very
rapid and copious effusion has suddenly compressed the lung
against the mediastinum; and (2) where a former attack of the
same disease has firmly attached the posterior parts of the lung to
the pleura.

From the preceding observations I think we are entitled to
conclude that haegophonism is a favourable sign in pleurisy, as it
seems uniformly to indicate a moderate degree of effusion. Its
continuance for some time is a favourable omen, as showing that
the effusion does not increase; if it continues as long as the fever,
or longer, we may be assured that the disease will not become
chronic, as this never happens except when the effusion is ex-
tremely abundant.

I am of opinion that simple peripneumony is never accompanied
by this sign: but it does not prevent it from being perceptible,
when there is pleuritic effusion, even though it has arrived at the
degree of hepatization.

Haegophonism, like pectoriloquism, is sometimes suspended for
a longer or shorter time, reappearing after the patient has coughed
or expectorated. The cause of this suspension is, doubtless, the
same in both, namely, the temporary obstruction of the bronchia
by the sputa. In the site of this phenomenon the respiration is
frequently found to be of the kind already described where the
patient seems to inspire through the tube of the cylinder.

PLEURISY. 245

Contraction of the Chest. Those kinds of pleurisy which ter-
minate by the production of false membranes of a fibro-cartilagi-
nous character, are often extremely obscure, being very variable in
their symptoms, and very irregular in their progress. Very fre-
quently there is nothing in their commencement which resembles
the acute disease, and it is to them especially that the term latent
Pleurisy can be applied. The stitch of the side is infrequent
and transient, and often so slight as not to be mentioned by the
patient unless questioned respecting it. Someiimes the dyspnoea
is very slight, and the cough is infrequent and dry; at other times,
especially in asthmatic patients, and those subject to catarrhal
seizures, there is well marked dyspnoea, and a plentiful expectora-
tion. In these last, however, the symptoms rather indicate catarrh
or asthma, than pleurisy. In some cases the symptoms are quite
anomalous, and entirely mislead our attention from the chest. In
all such doubtful cases mediate auscultation and percussion offer
the only means for detecting the true nature of the disease, by the
absence of the usual sound on percussion, and the absence of the
respiratory murmur every where except at the root of the lungs.*

In the less severe cases of this nature, and when the contrac-
tion of the chest is not very considerable, after the complete con-
version of the false membranes into cartilage, the murmur of res-
piration returns in a slight degree in the affected side, but still con-
tinues less than in the sound one. This circumstance points out
the period of this conversion, and consequently the final cure of
this variety of pleurisy. In the patient, from whom Plates VI.
and VII. were designed, it was not until two years and half, to
reckon from the invasion of the disease, or a year and half, to
reckon from the period of his convalescence, that respiration began
to be perceptible in the upper parts of the chest. Sometimes the
respiration returns completely in the superior parts of the chest,
while it is entirely absent in the inferior.

Circumscribed Pleurisy. The absence of respiration in the af-
fected part is the only sign by which the cylinder can indicate the
circumscribed pleurisy; consequently it cannot distinguish it from
an extensive tumour in the lungs, or from chronic peripneumony.
The difficulty, however, will, in general, be removed by attending
to the history and general symptoms of the disease.

As the Hippocratic Succussion of the chest affords no indication
of the simple pleurisy, I shall not notice it in this place. We shall

* For an account of Mensuration of the Chest as a diagnostic sign in certain
cases of both the acute and chronic pleurisy, see Part First.

246 DIAGNOSIS.

afterwards find it described, and its importance proved, when we
come to treat of the diagnosis of those liquid effusions into the
ch«st which are complicated with gaseous fluids. — See Pneumo-
thorax.

HYDROTHORAX.

(Part I. Page 151.)

The chief and almost sole symptom of this disease is impeded
respiration. Percussion elicits the dull sound, and the cylinder
detects the absence of respiraiion over the whole chest, except at
the root of the lungs. I should expect that haegophonism must also
be sometimes present. The nature of the general symptoms and
the progress of the disease can alone distinguish it from chronic
pleurisy.

H^MA-THORAX.

(Part I. Page 155.)

The cylinder and percussion afford the same indications in this
ease as in the effusion of pleurisy.

ACCIDENTAL PRODUCTIONS.

(Part I. Page 156.)

Extensive tumours may be distinguished from the effusion of
pleurisy and hydrothorax by the very gradual and progressive

PNEUMOTHORAX. 247

diminution of the sound of respiration in the former; and from
peripneumony, by the absence of the crepitous rattle which we
have mentioned as pathognomonic of this affection in its first
degree.

Intestinal Hernia in the thorax will be readily distinguished, not
merely by the absence of respiration in the site of the tumour, but
by the existence of borborygmi in a situation superior to the region
of the stomach.

PNEUMOTHORAX.

(Part I. Page 159.)

The general symptoms of this affection are very obscure. Per-
cussion, by itself, tends but little to remove the obscurity, or even
misleads us. When the gaseous effusion is very considerable, the
diseased side yields a more distinct sound than the sound one, and
may thus induce us to apprehend disease in the latter. Dilatation
of the chest is, also, little to be depended on as a diagnostic sign;
its existence together with an increase of sound on percussion, will
be apt to lead us to fancy that the lesser volume of the other is
owing to a contraction of the latter. In proof of the uncertainty
of all these signs I may mention, that out of several cases that
occurred, during my attendance at the clinical lectures of M. Cor-
visart, not one was recognised before death.

The certain diagnosis of this affection is afforded by the com-
parison of the results of percussion and mediate auscultation.
Whenever we find one side of the chest sounding more distinctly
than the other, and, at the same lime, perceive the respiration
very well in the least sonorous side and not at all on the other, —
we may be assured that there exists pneumothorax on the latter.
We may be equally sure of our diagnosis when both sides are
alike sonorous, and even although the affected side were less
sonorous than the sound one. This latter case occurs when the
pneumo-thorax supervenes to pleuritic effusion, or any other fluid
extravasation. Here, before the supervention of the pneumo-
thorax, the affected side yielded a perfectly dull sound, and the
respiration was either entirely absent, or was heard very indis-
tinctly. As soon as the gas begins to accumulate, the resonance

248 DIAGNOSIS.

of the chest returns, in some degree, in the situation occupied by
the air, without, however, being as distinct as in the sound side.
Day by day, the extent and intensity of ihis resonance increase,
without any return of the sound of respiration; and if there had
previously been any remains of the respiratory murmur, even this
now totally vanishes.

There is only one circumstance which can render the diagnosis
difficult in such cases: this is, the case of the lung being attach-
ed to the side bv means of a very short cellular tissue; in the.
point of adhesion the respiration will be still audible. It is
hardly necessary to observe, that, in pneumo-thorax, as in pleurisy
and hydrothorax, some degree of respiration will be still percepti-
ble in that part of the back corresponding to the roots of the
lungs.

The only other disease which presents any signs analogous to
the above is emphysema of the lungs. The differences, however,
between the two diseases are so striking that none but a very
inattentive observer could be mistaken: These differences are
chiefly the following: In pneumo-thorax, the absence of the re-
spiratory sound is complete, except in the point between the
scapula and spine corresponding to the roots of the lungs; in
emphysema, therespiratory sound is never completely inaudible;
in the latter there is a slight rattle, and never in the former:
pneumo-thorax comes on rapidly, and cannot continue long with-
out giving rise to dangerous symptoms, or even proving fatal;
emphysema comes on slowly and is never so severe as to confine
the patient to bed or incapacitate him for his ordinary occupations.
I never saw a patient with pneumo-thorax that was not in bed.

These indications exist in every case of pneumo-thorax; but
when it is accompanied by an effusion of fluid, there is observed
an absence both of resonance on percussion, and of respiration,
in the parts occupied by the fluid; and an absence of the res-
piration only, in the parts occupied by the gaseous accumula-
tion.

The precise diagnosis of pneumo-thorax, and its existing in a
simple state or complicated with liquid effusion, is not a merely
speculative subject. It is extremely probable, as Hewson* and
Rullierf have imagined, that the simple pneumo-thorax is the
case which offers most chance of success to the operation of
empyema, or rather, of simple puncture of the thorax. This
opinion is strengthened by the assertion of Riolan, that he had

* Med. Obs. & Inq. vol. 3. \ Diet, des Sc. Med. Art. E-mpyemr

PNEUMO-THORAX. 249

met with several cases wherein air alone had escaped from the
chest on its being punctured.*

The stethoscope furnishes still another and very important sign
for the diagnosis of this affection, which has been more than once
alluded to already, and which I shall now explain more particu-
larly; — I allude to the phenomenon which I have named Metal-
lic Tinkling.

This phenomenon consists of a peculiar sound which bears a
striking resemblance to that emitted by a cup of metal, glass, or
porcelain, when gently struck with a pin, or into which a grain
of sand is dropped. This sound does not at all depend on the
nature of the materials of which the stethoscope is composed:
it is perceived during respiration, speaking, and coughing; but is
much more perceptible during the two latter than the former.
The reverse of this is, however, sometimes the case. It is, in
general, heard in a most striking manner, during cough; and
when in any degree doubtful, this action ought to be performed:
It may exist either with or without pectoriloquism.

This phenomenon only exists in that variety of the pneumo-
thorax complicated with empyema, and which communicates
with the bronchia by means of a fistulous opening, as has been de-
scribed in Part First; and it may be considered as the pathogno-
monic sign of this triple lesion. This peculiar sound seems
caused by the agitation of the air confined between the surface of
the puriform fluid and the solid parietes. The sound is in general
distinct in proportion to the size of the fistula communicating
with the bronchia; and, also, in proportion to the volume of gas
contained in the cavity of the chest.

When the tinkling originates in a large tuberculous excavation
in the lung, half-filled by purulent matter, it is less intense, and
its vibrations are confined to a small space; it, also, seems to
penetrate the tube of the cylinder, and is conjoined with pecto-
riloquism. All these peculiarities will distinguish this case from
pneumo-thorax, setting aside the little resemblance that exists be-
tween the general symptoms of the two complaints. I have only
observed the metallic tinkling four times in tuberculous excava-
tions.

There exists still another means of ascertaining the existence,
during life, of the pneumo-thorax complicated with purulent ef-
fusion, which I have also several times alluded to in the first part
of this work — I mean the exciting the sound of fluctuation by

* Enchirid. Anat.

32

250 DIAGNOSIS

the succussion of the chest. This method was practised by
Hippocrates, or his disciples, and is described by the author of
the treatise DeMorbis in the following words: "After having
placed the patient in a solid chair that will not vacillate, cause
his hands to be extended by an assistant, and hen shake him by
the shoulder, in order that you may hear on which side the disease
will occasion noise." Although this method is described in a
work not unanimously auributed to Hippocrates, there can be
little douhl of its having been known to him. Several passages
in the Hippocratic writings cither speak of it formally, or allude
to it; and it is uniformly represented as a certain test of empy-
ema. The incorrectness of this representation, doubtless, has
been the cause of the practice being abandoned by practical men,
and never had recourse to even by the commentators of Hippo-
crates. The authors of treatises of Surgery have, indeed, men-
tioned it, but doubtfully, and rather out of respect for Hippo-
crates than for any other reason. I am unacquainted with any
author who says he himself had tried the method in question.
A few mention the phenomenon as having been observed in cer-
tain cases during the spontaneous movement of the chest. Mor-
gagni observed this once, and has collected four other instances
of the same fact mentioned by preceding authors (Epist. xvi.}.
A similar case is mentioned by Ambrose Pare.* None of these
observers appear to have tried if artificial commotion of the chest,
in these cases, would produce the phenomenon; and Morgagni
and Fanton even attempt to prove that the practice can be of no
bciii fit as a means of diagnosis.

This opinion is, indeed, correct as far as it regards the simple
liquid extravasation, as in hydrothorax, and empyema uncompli-
cated wiih pneumo-thorax In this complication, however, the
fluctuation of the liquid is distinctly heard on shaking the patient
in the manner of Hippocrates. Sometimes, also, but much more
rarely, the motion of the patfent in bed, or in walking, gives rise
to it, so as to be heard both by him and the bystanders.

Morgagni has expressed an opinion that this succussion might
be dangerous. This, however, is totally unfounded. When pro-
perl) used, it is not more fatiguing to the patient than the percus-
sion of the chest, or the examination of the abdomen by compres-
sing its contents. To enable us to hear the sound it is not neces-
sary to shake the body much; all that is required being merely to
shake the shoulder pretty quickly and to stop all at once. In

* CEuvres, liv. viii. ch. x.

PNEUMO-THORAX. 251

several of the cases detailed in Part First, this means was suc-
cessfully used as a test of this peculiar complication of disease.
(See Cases 34, 36, 37, 38). In some instances the sound of
fluctuation will be perceived by the cylinder when inaudible by
the unassisted ear.

252 OF THE HEART.

OF THE HEART,

OF THE ACTION OF THE HEART IN GENERAL, IN HEALTH
AND DISEASE.

Before entering upon the diagnostic signs furnished by the
stethoscope in particular diseases of the heart, it will be necessary
to examine the general results afforded by it, as well in the sound
as diseased state of that organ. I shall do this under four prin-
cipal heads, viz. 1st, the extent of the heart's action, as ascer-
tained by the cylinder; 2nd, the.shock or impulse communicated;
3rd, the nature and intensity of the sound; and, 4th, the rythm of
its actions.

/. Of the extent of the Pulsation of the Heart.

This must be considered in two points of view: — first, the sen-
sation conveyed by the instrument when applied to the region ot
the heart; and, secondly, the parts of the chest (other than this
region) in which its action can be perceived.

1. In the natural condition of the organ, the heart, examined
between the cartilages of the fifth and sixth ribs, and at the lower end
of the sternum, communicates, by its motions, a sensation as if it
corresponded evidently with a small point of the thoracic parietes,
not larger than that occupied by the end of the stethoscope.
Sometimes, it appears as if it were placed deep in the mediasti-
nal cavity, leaving a vacant space between it and the sternum: in
this case its movements, even when pretty energetic, appear to
communicate no vibratory impulse to the neighbouring parts. In
other cases, again, the heart seems entirely to fill the cavity of the
mediastinum, and to extend much beyond the point on which the
instrument rests; and, in this case, its contractions, even when

EXTENT OF PULSATION. 253

slow and noiseless, seem to elevate, to a considerable extent,
the thoracic parieies before them, and to displace the adjacent
viscera within. This difference of sensation seems, in a word, to
convey the impression of the action of a smaller or a larger heart;
and, generally speaking, this indication is sufficiently correct,
when the organ is examined in the state of quietude which results
simply from repose of body.

2. The second point is of more practical importance. In a
healthy person, of moderate fulness, and whose heart is well propor-
tioned, the pulsation of this organ is only perceived in the cardiac
region, that is, in the space comprised between the cartilages of
the fifth and seventh ribs, and under the lower end of the sternum.
The motions of the left cavities of the heart are chiefly percepti-
ble in the former position, those of the right cavities in the latter.
This is so much the case, that, in disease of one side of the heart
only, the pulsation in these two situations gives quite different re-
sults. When the sternum is short, the pulsations extend to the
epigastrium. In very fat subjects, the pulsation of whose hearts
is quite imperceptible to the mere touch, the space in which it can
be detected by the cylinder is sometimes not more than an inch
square. In thin persons, in the narrow-chested, and, also, in
children, the pulsation is more extended; being perceptible over
the lower third, or even three-fourths, of the sternum, and some-
times even over the whole of this bone; also at the superior part
of the left side, as high as the clavicle, and sometimes, though
feebly, under the right clavicle.

When the pulsations are confined to the places above mention-
ed, in subjects of the kind noticed, and when they are much
weaker below the clavicles than in the region of the heart, we
may conclude that this viscus is well proportioned.

When the pulsations of the heart become more extended, they
are heard successively in the following places: — 1st, the whole
left side of the chest, from the axilla' to the stomach; 2nd, the
whole of the right side; 3rd, the posterior part of the left side of
the chest; and, 4th, the posterior part of the right side. This last
is rare. In these cases the intensity of the sound is progressively
less in the succession mentioned. This succession has appeared
to be constant, and may be taken as an index of the extent of pul-
sation. For instance, if this be perceptible on the right side, we
may be assured that it will be equally so over the whole sternum
under both clavicles, and over the left side; but we are not sure
that it will be so on the back. But if it be perceptible on the back

254 OF THE HEART.

on the right side, we may calculate on its being still more audible
in every other part of the chest.

Several circumstances -unconnected with the state of the heart
may derange the order above mentioned, and augment the extent
of the pulsation. This latter effect is produced by a hepatized or
compressed lung, and also by a part containing tuberculous excava-
tions. In every case the heart gives two distinct pulsations for one
beat of the arterial pulse. In my examinations of several hundred
individuals, I have only met with one in whom the pulsation of the
subclavian arteries could be heard by the stethoscope; and I may
state it is an almost universal fact, that neither the pulsation of this
artery, nor of the aorta, can be mistaken for that of the heart.

When the pulsation of the heart is heard over a greater extent
than what is above stated to be the range of a well proportioned
organ, the individual rarely enjoys good health. If he has not
formal dyspnoea, he has, at least, shorter breath than usual, is put
more easily out of breath, and is more subjec to palpitation. This
state, however, which is that of many asthmatics, may remain
stationary many years, and does not always prevent the attainment
of an advanced age.

With regard to the relation between the state of the heart and
the extent of its pulsation, I think it may be taken as a general
fact, that the extent of pulsation is in the direct ratio of the thin-
ness and weakness of the heart, and consequently, inversely as its
thickness and strength. The size of the organ must also be con-
sidered as affecting the extent of its pulsation.

In explanation of what has been just stated, we may presume,
when the pulsation extends over all the places above mentioned,
that the heart is increased beyond the natural size, and that this
increase is owing to the dilatation of one or both ventricles. This
presumption will be strenghthened, if the pulsation is as great un-
der the clavicles or in the axilla, as in the region of the heart. If
the pulsation is perceived neither in the back nor right side, but
only in the other points mentioned, and if its intensity is nearly
equal in all these, we may conclude that the ventricles are mode-
rately dilated, and that the parietes of the heart are naturally thin.
On the contrary, when there is very strong pulsation in the region
of the heart, and none or very little under the clavicle, we may
be assured (if the patient has other general symptoms of diseased
heart) that the disease is hypertrophia of the ventricles. If the
patient has never experienced any marked disorder of the circula-
tory organs, we may be certain that the parietes of the left ventri-

IMPULSE ON THE EAR. 255

cle are much thickened, though still not sufficient to constitute
disease.

Generally speaking, then, it may be taken for granted that a
great extent of pulsation is a mark of thin parietes of the heart,
more particularly of the ventricles; and that a confined range of
pulsation coincides with an increased thickness of these. Some
accidental causes may augment for a time the extent of the heart's
pulsation, such as nervous agitation, fever, palpitation, haemoptysis,
and, in general, whatever increases the frequency of the pulse.

//. Of the Impulse communicated to the Ear by the Action of the

Heart.

In investigating this we must be careful not to confound with the
action of the heart, the rise of the thoracic parietes during inspi-
ration. This caution is more particularly necessary when the res-
piration is very short and frequent.

The degree of impulse communicated by the cylinder to the
ear, is, in general, inversely as the extent of the pulsation of the
heart, and directly as the thickness of the walls of the ventricles.
In a person whose organs of circulation are well proportioned, this
impulse is very little perceptible, often quite imperceptible, espe-
cially if the individual is rather fat. When the parietes of the
heart are unnaturally thick, the impulse is usually so great as very
sensibly to elevate the head of the observer, and sometimes to give
a disagreeable shock to the ear. The more intense the hypertro-
phia, the longer lime the impulse is perceptible. When the dis-
ease exists in a high degree, we feel as if the heart, in dilating,
first comes in contact with the thoracic parietes in one point only,
and then with its whole surface, and that it contracts and falls back
all at once. The impulse of the heart is only felt during Ihe sys-
tole of the ventricles; or if, in some rare cases, an analogous phe-
nomenon accompanies the contraction of the auricles, this is easily
distinguished from the former. In fact, when the systole of the
auricles is attended by any sensible action, this is perceived to have
its seat much deeper; and most commonly it consists merely of a
sort of vibration. In any case, it is very little marked as compar-
ed with the sensation produced by the contraction of the ventricles,
when these are of a good degree of thickness..

When the parietes of the heart are thinner than usual, no im-
pulse is communicated, even when the pulsation is the greatest;
and, in this case, the alternate contraction of its cavities is only

256 0F THE HEART.

distinguished by the sound these produce. A strong impulse,
therefore, must be regarded as the chief sign of hyperlrophia; and
the absence of all impulse as the characteristic of dilatation of
the heart. The correctness and constancy of this result have
been confirmed to me by many examples.

The impulse of the heart's action is usually perceptible only
over the region of the heart, or, at most, over the inferior half of
the sternum. When very great, it exiends to the epigastrium in
cases where the sternum is short. In simple hyperlrophia it is
usually perceived in no other part; but when this is conjoined
with a certain degree of dilatation, it is sometimes distinctly per-
ceived under the clavicles, and in the right side of the chest.
The impulse of the heart's action is, of course, diminished by
tvhatever debilitates the general strength of the system.

///. Of the Sound produced by the Action of the Heart.

The alternate contraction of the different parts of the heart
produces a peculiar sound, of which the individual is himself
sensible during palpitation and in fever. In certain states of
disease it can be heard at some distance from the patient; but this
is a very rare case. The sound is the only phenomenon usually
observable in any other part of the chest beside the precordial;
the impulse of its action being confined, as already observed, to
that part.

The sound produced by the action of the heart is great in pro-
portion as the parietes of the ventricles are thin and their impulse
fcehle: consequently, it cannot be attributed to the percussion of
this organ against the side. In a moderate degree of hypertro-
phia, the contraction of the ventricles yields only a dull sound,
like the murmur of inspiration, and the auricle, in like manner,
a much less noise than in the natural state. In a high degree of
hypertrophia, the contraction of the ventricles produces merely a
shock without any sound, and the sound of the auricles is scarcely
audible. On the other hand, when the ventricular parietes are
thin, the noise produced by their contraction is clear and loud,
approaching to that of the auricles; and if there be a marked
dilatation of the ventricles, the sound becomes very similar, and
almost as strong as that of the auricles.

In the state of health the sound of the contractions of the heart
is no where heard so strongly as in the region of the heart. In

RYTHM OF PULSATION. 257

certain states of disease it may be heard more distinctly in other
places.

The softening of the substance of the heart deadens the sound
of its contractions; as does also any impediment of the circulation,
whether caused by too much blood, or by an obstacle in the auri-
culo-ventricular orifices This latter state, further, gives rise io a
dull rustling sound, very like the noise of bellows, or (when
stronger) like that produced by the action of a file on wood. The
particular orifice affected is, in this case, indicated by the place
and time in which the sound is observed. When the orifice is
on the left side, we can sometimes feel with the hand a sort of
vibratory sensation like that produced bi the purring of a cat.
In this case, the noise produced by the contraction of the cavity
having the obstructed orifice is not only duller, but much more
prolonged than in the natural state.

IV. Of the Rythm of the Pulsations of the Heart.

By rythm I understand the order of the contractions of differ-
ent parts of the heart, and their relative duration and succession,
as detected by the cylinder. Before entering on this subject I
think it necessary to notice the relative proportions of the heart
to the body of the individual, and of the different parts of the
heart to each other, in a state of health, and in a well propor-
tioned subject.

The heart, including the auricles, ought to be of a size equal
to the closed hand of the subject, or only a little less or greater
than it. The walls of the left ventricle ought to be of a thick-
ness somewhat more than double that of the right. The texture
of the left ventricle, firmer and more compact than that of the
muscles, ought to keep it from collapsing when laid open. The
right ventricle ought to be a little larger than die left, with colum-
nar carneae of grt-ater size, and ought to collapse on being cut
into. In a heart so proportioned, the alternate contractions of the
ventricles and auricles, as examined by the cylinder, and the
pulse as examined by the finger, afford the following results: —

At the moment of the arterial pulse, the ear is slightly elevated
by an isochronous motion of the heart, which is accompanied by
a somewhat dull, though distinct sound. This is (he contraction
of the ventricles. Immediately after, and without any interval,
a noise resembling that of a valve, or a whip, or the lapping of a
dog, announces the contraction of the auricles. (I make use of

33

258 OF THB HEART.

these trivial expressions because Hhey appear to me to express,
better than any description, the nature of the sound in question.)
This noise is accompanied by no motion perceptible by the ear,
and is separated by no interval of repose from the duller sound
and motion indicative of the contraction of. the ventricles, which
it seems, as it were, to interrupt abruptly. The duration of this
sound, and consequently the period of contraction of the auricles,
is less than that of the ventricles, — an incontestible fact of which
Haller entertained doubts. Immediately after the systole of the
auricles there is a very short, yet well-marked interval of repose,
subsequently to which we feci the ventricles swell anew, with the
dull sound and gradual progression which characterise their action;
then follows the quick and sonorous contraction of the auricles,
and again the renewed but momentary immobility of the heart.
This slate of quietude after the contraction of ihe auricles does
not appear to have been known to Haller as a natural condition.
The relative duration of the contractions of the auricles and ven-
tricles, appears to me to be as follows: Dividing the whole into
four parts, a fourth (or third) belongs to the systole of the auricles,
a fourth (or somewhat less) to the state of quiescence, and two-
fourths to the systole of the ventricles. — These observations are
most conveniently made when the pulse is slow.

From the foregoing observations it appears that the heart, far
from being in a state of constant action, as is usually supposed,
presents alternations of action and repose, the sum of which does .
not differ from those of many other muscles, more especially the
diaphragm and intercostal muscles. From the proportions above
slated it follows that in twenty-four hours the ventricles have
twelve, and the auricles eighteen hours of quiescence. In persons
whose pulse is habitually below 50, the repose of the ventricles
is more than sixteen hours in the four-and-twenty.

Hypertrophia of the ventricles, when in a moderate degree,
presents, in some respects, an exaggeration of the natural rythm
of the heart's actions. The contraction of the ventricles becomes
less noisy, and more readily distinguishable from that of the auri-
cles. After the latter, the interval of quiescence is well-marked,
and contrasts very sensibly with the sound that precedes, and the
motion which follows it. But in hypertrophia carried to a very
nign degree the rythm of the heart is singularly changed.

In this case, the contraction of the ventricles is greatly pro-
loDged. This at first is perceived as a profound and obscure
motion, which gradually augments, elevates the applied ear, and
Mien terminates in producing the impulse or shock- This con-

RYTHM OF PULSATION. 259

traction is unaccompanied by any noise, or, if this exists, it is
merely a sort of murmur like that of respiration.

The contraction of the auricles is extremely short, and almost,
or altogether, without sgund; and in some cases the systole of the
ventricles seems scarcely over before they begin to swell afresh.

In extreme cases there is no sound distinguishable but the
murmur above mentioned, and we merely recognise an elevation
of the heart corresponding to each beat of the pulse. In these
cases the increased brevity of the auricular contraction is not the
consequence of their diminished conlractibility merely, but, also,
of their contraction commencing before that of the ventricles has
entirely ceased.

When the walls of the left ventricle are naturally thin, or have
become so from dilatation, the rythm of the heart's actions is
quite different. In this case, the interval of repose after the con-
traction of the auricles is no longer perceptible. The contraction
of the ventricles is more sonorous, more resembling that of the
auricles, and more approaching the latter in duration. In this
condition of the heart, there is, as already observed, a less degree
of impulse during the contraction of the ventricles, and a greater
extent in the pulsation of the heart. This condition of the organ
of circulation is congenital in many cases. It does not necessa-
rily abridge life, but is usually conjoined with a delicate consti-
tution.

Actual dilatation of the heart produces merely an increase of
all the characters which indicate a heart with thin parietes. The
contraction of the ventricles becomes as short and noisy as that
of the auricles; the pulse, consequently, becomes very frequent;
and the isochronism of the arterial pulse and the contraction of
the ventricles becomes quite indistinguishable. In addition to
these signs we must add — the absence of any sensible impulse;
the extension of the heart's pulsation over the whole or greater
part of the chest; and the existence of this in as great force under
the clavicles and the axilla as in the region of the heart itself.
This last character, particularly, may be regarded as pathogno-
monic, if the patient is not phthisical and pectoriloquous in the
places mentioned.

260 P* THE HEAH'I

V. Of Palpitation of the Heart.

By palpitation of the heart is meant, in the common language
of medicine, every beating of the heart which is sensible and un-
pleasant to the individual, and, at the same time, more frequent
than naiural. When this affection is studied by the aid of the
cylinder, we find that there are many varieties of it, all of which
appear to have merely this one character in common, viz. that
the individual is sensible of the heart's action. Frequently, also,
the patient hears the pulsation, especially when in the horizontal
pos tire. In the upright position, 'he contraction of the veuiricles
only is heard; while, when lying on the side, the individual is
sensible of a pulsation of his ear double that of the pulse, viz.
the alternate contraction of both the ventricles and auricles. In
many cases (lure is merely an increased frequency of pulsation,
although the patient imagines, from his sensations, that tin re is
a.rso great increase of force. This species of palpitation is most
common in dilatation of the ventricles, and lasts the longest of
any. I have known it continue eight days; the pulse remain-
ing, through the whole of this time, extremely small and weak,
and between 1.60 and 180.

Another variety consists in an increase both of frequency and
force of pulsation This is what arises in healthy persons from
great exertion or from moral causes; it also accompanies slight
degrees of hvpertrophia. In simple bypertrophia in a high degree,
the ventricles are found to contract will) great force, and to elevate
the thoracic parietes in an extent and to a height much greater
than natural. The noise, however, produced by their contraction
is much duller and more indistinct than usual; the extent of tho-
rax over which the pulsation is perceptible is not increased; and,
notwithstanding the increase of the heart's power to double or
triple its ordinary force, the pulse is, almost always, two or three
times more feeble and smaller than in the natural condition of the
circulation. In hypertrophia with dilatation, the impulse, noise,
and extent of the heart's action, are usually equally increased.

INTERMISSION OF PULSATION. 261

VI. Of Irregularity of the Heart's Action.

Irregularity in the pulsation of the heart may exist without
palpitation In old persons this is often met with without any
perceptible alteration of the general health. The irregularity
which occurs in palpitation consists usually in mere variations in
the frequency of the heart's pulsation. Sometimes this variation
is almost constantly recurring; at other times it is at longer inter-
vals, and consists only of a few contractions longer or shorter
than the rest. These irregularis occur most frequently in cases
of dilatation.

In hypertrophia, and during the existence of palpitation, the
contractions of the ventricles are so quick, and so much prolong-
ed, that those of the auricles cannot be perceived. It sometimes,
though very rarely, happens during palpitation, that each contrac-
tion of the ventricles is followed by several successive contrac-
tions of the auricles, so quick as only to equal in point of time
one ordinary contraction. Sometimes these contractions are two
or four, .but most frequently three.

VII. Intermission of the Pulsation of the Heart.

By intermission, we usually understand a sudden and momen-
tary suspension of the pulse, during which the artery is no longer
perceptible beneath the finger. The duration of the intermission
is very variable, and may serve to divide this affection into well-
marked varieties. Sometimes the intermission is shorter than
one arterial pulsation; sometimes it is equal; and sometimes it is
longer.

The first kind of intermission is the most common; it is fre-
quent in old age, even during health. At other periods of life,
it is only observed in certain diseased states of the heart, parti-
cularly hypertrophia. By means of the stethoscope we ascertain
that this species of intermission always succeeds the contraction
of the auricles. It, therefore, only differs /rom the natural qui-
escence after this contraction, in the irregularity of its recurrence.
The duration and recurrence of this species of suspension of the

£62 °F THE HEART.

heart's action are very variable. This, the real intermission,
must be distinguished from the false intermission, already noticed,
produced by the variation of the duration and strength of the
heart's contractions. This can easily be done by the cylinder.
The species of intermission which consists in the absence of one
complete pulsation, returning sometimes with an exact periodicity
at longer or shorter intervals, constitutes the sign deemed by
Solano indicative of the approach of critical diarrhoea. The
third variety is accompanied by a state of fulness of the artery
during its continuance.

Many considerations, some of which have been stated, prove
that the mere examination of the pulse is insufficient to inform us
of the true state of the circulation; and must often lead us into
error. — To notice only the indications afforded by it as to blood-
letting, to prognosis in all diseases, and to diagnosis in several: —

We have seen, that, in rleripneumony and pleurisy, the absence
of fever and a perfectly natural state of the pulse, frequently
accompany an incurable disease. In diseases of the heart, the
pulse is often feeble, sometimes even almost imperceptible, al-
though the heart's contraction, that especially of the left ventri-
cle, is much more energetic than natural. In apoplexy, on the
contrary, we often meet wish a very strong pulse in persons in
whom the impulse of the heart's action is scarcely observable.
These two opposite facts may easily "be verified by the use of
the cylinder; I have myself done so, perhaps pore than a thou-
sand times, within the last three years. They appear quite in-
explicable, unless we admit the arteries to possess a power of
action independent of that of the heart.

It would seem to be proved, also, by many other facts, that the
different systems subservient to the circulation, although neces-
sarily and reciprocally dependent, have still, in other respects, a
particular or individual existence, which, in certain states of dis-
ease and in certain individuals, is more marked and isolated than
in ordinary cases and circumstances. This view of the case is
supported by the observations of practitioners, in all ages, of the
different effects of bleeding, according as it is general or local,
venous or arterial, depletive or derivative. The same is shown by
the great benefit of a natural hemorrhage of a few ounces only,
and the inefficacy of copious venesection in the same case; and
by the trifling degree of exhaustion produced sometimes by very
profuse hemorrhage, campared with die great collapse occasioned
by the bleeding of a few leeches in the same person. These
facts prove, I think, that the capillary circulation is in some sort

INTERMISSION OP PULSATION. 263

independent of the general. The influence of the latter on the
former seems very inconsiderable indeed in certain hemorrhages
trom the uterus, bowels, nose or lungs, which are found to be
very little affected by the most copious venesection.

The mere state of the pulse, (hen, is far from indicating the
state ol the circulation in general; it does not even certainly in-
dicate its condition in the whole heart, as it merely corresponds
with the contraction of the left ventricle, which may be regular
at the tune when that of the auricles and right ventricle is irre-
gular. In like manner, the state of the pulse fails to be a sure
guide as to the expediency of blood-letting. Every one knows
that in certain cases, for instance in apoplexy, peripneurnony,
pleurisy, and inflammatory affections of the abdomen, the weak-
ness and smailness of the pulse do not always contra-indicate
venesection; on the contrary, that the arterv, in such cases, re-
covers its force and fulness after the loss of blood- The recog-
nition of this kind of pulse {fictitie debtiis) is one of the most
important and difficult points in the treatment of the acute dis-
eases, as an error in respect of it may be fatal. In cases of this
sort, the stethoscope affords a rule much surer than the pulse.
Whenever the contraction of the ventricles is energetic we may
bleed without fear— the pulse will rise; but if the contractions
of the heart are feeble, although the pulse still retains a certain
degree of strength, we must be cautious respecting the employ-
ment of venesection. When the pulse is very strong, and the
contractions of the heart moderately strong (as is frequently the
case in apoplexy), we may still bleed with advantage as long as
there is not a marked diminution in the noise and impulse of the
heart's actions. But when both the pulse and the heart are fee-
ble, we must not open a vein, whatever be the name or the seat
of the disease, as such practice must infallibly destroy the few
resources still left to nature. The most we can do, in such a case
if there be any local congestion, is, to try, by the application of a'
{ew leeches, if the patient can bear the subtraction of blood
from the capillaries.

The certainty and facility with which the cylinder indicates the
propriety of blood-letting in such cases as those above mentioned
(which have been hitherto considered among the most difficult in
practical medicine,) appears to me to be the greatest advantage
to be derived from the employment of this instrument.

After what has been said, and after its general uncertainty
ivowed by the most experienced practitioners, it may seen) sur-
prising that the practice of feeling the pulse has been so generally

264 DIAGNOSIS.

followed in all ages. The reason of the practice is, however,
sufficiently ohvious: it is of easy performance, and gives liitle in-
convenience either to the physician or patient; the cleverest, it is
true, can derive from it but a few indications and uncertain con-
jectures; but the most ignorant can, without exposing themselves,
deduce from it all sorts of indications. lis very uncertainty gives
it a preference with persons of inferior qualifications, over means
quite certain in (heir nature, and which enable the non- professional
observer to judge of the skill of the physician by the correctness
of his diagnosis and prognosis.

The fads above stated relative to the discordance existing be-
tween the pulsation of the heart and of the arteries, — more espe-
cially as to strength, are contrary to the more general opinion of
modern physiologists, who consider the action of the arteries as
entirely dependent on that of the heart. Bichat himself has fallen
into this error.*

OF SYMPTOMS COMMON TO ALL THE DIS-
EASES OF THE HEART.

These are — an habitually short and difficult respiration; pal-
pitations and oppression constantly produced by the action of as-
cending, by quick walking, by emotions of mind, — or without any
perceptible cause; frightful dreams, and sleep frequently disturbed
by sudden starts; a cachectic paleness and a tendency to anasarca,
which, indeed, comes on after the disease has persisted some time.
To these symptoms is frequently added the angina pectoris, — a
nervous affection characterised by a sense of oppression, constric-
tion and oppression in the region of the heart, and a pain or numb-
ness of the arm, more commonly of the left, sometimes of both at
once. When the disease has reached a high degree it is recognised
at a single glance. The patient, unable to bear the horizontal
posture, remains night and day seated in his bed, with the face
nv^re or less swollen, sometimes very pale, but more commonly of
a li;ep violet tint, either over the whole or only on the cheeks.
The lips are swollen and prominent, of a deeper violet than the

* Anat. Gener. Ire part. torn. II. page 371.

DISEASES OP THE HEART. 265

rest of the face, or of this hue when it is quite pale. The whole
body is more or less anasarcous. The congestion and lentor of
the capillary circulation are further shown by affections of the in-
ternal organs; for instance — haemoptysis, pains of the stomach,
vomiting, apoplexy (which frequently terminates such affections),
and most of all, dyspnoea, which last symptom has been the cause
of confounding such diseases (with many others) under the name
of JlsLhma. Emphysema of the lungs likewise bears much resem-
blance to some varieties of disease of the heart, but the following
marks will distinguish them from each other.

In disease of the heart, the patient, although with the respiration
habitually short, does not usually experience the feeling of oppres-
sion and dyspnoea, except when walking rather quick, or using
much exertion, or, more particularly, when ascending an elevation.

On the other hand, the individuals affected with emphysema,
become oppressed on the breath when they are quite still: and
these attacks recur without any known cause, or from a slight
change of the weather. Moderate exercise seems often- to re-
lieve them, if the disease has not reached a great degree of in-
tensity.

In diseases of the heart the general circulation is not always so
much affected as the capillary. Sometimes the pulse is almost
natural, but is often irregular. — At all events, it is evident that none
of the general symptoms already mentioned suffice to characterise
disease of the heart; and that for a certain diagnosis we must recur
to mediate auscultation. It is necessary here to remark that the
study of the physiological conditions of the heart, by means of
the cylinder, requires much more time and application than that
of the voice and respiration. In hospital practice, also, owing to
our general ignorance of the anterior history of patients, we are
liable to be led into error by its use, without proper care. For
example, we may, in some cases, consider a patient as labouring
under hypertrophia or dilatation of the heart, when he is merely
affected with nervous palpitations. Another, and more insidious
cause of mistake, arises in diseases which diminish the extent of
respiration; for instance, peripneumony, emphysema, and more
particularly chronic pleurisy. In cases of this kind I have some-
times found the heart enormously dilated and thickened after death,
although, during life, its contractions had been perfectly natural
in respect of sound, impulse and rythm. It would seem as if the
diminished capacity of the lungs produced a diminished action of
the heart. The fact here alluded to was observable in cases 6, 19,

34

266 DIAGNOSIS.

21, and 23. Cases of this kind are, however, rare, even in an
hospital; in private practice, the previous history of the disease will
generally prevent us from being misled.

HYPERTROPHIA OF THE LEFT VENTRICLE.

(Part I. Page 165.)

It is to this variety of the disease, especially, that the symptoms
attributed by M. Corvisart to active aneurism of the heart, must be
referred. These are, — a strong full pulse, strong and obvious pul-
sation of the heart, absence or diminution of the sound afforded by
percussion on the region of the heart, and a tint of complexion
rather red than violet. None of these symptoms,' however, are con-
stant; and it is not uncommon to find the disease in persons who
have none of them. The pulse, in particular, is very deceptive,
being almost as frequently weak as strong, in such cases.

The cylinder furnishes signs which are much more constant
and positive. The contraction of the left ventricle, examined
between the cartilages of the fifth and sixth ribs, gives a very
strong impulse, and is accompanied by a duller sound than natural;
it is more prolonged in portion as the thickening is more consider-
able. The contraction of the auricle is very short, productive of
little sound, and, consequently, scarcely perceptible in extreme
cases. The pulsation of the heart is confined to a small extent,
being, in general, scarcely perceptible under the left clavicle, or
at the top of the sternum; sometimes it is confined to the point
between the cartilages of the fifth and seventh ribs. In this disease
the patient experiences, more constantly than in any other, the
sensation of the action of the heart; but he is less subject to
violent attacks of palpitation, except from accidental causes, such
as moral affections and violent bodily exertion. In this case,
during the palpitations, irregularity and intermission of she pulse
are uncommon: there is rather increase of the power of the ventri-
cles than of the noise produced by their action.

HYPERTROPHIA OP THE VENTRICLES. 267

HYPERTROPHIA OF THE RIGHT VENTRICLE.

(Part I. Page 165.)

According to M. Corvisart, the symptoms are the same as when
the disease is on the other side, only that the respiration is more
oppressed, and the colour of the face is deeper. Lancisi has men-
tioned the swelling of the external jugular veins, with a pulsation
analogous to that of an artery, as a sign of the aneurism of the
right ventricle. M. Corvisart has rejected this symptom, because,
he says, " it has been found in cases where the left side of the
heart was dilated, and because the pulsation may be confounded
with that of the carotids." In this opinion I differ from M. Cor-
visart. I have uniformly found this symptom in every case of this
kind, of any degree of severity; and I have never met with it in
hypertrophia of the left ventricle unless there existed, at the same
time, a similar affection of the right I think a very little atten-
tion must distinguish this pulsation from that of the carotids. I
would, therefore, be disposed to regard this symptom as one which
ought to lead us to suspect the existence of the thickening of the
right ventricle.

The contractions of the heart, as explored by the cylinder, give
the same results nearly, whether the hypertrophia be on the right
or leftside; only, in the former case, the shock of the heart's ac-
tion is greater at the bottom of the sternum than between the car-
tilages of the ribs, which is the reverse of what happens when
the disease is in the left side of the organ. In most men, in health,
the heart is heard equally in both these places; and I am disposed
to believe, when heard better below the sternum, we may suspect
an incipient hypertrophia or dilatation of the right ventricle.
When both ventricles are affected, the symptoms of both coexist,
only those of the right side are almost always more marked.

363 6IAGNOSIS,

DILATATION OF THE LEFT VENTRICLE.

(Part I. Page 167.)

The symptoms of this affection, according to M. Corvisart, are
— " a soft and weak pulse, and feeble palpitations: — the hand ap-
plied to the region of the heart feels as if a soft body elevated
the ribs, and did not strike these with a sharp and distinct stroke."

The only certain sign of the existence of this disease is that
given by the stethoscope, viz. the clear and sonorous contractions
of the heart between the cartilages of the fifth and seventh ribs.
The degree of distinctness of the sound, and its extent over the
chest, are the measure of the dilatation: thus, — when the sound
of the contraction of the ventricle is as clear as that of the con-
traction of the auricle, and if it is, at the same time, perceptible
on the right side of the back, the dilatation is extreme.

DILATATION OF THE RIGHT VENTRICLE.

(Part I. Page 167.)

According to M. Corvisart the stale of the pulse and the pul-
sation of the heart, are very nearly the same as in dilatation of
the left ventricle, only that the action of the heart is heard some-
what better towards the bottom of the sternum than in the region
of the heart. More certain symptoms he considers to be — a
greater degree of oppression, more marked serous diathesis, more
frequent haemoptysis, and a more livid state of the countenance,
- — than in the affection of the left ventricle. With regard to the
swollen state of the jugulars without pulsation, which M. Corvi-
sart considers of little importance, I am disposed to look upon it
as the most constant and characteristic of the equivocal signs of
this affection. The only constant and truly pathognomonic symp-

DILATATION OF THE VENTRICLES. 269

torn, however, is the loud sound of the heart perceived at the bot-
tom of ihe sternum, and between the cartilages of the fifth and
seventh ribs of the right side. The degree of dilatation is mea-
sured by the extent of the action of the heart over the chest. The
palpitations which accompany this affection consist, principally,
in an increase of the frequency and sound of the contractions,
while, at the same time, the impulse of the heart's action is fre-
quently feebler than in the ordinary state of the patient.

DILATATION WITH HYPERTROPHIA OF THE
VENTRICLES.

(Part I. Page 167.)

In this case there is a combination of the symptoms of the two
affections. The contractions of the ventricles yield at the same
time a strong impulse and a very marked sound, and they are felt
widely over the chest. When palpitation is present, the hand ap-
plied to the region of the heart is forcibly raised. Even in the
absence of palpitation, if we observe the patient, we find his head,
limbs, and even his bed-clothes shaken at each contraction of the
heart. The beating of the arteries is often visible.

270 DIAGNOSIS.

DILATATION OF ONE OF THE VENTRICLES WITH
HYPERTROPHIA OF THE OTHER.

(Part I. Page 168.)

The signs of this complication are — a mixture of those com-
mon to each affection, with predominance of those belonging to
the one of greater intensity. They are to be discovered by com-
paring the two sides of the heart together. In this case, however,
the indications of the cylinder must be taken in conjunction with
those of the general symptoms of disease, else we shall be led
into error.

DILATATION OF THE AURICLES.

(Part I. Page 168.)

The symptoms of this affection are obscure: M. Corvisart does
not distinguish them from those of the corresponding ventricle.
I have not myself had yet sufficient experience of the use of the
stethoscope in this affection, to speak confidently on the subject.
I think, however, there can be little doubt that the signs afforded
by it must be confounded with those arising from the disease of
the ventricles, or of the valves, of which the auricular affection is
the consequence.

Of partial dilatation of the heart, and of the induration of its
substance, 1 have nothing to say in this place.

CARDITIS. 211

SOFTENING OF THE HEART

(Part I. Page 171.)

Cases of total softening of the heart are usually accompanied
by a certain degree of cachexy, even when the individuals are
otherwise in tolerable health. When such subjects are attacked
with dilatation or hypertrophia of the heart, as almost always
happens, they do not present the usual swollen and livid state of
the face observable in other cases of this sort.

When softening exists along with dilatation of the ventricles,
the sound produced by the contraction of these cavities, although
loud, is yet dull, and without the clearness which attends com-
mon dilatation. When it is complicated with hypertrophia, the
sound of the contraction of the ventricles is so obtuse as to be
nearly inaudible; and in extreme cases, the impulse of the heart
is attended by no noise whatever.

CARDITIS.

(Part I. Page 177.)

In the present state of our knowledge it is impossible to ascer
tain the existence of either an abscess or ulcer of the heart.

272 DIAGNOSIS.

CARTILAGINOUS AND BONY INDURATION OF THE
VALVES OF THE HEART.

(Part I. Page 180.)

The symptoms of ossification of llie mitral valve are somewhat
different from those attending ihe same affection of (he sigmoid.
According to M. Corvisart the principal sign of the former les<on
is " a peculiar rustling sensation, perceived on the application of
the hand to the region of the heart." I have often noticed this
symptom, which is very readily recognised after being once per-
ceived, although it is difficult to give a description of it The
nearest idea I can give of it is by comparing it to the purring of
a cat when pleased. The same sort of quality is said, by M.
Corvisart, to exist in the pulse, which, he adds, is weak, but with-
out hardness or fulness. To these symptoms may be added those
characteristics of hypertrophia and dilatation of the left auricle
and whole right side of the heart, which usually follow the affec-
tion of the valve.

I must confess that I have never perceived the peculiar charac-
ter of the pulse described by M. Corvisart; and that I have fre-
quently found wanting the peculiar vibration in the region of the
heart in cases of undoubted disease of the valves. I believe the
latter sensation is only perceptible by the hand when the contrac-
tion of the orifice is very considerable. In ossification of the
sigmoid valves, several signs deduced from the state of the circu-
lation are given by M Corvisart, but the whole may be reduced
to the purring sensation above mentioned.

Since I have used the cylinder I have only met with three cases
of ossification of the mitral valve accompanied by the purring
sensation; and only four cases of the same affection of the sigmoid
in a slight degree, and unattended by the purring. In comparing
these, however, with the numerous cases I had before studied, I
thijik I can give the following results, if not correct, as, at least,
approaching to correctness.

Ossification of the mitral and sigmoid valves does not produce
irregularity of the circulation, and cannot therefore be suspected
from the state of the pulse, or by the application of the hand to

PEMCARD1TIS. 273

the region of the heart, unless it is so considerable as materially
to lessen the orifices of the left ventricle Iu ossification of the
mitral valve, in a middling degree, the sound which attends the
contraction of the auricle becomes much more prolonged, more
dull, and with something in its tone which reminds one of the
rasping of a file on wood, and sometimes of a bellows smartly
compressed. This sourn^ is well-marked when the purring is not
perceptible to the hand, but it is much more distinct when this is
perceptible, and is, indeed, proportional to its intensity.

The ossification of the sigmoid valves of the aorta is shewn by
the existence of this sound during the contraction of the ventricle;
but this does not exist in slight degrees of the affection, nor in a
similar condition of the mitral.

In these cases, as in dilatation and hypertrophia, the alternate
examination of the heart under the. sternum and between the car-
tilages of the fifth and seventh ribs, as well as the state of the
external jugulars, will always enable us to decide in which side of
the heart the disease exists.

PERICARDITIS

(Part I. Page 197.)

1. Jlcute Pericarditis. There are few diseases attended by
more variable symptoms, or of more difficult diagnosis, than this.
Sometimes it appears with all the symptoms of a very violent
disease of the chest; at other times it proves fatal without leading
us, in the least, to suspect its existence. Again, we find cases
marked by all the symptoms usually attributed by nosologists to
this disease, and in the subjects of which, after death, we discover
no traces of its existence. The same difficulty is acknowledged,
or at least encountered, by most practitioners. Corvisait attributes
the difficulty to the circumstance of pericarditis being almost
" always complicated with pleurisy, peripneumony, or some other
disease of the chest, which masks its peculiar symptoms." Thes**

35

274 DIAGNOSIS.

complications, which are very common, must, unquestionably,
have this effect where they exist; I must, however, confess, that
the most completely latent affections of this kind that I have met
with, were in subjects whose thoracic viscera were, in every other
respect, quite sound, and who had died of disease of the abdo-
men. These facts seem to prove that inflammation of the peri-
cardium is sometimes a local affection of little violence, and of
very inconsiderable influence on the general system or even on the
circulation; while, in other cases, it is accompanied by an acute
fever, and by such violent disorder of almost all the functions, as
to compromise the life of the patient.

M. Corvisart is likewise of opinion that it is when the disease
is very acute, that the symptoms are very obscure. " Its invasion,"
he says, " is sudden, its progress rapid, its termination almost instan-
taneous." When it exists in a- less violent degree, but still acute,
he thinks that it can be recognised by the following symptoms:'
viz. sense of heat in the region of the heart; great difficulty of
respiration; greater colour of the left cheek than the right; pulse
at first frequent, hard, and rarely irregular,— becoming about the
third or fourth day, small, hard, contracted and often irregular;
great anxiety, slight palpitations; partial faintings; peculiar change
of features; and (towards the close of the disease) total or partial
cessation of the local pain.

These symptoms are certainly sometimes present in pericarditis-
but each, or all of them may be absent, and some of them are
very rare. I have never observed the increased colour of the
cheek, have rarely heard complaints of local heat or pain, and, in
place of the progressive increase of irregularity in the pulse '(as
described by M. Corvisart), I have uniformly found this irregu-
larly intermitting, wiry, and almost insensible, from the very com-
mencement of the disease.

I must admit that the stethoscope scarcely furnishes us with any
more certain signs of this disease. The following appear to me
to be the most common symptoms of the inflammation of the peri-
cardium, when not latent: the contraction of the ventricles yields a
greater shock, and sometimes a more marked sound, than usual,
and, at intervals, feebler and shorter pulsations are perceived'
which correspond with intermissions of the pulse, the smallness
of which contrasts remarkably with the strength of the heart's
pulsation. When these symptoms come on suddenly in a person
who had never been affected with disease of the heart, there is
great probability of their being the consequence of this disease
In addition, it is further common for the patient to have much

HYDUO-PERICARD1UM. 275

dyspnoea and very great anxiety; and to suffer syncope on taking a
few steps, or on moving suddenly in his bed.

2. Chronic Pericarditis. The signs of this variety are still more
uncertain than those of the acute disease. I have attended seve-
ral cases which I considered, throughout their whole course, as
chronic inflammations of the pericardium, but which almost all
were cured. In two or three cases only have I been able to verify
the correctness of my diagnosis by examination after death; whilst
very frequently I have found the pericardium full of pus and in a
true state of chronic inflammation, without having been at all led
to suspect such an affection. In the cases which have occurred
within the last three years, I have found the symptoms to be pre-
cisely the same as in the acute disease, only less violent. From
one to two years has elapsed before a cure has taken place; and
when this has been effected the action of the heart and pulse has
become natural and regular.

HYDRO-PERICARDIUM.

(Part I. Page 201.)

Authors vary respecting the symptoms of this affection. Lan-
cisi states the principal to be a sensation of an enormous weight in
the region of the heart. Reimann and Saxonia assure us that the
patient feels his heart swimming in water. Senac says he has seen
the fluctuation of the fluid between the third, fourth and fifth ribs.
M. Corvisart says he has perceived this fluctuation by the touch,
and adds the following as marks of the affection: — sense of weight
in the region of the heart; inferior resonance on percussion; pul-
sation of the heart irregular and obscure, and felt over a large
space and with variable intensity in the same and different points
of this space; pulse small, frequent and irregular; threatened suf-
focation on lying in the horizontal posture; frequent syncope, but
rarely palpitation; oedema. To these symptoms I may apply the
same remarks as to those of pericarditis: they may exist, in greater
or less number, with or without hydro-pericardium. I am unable

276 DIAGNOSIS.

to say, from experience, how far, and in what respect, the cylinder
will assist the diagnosis of this disease.

ANEURISM OF THE AORTA.

(Part I. Page 204.)

There are few diseases so insidious as this. It cannot be cer-
tainly known till it shows itself externally. It can hardly be
suspected, even when it compresses some important organ and
greatly deranges its functions. When it produces neither of
these effects, the first indication of its existence is often the death
of the individual as instantaneously as if by a pistol-bullet. I have
known men cutoff in this manner, who were believed to be in the
most perfect health, and who had not complained of the slightest
indisposition. We must, therefore, admit that aneurism of the
aorta has no symptoms peculiar to ij:; all those noticed by authors,
and especially by M. Corvisart, being indicative merely of the
change or compression of adjoining organs. This will be evident
by the enumeration of the principal of these; viz. oppression on
the chest, — dissimilarity of the pulse in both arms, — a whizzing
or rushing at the top of the sternum, perceptible by the hand, — ob-
scure sound on percussion, — rattling in the throat, and dragging
downwards of the larynx, when the tumour compresses the
trachea, &c. After what has been said of the symptoms of other
diseases of the chest, I need not remark how very equivocal all
these are. In the present state of our knowledge there certainly
exists no certain means of ascertaining the existence of this disease
until it shows itself externally. And hitherto, my experience has
been insufficient to enable meto say how far this difficulty is likely
to be removed by the use of the stethoscope. Since my employ-
ment of this instrument I have met only with a dozen cases of
what I conceived to be aneurisms of the aorta. Most of these
left the hospital after obtaining relief by blood-letting and proper
diet. In two instances of moderate dilatation of the arch, I was
enabled to verify by dissection my previous diagnosis afforded by
the cylinder; and in a third, which showed itself externally, I was

ANEURISM OF THE AORTA. 271

enabled to verify still further the diagnostic indications. In this
last case, I found the pulsations of the tumour perfectly isochro-
nous with the pulse at the wrist; they gave, at the same time, a
much greater impulse and louder sound than the mere contraction
of the ventricles; and the contraction of the auricles was not at
all perceptible. This pulsation, which I shall call simple, in op-
position to that of the heart, which is double (including the alter-
nate contraction of aurichsand ventricles), was distinctly percep-
tible between the right scapula and the spine. In some cases,
this simple pulsation and greater impulse may indicate the disease,
but I must confess that I have myself bern deceived in three cases
notwithstanding these indications. I would, therefore, say that
even this simple pulsation will not assist us in distinguishing
aneurisms of the arch or ascending aorta from dilatation of the
ventricles.

Another sign, however, will still remain, though less marked than
the simple pulsation above mentioned: it is this. If we find under
the sternum, or below the right clavicle, the impulse of the circu-
latory organ isochronous with the pulse, and perceptibly greater
than that of the ventricles examined in the region of the heart, we
have reason to suspect dilatation of the ascending aorta, or arch, —
the more so, as it is extremely rare to feel the impulse of the organ
of circulation beyond the region of the heart, even in cases of the
most marked hypertrophia.

The whole of my experience on this subject leads me to the
following conclusions: 1st, in several cases aneurisms of the ascend-
ing aorta can be ascertained by the cylinder; 2nd, in other cases,
it requires the greatest attention to distinguish their pulsation from
that of the heart ; 3rd, aneurisms of the pectoral aorta can be re-
cognised, more especially when they have produced injury of the
vertebral ; and 4th, all of them will be often'mistaken,* because
nothing will lead to the examination of the chest, and because
there will often be no sign whatever of ill-health.

END OF PART SECOND,

APPENDIX,

CONTAINING SOME CASES NOT TRANSLATED IN THE BODY

OF THE WORK, AND FULLER DETAILS OF SOME THAT

HAVE BEEN TOO MUCH ABRIDGED.

Case. (No. xxxvi. of the Author, not translated in the body of
the work). Phthisis Pulmonalis. — Tuberculous cavity partly
converted into fistula, producing the metallic tinkling. A woman,
50 years of age, who had been affected with cough and expectora-
tion for several years, and which had got much worse within a
few months past, came to the Hospital on the 13th April, having,
for the first time, been obliged to desist from her ordinary occupa-
tion. She looked much older than she was, and was very thin.
The pulse was quick, skin slightly hot, and the expectoration,
which was in moderate quantity, consisted of thick yellow sputa
intermixed with much transparent ropy mucus.

The stethoscope applied to the anterior and upper part of the
right side, and to the right axilla, detected distinct pectoriloquism;
and, in the same places, when the patient coughed or spoke, and
still more during respiration, there was heard a tinkling, like that
of a small bell which has just stopped ringing, or of a gnat buz-
zing within a porcelain vase. A mucous rattle, or strong guggling,
existed in the same points; and all these phenomena were distinctly
perceptible over the whole space from the top of the shoulder to
the fourth rib, — being, only, more distinct anteriorly and under the
axilla than behind. The murmur of respiration was sufficiently
distinct over the greater part of the chest, except at the roots of
the right lung and the top of the left. The Hippocratic succus-
sion afforded no result. From these various signs I made the fol-
lowing diagnosis: Vast tuberculous cavity occupying the whole of

280 APPENDIX.

the superior lobe of the right lung, and containing a small quantity
of fluid; tubercles, especially at the top of the left and root of the
right lung. Four days after her entry this woman was discharged,
for irregularity. She came into the hospital again in the end of
May, affected with precisely the same symptoms. She died sud-
denly on the 6th of June.

Dissection twenty-four hours after death. On penetrating with
the scalpel between the fourth and fifth ribs of the right side a
small quantity of air escaped.* The lungs on this side were flat-
tened from within outwards towards the ribs, and adhered through-
out to the pleura of the ribs, mediastinum and diaphragm. Above
the sixth rib the adhesion was very close. The upper half of this
lung was occupied by a vast tuberculous cavity, which contained
about two spoonfuls of a purulent fluid. The parietes of this ex-
cavation (except on the lower side) consisted of condensed pul-
monary tissue, surrounded by a thin layer of a fibrous texture like
the lateral ligaments of the joints, which was intimately connect-
ed with the pleura of the ribs and lungs. The cavity was large
enough to contain the hand of the largest man, and branched out
into many anfractuosities. This cavity was crossed at one point
by a band of flaccid pulmonary tissue, pretty healthy, and covered
by the lining membrane of the excavation. Here and there, blood-
vessels of the size of a crow-quill ramified on the interior of this,
some adherent and others 'partially detached, some quite obliterat-
ed, others only partially. A semi- cartilaginous membrane, ex-
tremely uneven and of very variable thickness, lined the cavity
throughout; and this was the only boundary, on the inferior part,
between it and a branch of the pulmonary artery large enough to
admit the little finger. The anterior part of this excavation ter-
minated in a longish cul-de-sac, which was lined by a membrane
entirely cartilaginous, and much thicker than that of the other parts
of it. In cutting this part of the lung from above downwards, we
could trace this cartilaginous lining under the form of a lamina of
cartilage, for more than an inch into the substance of the lung,
beyond the walls of the excavation. This was no doubt the re-
maining cicatrization of a cavity which had communicated with
that which existed at present. Some bronchial tubes that stretched
towards this lamina terminated in culs de sac before reaching it,
still, however, retaining a considerable caliber, and having their
mucous membrane very red and thickened Several other

* This must have come from the excavation which will be immediately
noticed, as the cavity of the pleura was obliterated.

CASES. 281

branches of the bronchia opened into the existing cavity, with their
terminations quite smooth and polished.

The anterior portion of the superior and middle lobes, which
had not been implicated in this destruction, was still crepitous,
and contained, in different parts, small groups of tubercles in
different stages, as did also the lower lobe.

On puncturing the left side of the chest there was an escape
of gas, which must have come from the cavity of the pleura.
There was no effusion in this side of the chest, and the greater
part of the lung was unattached, except at its very upper point.
This was strongly attached to the costal pleura by a very thick,
whitish, fibrous membrane. This covered a sort of cartilaginous
cicatrice in the lung, of two or three lines in thickness, which
surmounted an irregular cavity of the size of a pigeon's egg.
The walls of this were formed by condensed pulmonary substance
and inclosed a small calcareous concretion. The remaining parts
of this lung were pretty sound, only containing some tubercles.

Case. (No. xxxvii. of the Author, not translated in the body
of the work). Phthisis Pulmonalis — Tuberculous excavation
producing ihe metallic tinkling. A women, aged 40, came into
the Hospital 29th January, having been affected with cough for
five months, and which had increased since her confinement, three
months ago. At this time the respiration was short and quick,
and difficult; the chest resounded pretty well in the back and left
side before, — but better on the right side; there was distinct
pectoriloquism near the junction'of the sternum and left clavicle
and the same phenomenon, but less distinct, on the same, side
where the arm joined the chest; the sound of the ventricles was
dull, and the heart gave hardly any impulse. Two days after, by
means of the cylinder, we distinguished a sound resembling
fluctuation, in the left side, when the patient coughed, and the
metallic tinkling when she spoke. Succussion of the trunk did
not produce the sound of fluctuation. From these results the
following diagnostic was given: very large tuberculous excavation
in the middle of the left lung, containing a small quantity of very
liquid tuberculous matter. The patient died five days after this.

Dissection twenty-four hours ajter death. In the right lung through
its whole extent, there were innumerable tubercles of a yellow-
ish white colour, and varying in size from that of a hemp-seed
to a cherry-stone, and even a large filbert. These last were evi-
dently formed by the reunion of several smaller ones. and. for
the most part, were more or less' softened. Besides these >here
were, in other parts, several cavities, the largest of which would

36

282 APPENDIX

have contained a hazel-nut,- completely filled by pus, thicker than
that of an abscess, and lined by a double membrane, the inner
layer of which was white, soft, and little adherent to the other;
the outer was of a cartilaginous character and semitransparenr,
and incomplete in certain points. The left lung adhered closely
to the pleura ot the ribs and pericardium. On its anterior and
lateral part it contained, near its surface, three cavities, one above
the other, and communicating by two large openings. The up-
per, of the size of a pigeon's egg, occupied the top of the lung,
and corresponded to the junction of the clavicle and sternum; the
second might have contained a pullet's egg, and the lowest, which
reached within an inch of the base of the lung, was of the size
of a walnut. These excavations were lined by two membranes,
like those in the right lung, contained a liquid pus, and commu-
nicated with several bronchial tubes. This lung contained also
some smaller cavities and tubercles, and exhibited marks of in-
flammation in several places.

Case 1. Page 44. (No. i. of the Author). Phthisis Pul-
monale. Ulcers of the lungs cured by transformation into semi-
cartilaginous jistuloz, A woman, aged 6b, had been for several
years affected with much cough and expectoration; accompanied
by habitual shortness of breath, greatly aggravated by the least
exercise. In other respects she was pretty well, and was able to
discharge the laborious duties of a servant. She was sufficiently
stout and had good appetite; but her lips and cheeks were of a
violet red colour. On the last day of December she was seized
with fever, very severe dyspnoea, and cough attended by very
viscid frothy sputa, of a pale green colour and semi-opaque. She
was bled, and thereby obtained some relief Four days after
this attack she was removed to the hospital, and presented the
following symptoms on being examined by the stethoscope: —
Respiration was barely perceptible (and was accompanied by a
well-marked rattle in the inferior and left part of the chest) to
the height of about the fourth rib. Percussion elicited a dull
sound over the same extent, especially on the back. The pulsa-
tion of the heart gave no shock, but was perceptible over the
whole anterior and lateral part of the chest, and slightly on the
left side of the back. The contraction of the auricles and ven-
tricles produced a considerable sound, and nearly equally so.
The external jugulars were swollen. The dyspnoea and expec-
toration were as stated above. Qn these data the following
diagnostic was given: Peripneumony of the inferior part of the
left lung: slight dilatation of the ventricles.

cases. 283

Fresh bleedings gave temporary relief; but on the eighth day
the fever increased and was attended by stupor and delirium.
At this time respiration was much more perceptible on the upper
part of the left side than any where else; and naturally led us to
suspect the existence of pecloriloquism there; but the patient
was loo weak to have this tried, and died the following day.

Dissection twenty-four hours after death. The lungs adhered to
the costal pleura, nearly through their whole extent, by means of
well organized cellular substance, evidently of ancient date.
The right lung was crepitous and very sound, exclusive of the
upper lobe, which contained an excavation of the size of a large
filbert. This was lined by a thin smooth, equable membrane,
pearl-grey, and of a semi-cartilaginous nature. Several bron-
chial tubes opened into this, extremely dilated, so as, at first sight,
to look like appendices of the cavity. The mucous bembrane of
some of these tubes was very pale, and that of others red, but
not swollen. The top of the left lung contained a similar cavity,
only larger and more irregularly shaped. It was lined by a
similar membrane, which was continuous with the mucous coat
of a great number of bronchial tubes (large as a crow-quijl)
which opened into it. It contained merely a small portion of
nearly colourless serosity. The substance of the lungs around
these cavities was sound and crepitous; except in the places
where some of the projecting angles came nearly in contact, in
which cases the intervening substance appeared like a compound
of fibro-cartilage and black pulmonary matter. There were no
tubercles whatever in the lungs; but the whole of the inferior
lobes, and the lower portion of the superior, had a consistence
equal to that of liver, which, when cut, exhibited a granulated
surface, and poured out a purulent fluid intermixed with blood.

The heart was somewhat larger than natural, and was filled
with coagula. The right ventricle, in particular, was evidently
enlarged, and both of these were thin, especially the right.

Case 3, Page 45. (No. iii. of the Author). Phthisis Pul-
monalis. Ulcer converted into semi-cartilaginous fistula. A wo-
man, aged 42, had been long subject to much cough, and dysp-
noea, varied by temporary aggravations, especially by certain
states of the weather. These symptoms, which she called Asth-
ma, had not incapacitated her for labour, until the last fifteen days,
at the end of which time she came into hospital. At this time
she could not at aH lie down, — the respiration was very short and
difficult, the lips violet, and there was anasarca of the lower
limbs. The chest yielded, on percussion* a pretty good sound

284 APPENDIX.

throughout, though, perhaps, somewhat less than natural. Inline
diately below the clavicle on each side, the cylinder discovered a
w ell marked rattle. The thoracic parietes were "much and for-
cibly elevated at each inspiration. The cough was very frequent,
and followed by expectoration of opaque yellow sputa. Pectorilo-
quism was not discoverable. The pulse was frequent, small, and
regular; the external jugulars were swelled and distinctly pulsative;
the pulsations of the heart (examined by the stethoscope) were
deep, regular, little sonorous, and without impulse to the ear.
From this examination I thought myself justified in considering
the heart as sound, notwithstanding the contrary indication afford-
ed by the general symptoms; and accordingly gave my diagnos-
tic — Phthisis without- disease oj the heart. A few days after, the
contraction of the ventricles gave some impulse, a symptom which,
taken along with the pulsation of the jugulars, gave reason to
suspect slight hypertrophia of the right ventricle. The symptoms,
especially the anasarca, got gradually worse; and she died on the
19th of February. The day before her death evident pectorilo-
quism was discovered in the anterior third of the fourth intercos-
tal space, on the right side, a point which had not been examined
before.

Dissection. The heart was of a natural size. The right ven-
tricle was perhaps a little thicker than natural; and there was
an ecchymosed spot, the size of the nail, on the inner surface of
the pericardium. There was about a pint of serum in the left
side of the chest, and the lung was attached to the costal pleura,
at its top, by short cellular adhesions. In this point there were
several radiated linear impressions depressed in the point of their
union. These impressions correspond to three or four laminae of
condensed cellular substance traversing the substance of the lung.
In the same place there was a dozen of tubercles in different
stages, and one small excavation of the size of a filbert*, lined by
a soft membrane, and filled by softened tuberculous matter. The
rest of this lung was crepitous and gorged with blood.

The right lung adhered firmly, throughout its whole extent, to
the costal pleura. Immediately opposite the fourth intercostal
space, and at the depth of half an inch, there was a cavity the
size of a walnut. It was lined by a semi-cartilaginous membrane,
of the kind so often already described, and contained a small
portion of a yellowish pus. A bronchial tube opened into this on
the inferior side, of the size of a crow-quill, but partially ob
structed by a small chalky concretion which lay loose in it.
There were seven or eight similar concretions in other parts of

CASES.

185

the lung, two of which, situated immediately under the pleura
were of the size of prune-stones. The lungs were in other re-
spects sound.

Case 4, Page 45. (No. iv. of the Author). Phthisis Pulmo-
nale— cured by the conversion of an ulcerous excavation into a fis-
tula. A lady, aged 48, of a good constitution and healthy, with
the exception of a local disease, until her thirtieth vear, when she
became subject to very severe pulmonary catarrhs, several of
which confined her to bed for two or three months, and produced
considerable emaciation. Subsequently to one of these attacks
she had a diarrhoea, which was at length checked with great diffi-
culty, but her bowels continued lax for several years. After bein<*
long without an attack of catarrh, and in very good health, she
was, in the beginning of 1817, attacked with a distressing cough,
attended by a slighf watery viscid and colourless expectoration. I
saw her in July, at which time she was considerably emaciated,
and, though still able to attend to her occupation, we'ak and lan-
guid. The pulse and skin were not uniformly febrile. Respira-
tion was very perceptible over the whole chest, but less distinctly
at the top of the right lung. From this, and the nature of the
expectoration, I consider her as having tubercles in an early sta^e,
and applied leeches, &c. The symptoms continued nearly The
same throughout the summer and part of the winter. In the end of
February, 1818, the cough became suddenly loose, and the pa-
tient began to have thick yellow puriform expectoration. This
state of the sputa lasted a month, when the cough in a °reat
measure left her and became nearly dry. I did not see the patient
during this attack, which she looked upon as a cold; but I visited
her in the beginning of April, and upon examining her chest I
found most distinct pectoriloquism at the anterior and upper part
of the right side. I was convinced by this that the supposed
catarrh had been the discharge of the softened tuberculous matter.
The sound of respiration was good over the whole chest; and even
in the vicinity of the pectoriloquous spot; the pulse was not fre-
quent and the beat moderate. On this account I entertained hopes
of her recovery, and prescribed ass's milk. The cough and ex-
pectoration progressively lessened, the flesh and strength returned;
and, in the beginning of July my patient had regained every ap-
pearance of the most perfect health, although the pectoriloquism
still continued most distinct, beneath the anterior part of the
second rib on the right side, in a space of about an inch square.

During the succeeding winter this lady had an attack of catarrh,
but it lasted only fifteen days, and was not severe. In other rf--

2$6 APPENDIX.

spects she bore the winter well, and she continues (1819) in
good health, though still pectonloquous in the same degree. Her
pulse is rather slow, and she has little cough and less expectora-
tion.

Case 6, Page 4S. (No. vi. of the Author). Phthisis Pulmo-
nale. Jlncient cicatrice in the lungs in a patient dead of pleurisy
and peritonitis. A man, aged 65, came into hospital on the 29th
of November, affected with slight pulmonary symptoms, chiefly
marked by dyspnoea, to which he had been long subject, and
which he considered as Asthma. Percussion afforded no result,
owing to the excessive fatness of the individual; only the chest
appeared to sound somewhat less below the right clavicle. Res-
piration was inaudible over the whole of the right side, but was
very sonorous on the left. From these results I considered this
person as affected with a latent peripneumony of the right lung.

Five days after this, there was observed slight oedema of the
right side of the chest; and on applying the stethoscope to the
back, respiration was somewhat perceptible along the edge of the
spine on the right side, though less so than on the left. There
was very little cough, and scarcely any expectoration. These
symptoms indicating pleurisy rather than peripneumony, necessa-
rily modified our diagnostics. After a few days the oppression
became less, and we began to hear the sound of respiration, in a
slight degree, below the right clavicle; and haegophonisrn (see
page 243) was perceptible in the same spot for a few days. On
the eleventh the chest sounded still better in this point, and respi-
ration became distinct as in the opposite side, but was not percep-
tible lower than the third rib. It was, also, sufficiently distinct
between the spine and scapula. At this time the patient expecto-
rated some opaque, yellow, puriform sputa. The symptoms con-
tinued much the same until the middle of February, when he died,
apparently from an attack of peritonitis.

Dissection twenty-four hours after death. The cavity of the
right pleura contained about a pint of yellow and somewhat turbid
serum. The lung of the same side adhered to the diaphragm and
posterior part of the chest by a strong, short and well-organized
cellular tissue. On the anterior surface of the lung, there was a
false membrane about the size of the palm of the hand, soft,
opaque, yellowish, of a consistence inferior to that of half-concrete
albumen, and appearing, at first sight, like the matter of thick
puriform sputa. This patch was traversed by numerous blood-
vessels, and adhered to the costal pleura by a lamina of greater
consistence, also very vascular, and approaching more to the

CASES. 287

texture of cellular substance. Above and behind another firm
albuminous crust, yellow and vascular, attached the lungs to the
pleura.

The substance of the lung was sufficiently crepitous in the
upper portions, although somewhat injected with a bloody' serum.
Its lower portions were more compact, of a deeper red, and, in
spots, somewhat granular on incision ; it was also gorged with fluid,
and less creptious than the upper portions.

The left lung adhered to the pleura, at its summit, by means of
old cellular attachments. In this point there was an irregular
depression, in the centre of which lay a small ossification. From
this point could be traced into the substance of the lung a band of
very white cellular tissue, very dense, yet scarcely amounting to
the consistence of a membrane. This band was about an inch
long, six lines broad, and three or four thick. Its while colour
formed a striking contrast with the natural pulmonary tissue.
Some bronchial tubes of the size of a crow-quill, or larger, ter-
minated and became lost in this band. An accidental circum-
stance prevented me from examining this substance more minutely.
The pulmonary substance was crepitous throughout, and there
were no tubercles in either lung. The pericardium contained a
few ounces of limpid serum, and the heart was larger than the
hand of the individual. The parietes of the left ventricle were
about eight lines thick at the origin of the columnae, and six lines
at the base, and were very firm; the cavity of the ventricle was very
small.* The right ventricle seemed small, but its parietes were
of natural thickness. The peritoneal coat of the intestines was
inflamed.

Case 7, Page 48. (No. vii. of the original). Phthisis
Pulmonalis. Jlncient fibro- cartilaginous cicatrice of the lung, in
a person dead of Peripneumony. A man, aged 62, had been affect-
ed five years with an habitual cough, but was otherwise of a
good constitution. On the 4th of April 1818, he was suddenly
seized with acute pain in the lower part of the left chest, which
soon extended over nearly the whole side, attended by difficult and
painful respiration, and inability to lie on the affected side. He
came into hospital on the 8th, and exhibited the following symp-
toms: — general paleness, left cheek slightly coloured, lips bluish,
external jugulars swelled, pulse weak and frequent, breathing short,

* This well-marked case of hypertrophia had not been suspected, al-
though the heart had been examined several times by the stethoscope, owing 1
to the existence of the disease in the lungs, which masked the symptoms. —
See Page 265.

288 APPENDIX.

loud and painful, and with the mouth extended, cough not very fre-
quent and by fits, expectoration scanty, very viscid, frothy, semi-
transparent, and intermixed with some yellow and opaque sputa.

Percussion yielded a very good sound on the right side, but not
so good on the left. Respiration (by the cylinder) was quite in-
audible in almost the whole extent of the left side, whilst on the
right it was strong, and attended by a rattle and sort of hissing
sound. The pulsations of the heart were regular. The contrac-
tion of the auricles was sonorous and heard distinctly below the
clavicles.

The paleness of this man, and the cough to which he had been
so long subject, leading to the suspicion of tubercles, we examin-
ed the chest in several points with the view of discovering pecto-
riloquism, but did not find it. From these results the following
diagnostic was (provisionally) made: Pleura-peripneumony of the
left side. — Tubercles? Slight dilatation of the lieart 1 ? This man
died the following night.

Dissection thirty-six hours after death. The left cavity of the
chest was larger than the right. The right lung adhered, through-
out, to the pleura by means of ancient attachments. On the top
of the right lung there was a fibro-cartilaginous mass three lines
in thickness in its centre, which formed, in this point, the medium
of adhesion to the ribs. The substance of the lung was very
crepitous anteriorly, but little .posteriorly, in which part it was
flaccid and much injected by very fluid blood. This lung was
also marbled by a great number of spots formed by black pulmo-
nary matter. [The morbid appearances in the lungs indicating
the cure of tuberculous excavations in this case are detailed in
the treatise, pages 48 and 49.] In its anterior quarter the left
lung was crepitous, but the remaining part was of the consistence
of liver, and exhibited the characters of lung in this degree of
inflammation (see page 60). The base of this lung adhered to
the diaphragm by its whole border; and in its centre there was a
patch of concrete lymph of the consistence of white of egg. It
was easily separated from the pleura of the lungs, which appeared
redder than natural.

The inner surface of the pericardium, where this membrane is
attached to the diaphragm, was of an intense punctuated red for
the space of a square inch. The pericardium contained about
two ounces of a very bloody serum, and two or three flakes of
half-concrete lymph. The heart was larger than the hand of the
subject, and exhibited on its anterior surface a white spot of a

CASES. 28 ( J

cellular character, of the size of the nail. The right ventricle
was larger than natural, of the usual thickness, but yellowish and
of a flaccid texture. The left ventricle was evidently dilated,
and it was only four or five lines thick; its texture was soft and
pale like the right.

Case 14, Page 68. (No. xvi. in the original). Gangrene of
the Lungs . Pleurisy and pneumothorax consequent to the bursting
of a gangrenous abscess of the lungs. A labourer, aged 42, sublet
for six years tooccasional attacks of severe pains of the chest, &c.
for which he had been several times in the hospital, began to
have cough, with copious and extremely fetid expectoration, in
the beginning of April 1818; which symptoms continuing, he
came into the hospital Necker on the 30th of May following At
this time he exhibited the following symptoms: moderate degree
of fatness; decubitus practicable on either side, but more easily
on the left; cough frequent, and usually by fits; expectoration co-
pious, yellow and opaque; respiration very distinctly audible on'
the right side, much less on the left, and accompanied with a mu-
cous rattle;, resonance on percussion somewhat lesson the left
side both before and behind. Action of the heart natural. After
the examination the following diagnosis was given: Slight chronic
peripneumony, occupying tlie centre of the left lung.

On the 7th June, the respiration was still very distinct on the
right side, but on the left it was quite inaudible except at the top
of the chest, where, however, it was much weaker than formerly,
— and at the roots of the lung, where it was much more distinct
than formerly. The left side sounded still worse on percussion
than at first. These results induced me to add to my former diag-
nostic: — the peripneumony has begun to resolve towards the root of
the lung; but there has supervened a pleurisy, with sero-purulent effu-
sion, of the left side. On the 12th the respiration was very slightly
perceptible below the left clavicle; and on the 16th it could scarce-
ly be at all distinguished over the whole anterior and superior half
of this side of the chest; but the resonance, on percussion, had
again become very distinct over this space. From this last sign
I added to the diagnostic — Pneumo-thorax. There was now much
cough, and the expectoration was copious, opaque and ropy. On
the 17th the pain, which had left him since April, returned very-
severe, between the fifth and sixth ribs of the left side. On the
1st July the sound of respiration was quite extinct over the left
side. 3rd. Resonance of the chest equal on both sides; respira-
tion very distinct on the right, not at all on the left side, either be-
fore or behind, except at the roots of the lung, and perhaps a little

37

0*90 APPENDIX. '

under the clavicle. The pain and cough being more violent, he
expectorated in the space of a few minutes half a pint of yellow
opaque purulent sputa. This kind of expectoration continued for
some days, with increase of pain and dyspnoea Pectoriloquism,
sought for in several points, was not discovered.* This man died
on the 31st.

Insseclion twenty-four hours after death. [For this see the work,
page 68.]

Case 16, Page 73. (No. xxxvi. in the original). Hemopty-
sis. Pulmonary Jlpophxy in a subject affected with hypertrophia
and dilatation of the heart. A labourer aged 45, subject for seve-
ral years to a feeling of suffocation on using violent exercise,
came into the hospital in the end of August, on account of his dysp-
noea having become greater and more permanent during the pre-
ceding fortnight. At this time there was no emaciation, but the
face was pale; the feet and legs were cedematous, and the pulse
was scarcely perceptible, in both arms; there was no appetite, and
the sleep was frequently interrupted by sudden startings. The
respiration, though short and impeded, was very audjile by means
of the cylinder- The chest sounded well throughout, except in the
region of the heart; and the exploration of this organ by the
cylinder gave the following results: — impulse of the left ventricle
very strong and sonorous; sound and impulse of the right ventricle
middling, sound of the auricles quite imperceptible. In conse-
quence of this the diagnostic was given — Hypertrophia of the heart.
(V. S. & Aperients.) In a month's time the patient finding him-
self better left the hospital; but he returned in another month,
with precisely the same symptoms, which being again relieved,
he left the hospital a second time after six weeks' stay.

On the 16th of January he once more returned to the hospital.
At this time the difficulty of respiration was very great, especially
when lying on the back; it was relieved by bending forward and
by lying on the belly; in this last position he felt a pulsation in his
throat opposite the top of the sternum. The oedema was increas-
ed, and he had cough and diarrhoea, with a pain in the epigastrium.
The heart still gave a very strong impulse, and the pulse continued
imperceptible. The symptoms continued much the same until the
4th of February, when he was seized with haemoptysis. At this
time the chest yielded a good sound throughout; but the respiration
was nearly inaudible over the inferior portion of the right side.

* Neither was the metallic tinkling observed. The hippocratic succussion
was not tried.

CASES. 291

Nearly over the whole chest, a mucous rattle (apparently with
very large bubbles) was heard, and more strongly on the right side.
He died on the 8th.

Dissection sixty hours after death. The pericardium contained
nearly an ounce of serum. The heart was, at least, thrice the
natural size. It had on its surface several irregular white spots,
half as large as the palm of the hand. The right ventricle was
partly, and the right auricle entirely, filled by a firm polypus,
which, in some places, showed some traces of vascularity. This
ventricle was in other respects natural, except that its column©
were flattened, and that it contained near its apex two or three
of those bodies which I have named globular excrescences. The
auricle was natural.

The left ventricle was from nine to eleven lines thick and of
a remarkable degree of firmness; its parietes did not at all collapse
when laid upon, although the cavity was at least double the na-
tural size; being capable of containing the fist. The columnar
carneae were very large and very strong. The mitral valve con-
tained several cartilaginous indurations, but retained its shape:
the sigmoid of the aorta were sound. On the inner surface of
this ventricle there were one or two white spots of the size of the
nail, apparently situated beneath the lining membrane. The aorta
was slightly dilated at its origin, and more so in the arch, and was
otherwise diseased, containing many cartilaginous and bony in-
crustations.

The morbid appearances found in the lungs are detailed in the
work, page 74.

Case 26, Page 96. (No. xxxiv. of the original). (Edema
op the lungs supervening in the convalescence from pcripneumony.
The only thing of any importance omitted in the abridgment of
this case, given in the body of the work, is the account of the
signs of diseased heart afforded by percussion and auscultation,
and the morbid appearances found in this organ: I shall now
briefly notice these. When she came into the hospital, in ad-
dition to the symptoms mentioned, it is stated that " the resonance
of the chest is not good on the right side behind, and the left
side before; this resonance is quite wanting in the region of the
heart; and the respiration, as explored by the stethoscope, is
inaudible in these points. The action of the heart gives scarcely
any impulse, but yields a distinct sound. 1 ' In consequence of
these, and the other symptoms mentioned in the work, the di-
agnostic was given — Partial peripneumony of both lungs ^ and di-
latation of the heart without hypertrophia. The morbid appear-

j2 appendix.

ances in the lungs are detailed in the work. The following arc
those observed in the heart: — The pericardium contained aboiK
two ounces of serum. The heart was larger than the hand of the
individual; it was soft and easily torn, and its cavities were very-
large.

Case (No. xxiv of the original, not translated in the body
of the work). Pleurisy. Pleurisy with hcegophomsm, cured,
A man, aged 42, came into the hospital the 23rd of April. Six
years before he had had an attack on the chest attended by a
severe stitch in the left side; and he had a similar attack in the
spring of last year. Ever since his first seizure he had been
subject to colds, especially in winter; and during the last year
his cough had been almost constant. During the four days preced-
ing his entry into the hospital he suffered from stitch in the left
side, dry cough, impeded respiration, and fever. On coming
into the hospital he exhibited the following symptoms: cheeks
very red, pulse frequent, skin hot, decubitus on the left side im-
practicable, very acute pain in the left side. The respiration
very distinct, and even loud, below the left clavicle, and as low
as the fifth rib on the same side anteriorly,* of moderate inten-
sity below the axilla, but very indistinct behind, especially on the
lower parts, where it is accompanied by a slight crepitous (al-
most mucous) rattle. On the right side the respiration is less
perceptible below the clavicle than on the left side; behind and
below the axilla, it is very distinct but not strong. On per-
cussion the chest sounds, perhaps, somewhat worse below the
right than the left clavicle; but behind, and below the axilla it
sounds much less on the left than right side, particularly on the
lower parts: this difference of sound is. perceptible even over the
scapulas. Hcegophonism is extremely evident about the point ol
the left scapula and all along its inner edge. The patient's voicr
appears as if it traversed a trumpet and not the tube of the ste-
thoscope. Haegophonism is also perceptible below the axilla, and
as high as the fifth rib, but less distinctly. In consequence ot
, these signs the following diagnosis was given: Pleurisy of the
left side, complicated with a slight degree of peripneumony.] (Ve-
nesection.)

* it would seem probable from this that there was adhesion between the
ribs and summit of the left lung, the consequenc of some of the preceding
attacks of pleuris)'.

f The latter part of the diagnostic was founded entirely on the existence
of the crepitous rattle.

•-am . 293

24th. Fever still high,— continued incapacity to lie on the
left side, — almost* constant cough, with liquid semitransparent
sputa, which adhere but slightly to the vessel; respiration distinct
on the left side anteriorly, as low as the fifth rib, — quite impercep-
tible over the whole of this side behind, (where it is replaced by
a mucous and slightly crepitous rattle,) but very distinct on the
side as low as the seventh rib. Haegophonism "not discoverable
on the upper and anterior parts, where the respiration is still
perceptible, — doubtful below the fifth rib, — but most distinct over
the whole of the back. Near the angle of the scapula the patient,
when speaking, seems to blow into the tube of the cylinder; and
in breathing, seems to inspire and expire by the same. Nothing
of all this is perceptible on the right side, where the respiration is
very distinct throughout. The haegophonism becomes less distinct
when the patient lies on his face. I concluded from these signs that
the left lung was compressed upwards and laterally, in which point?
it was probably attached to the ribs. (Eight leeches to the side.)

25th. Results the same, only the respiration more easy. Sputa
adhering to the vessel.* (Eight leeches to the anns.) 26th.
Pain of side nearly gone, cough mueh less", expectoration more
easy and sputa more yellow and opaque, pulse less frequent.' The
patient -slept well. (Small bleeding.)

27th. Fever nearly gone, respiration easy, no pain o'f side.
Respiration more distinct on the left side, and haegophonism much
less evident. Respiration very distinct over the whole right side.
(Blister to the side.) '

28th and 29th. Much the same, — still much cough, but ex-
pectoration easy, the sputa partly frothy and semitransparent,
partly yellow and opaque; can lie on either side.

May 1st. Still better. Haegophonism still evident, but less
strong, along the whole inner border of the scapula, and over
the whole of the left side behind: but the respiration, which had
hitherto been merely bronchial over the site of the haegophonism,
is now possessed of the usual pulmonary character; it is perfectly
and forcibly audible on the side, except in the lower parts, where
it is much feebler.

' The patient continuing to amend daily, the haegophonism be-
came progressively less distinct and ceased entirely on the 8th;
the respiration became very distinct over the whole of the left
side, though, probably, scarcely so loud as in the other.

Case. (No. xxv. in the original, not translated in the body of

* Sign confirming' the complication of peripneumom

nj4: ai'PEJNTdix.

the work). Pleurisy. Chronic Pleurisy of the left side, with
ascites and organic disease of the liver. A man had an attack in
the chest when 24 years old; but afterwards enjoyed very good
health, until the summer of 1818, when he became slightly ana-
sarcous, and this was followed in December by cough. He came
into the hospital on the 13th of the following March, in his 47lh
year. At this time he presented the following symptoms: mode-
rate oedema of the feet and legs, slight expectoration, partly white
and frothy, partly yellow and opaque; the chest sounds equally
well throughout, and the respiration (on a hasty examination)
seems scarcely perceptible on both sides.

17th. The chest, on a more careful examination, gave the
following results: The left side behind seems to sound worse than
the right, — both sides laterally yield a very dull sound, — the
anterior superior parts sound better. The respiration is very
distinct over the whole of the right side; on the left, on the
contrary, it is but very little perceptible below the clavicle and at
the roots of the lungs, and not at all audible over the remaining
parts of this side. The following diagnosis was given: Imperfectly
cured pleurisy of the leftsidb, coexisting perhaps with tubercles.

In the end of March the oedema, which had been lessened,
now became greater, the belly swelled, and the appetite dimi-
nished. At this time, the respiration on the right side was accom-
panied with a strong and sonorous rattle on the side and anteriorly,
and was scarcely perceptible on the same side behind, and over
the whole of the left side. Percussion elicited a very imperfect
sound from the whole of the left side, except on the anterior
superior part; but the whole right side sounded well. Haegopho-
nism existed very distinctly over the supra- spinous fossa of the
left scapula. The voice, having the bleating character strongly
marked, seemed to come through the tube of the stethoscope, and
was more acute than the natural voice of the patient. In conse-
quence, I modified the diagnosis as follows: Chronic pleurisy of
the left side, with pulmonary catarrh.

From the 30th March to the 15th April, the repeated examina-
tion of the chest showed that on the right side the sonorous rattle
had in a great measure ceased, and that the respiration was louder
than natural, and marked by the peculiar sound which I have de-
nominated puerile; whilst, on the left side, the respiration seemed
extinct, except along the inner border of the scapula and imme-
diately below .the clavicle, in which places it was just barely per-
ceptible. The point just mentioned (under the clavicle) was the
only one on this side which yielded any sound on percussion.

CASES. 295

During the first days of April, haegophonism was stil! audible
along the inner margin of the scapula, but the voice had assumed
a grave key, and was heard belter with the stopper of the tube
removed, — it disappeared entirely on the 5th. The natural respi-
ration was short and somewhat noisy. The patient lay usually
on the left sicie, sometimes on the back, but he could not lie on
the right side. About the middle of the month the respiration •
seemed more easy, and the patient could lie two or three hours
on the right side; but the anasarca increased, and hectic fever
came on.

From the 7th to the 14th of May, the resonance of the chest
became clearer on the anterior and upper part of the left side,
and the respiration became more audible in the same point; it
was also somewhat perceptible below the axilla, and was here
accompanied by a pretty strong mucous rattle: in every other part
of this side both the resonance and the respiration were wanting.
He died on the 17th.

Dissection thirty hours after death. The thorax appeared larger
on the upper part, and smaller on the lower part, of the left side,
than the right. The left cavity of the pleura contained at least
two pints of a very bloody serum, and the lung, on this side, was
thereby compressed towards the mediastinum and upper part of
the chest. A large vacant space was thus left between the lung
and ribs, which space gradually lessened from below upwards,
but was still an inch in diameter as high as the middle of the
scapula. This space was lined by a false membrane, the internal
surface of which was tinged uniformly of a bright scarlet colour,
and was crossed in every direction by fine fibrous bands of the
same kind. In many parts of these false membranes there were
clots and thin layers of a dark-coloured blood. The under layer
of membrane which adhered to the pleura was of a greyish yellow
colour, homogenous, and of a structure and consistence resem-
bling the fibro-cartilages. It contained within it an immense
multitude of greyish tubercles, of a size from that of a millet-
seed to a grain of corn, or even a pea. These were of a firmer
consistence than the including membrane; and they formed more
than one half the whole of its substance.

The left lung, compressed as already mentioned, was reduced
to nearly one-fourth of its natural size; it was adhering to the
pleura by its inner side, its summit, and by two-thirds of its ex-
terior aspect superiorly. Detached from the false membrane it
was sound, only compressed, flaccid, and void of air except in its
lower lobe. The blood-vessels and smaller bronchial tubes were
flattened and much contracted.

29G APPENDIX.

The right lung adhered to the ribs only in a few points, and by
old and perfectly organized attachments. It was gorged with a
great quantity of frothy serum which flowed out on its being cut.

The cavity of the peritoneum contained five or six pints of se-
rum. The liver was reduced to one third of its usual size, and
when cut into was found to be entirely composed of a multitude
of small grains, of a round or ovoid shape, and varying in size
from that of a millet-seed to a hemp-seed.

Cask. (No. xlv. of the original, not translated in the body ot
the work). (Supposed) Ossification of the mitral valve. A strong
muscular young man, aged 16, came into the hospital complaining
of oppression on the chest and palpitation; symptoms which had
seized him suddenly, together with haemoptysis and epistaxis two
years before. These symptoms were relieved at the time, by
rest; but returned as often as he made any considerable degree of
exertion. He presented the following symptoms on coming into
the hospital: respiration and resonance good over the whole chest;
the hand, applied to the region of the heart, feels the pulsation
strongly, and accompanied with the purring sensation mentioned
in the treatise (page 257). This vibratory sensation is not con-
tinuous, but returns at regular intervals. The stethoscope, applied
between the cartilages of the fifth and seventh ribs, gives the
following results: — contraction of the auricle extremely prolonged,
accompanied with a dull but strong sound exactly like that produced
by a file on wood. This sound is attended by a vibration sensible
to the ear, and which is evidently the same as that felt by the
hand. Succeeding this, a louder sound and a shock synchronous
with the pulse point out the contraction of the ventricle, which
occupies only one fourth the time, and has something harsh in its
sound. Under the lower end of the sternum the contractions of
the heart are quite different. Here the impulse of the right ven-
tricle is very great, its contraction accompanied, by. a very distinct
sound, and being of the ordinary duration — viz. twice as long as
that of the auricle. The sound of the auricle is somewhat obtuse,
but without any thing analogous to the vibratory character of the
left.

* The action of the heart is audible below both clavicles, on both
sides, — (but feebly, especially on the right) — and over the whole
sternum. On the right side and below the left clavicle, the con-
tractions of the heart have the same rythm as at the end of the
sternum. On the left side, on the contrary, the whizzing sound
of the left auricle already described is much feebler than in the
left precordial region. From these signs the following diagnostic

cases. 297

Was given: Ossification of the mitral valve, slight hypertrophic
of the left ventricle; perhaps slight ossification of the sigmoid valves
of the aorta? great hypertrophia of the right ventricle.

The pulse, in this case, was pretty strong and very regular,
and all the functions natural, only the steep was habitually dis-
turbed by frightful dreams, and the lad could not use any severe
exercise, nor even walk rather fast, without being attacked by
strong palpitations and a feeling of suffocation.

Four venesections, after intervals of a few days, gave much re-
lief. After the first, the pulse became weak; and immediately
after each bleeding the purring vibration became imperceptible to
the hand, and the whizzing of the auricle changed from the sound
of a file to that of a bellows, the valve of which we keep open by
the hand; but the shock of the right ventricle continued to be very
strong This patient left the hospital after a month.

Case 43, Page 186. (No. xlvi. of the original). Excrescences
on the mitral valve and left auricle; rupture of one of the tendons
of this valve, and hypertrophia, with dilatation, of both ventricles of
the heart [The general symptoms and appearances on dissection
are given in the body of the work; I shall therefore only add the
account of the symptoms more immediately indicative of the dis-
ease in the heart.] ,

The pulsations of the heart, examined by the cylinder, give a
very dull sound, but a strong impulse on both sides: — they are
heard a little in the back. During the contraction of the left au-
ricle (which is almost as much prolonged as that of the ventricle)
a sound resembling that of bellows is perceptible. The purring
sensation is very distinct on applying the hand over the cartilages
of the sixth and seventh ribs. The action of the heart is, in
some other respects, irregular; the jugulars are swollen; the respi-
ration is distinct over the whole chest; the pulse is hard, small,
and very regular; the breath is rather short. After this examina-
tion the following diagnostic was given: Hypertrophia of both-
ventricles; excrescences or cartilaginous contraction of the mitral
valve.

Case (No. xlviii. of the original, not translated in the body of
the work). Double Peripneumony with Pericarditis. A man,
aged 30, who had been subject to a slight cough for some years,
and latterly, to dyspnoea, came into the hospital on the 30th Jan-
uary, apparently affected with pulmonary catarrh. ( V. S.) On
the following day the difficulty of respiration suddenly increased,
the pulse became irregular, and the sputa were viscid. To re-
lieve his breathing the patient sat upright. ( V. S. 8f Leeches.)

38

298 APPENDIX.

February 1st. Orthopncea much relieved. Pulsations of thd
heart very irregular, both in frequency and force; contractions oi
the ventricles sonorous, and the impulse considerable, but the
pulse extremely small and feeble; resonance of the chest middling,
perhaps less in Hie back and region of the heart; respiration in
the back very little perceptible and accompanied by a slight cre-
pitous rattle. Diagnostic: PericUrditis, with peripneumony of the
posterior part of both hngs.* 2nd and 3rd. — Much the same.
(Eight leeches each day).

4th. Orthopncea returned. Contractions of the heart very
feeble and unequal; sound of the auricles inaudible; impulse of
the ventricles pretty sirong and without noise; "the action of the
heart seems confined to a sn*all point on the parietes of the chest:
pulse nearly imperceptible. (Eight leeches).

5'.h The same. (Blister to the region of the heart).

6 h. Heart and pulse as before; respiration very audible over
all the anterior and lateral parts of the chest, on the back it is
scarcely perceptible and accompanied by a more distinct crepitous
rattle than before.

For several succeeding days the patient was obliged to sit up
constantly in his bed, with his head bent forwards, and immova-
ble, for fear of increasing the orthopncea. Respiration very per-
ceptible anteriorly and on the sides, and accompanied from time
to time with a rattle which was rather mucous than crepitous,
and much more marked during respiration than inspiration;! pos-
teriorly the respiration was quite imperceptible. Cough frequent,
with scanty expectoration; sputa transparent, somewhat frothy,
and so tenacious as to adhere to the vessel when this was revers-
ed. Pulsations of the heart difficultly analyzed, owing to their
frequency; one strong pulsation followed by three or four gradu-
ally decreasing in force; pulse feeble and intermitting. A sound
like the fluctuation of a liquid heard momentarily in the region of
the heart; which sound seems occasioned rather by strong inspira-
tions than the actions of the heart. Lower extremities cedema-
tous, no sleep. (Soap-pills, cautery on the left side.)

13th. Orthopncea still greater; sputa almost entirely sanguino-
lent; respiration less distinct on the sides; impulse of the heart
still strong. He was again bled, and thereby much relieved.

* I founded my opinion of pericarditis on the circumstance of the forci-
ble action of the heart coinciding with the extremely feeble pulse, and on
the irregularity of the heart's action in a man who appeared to have had
no previous symptom of this kind.

t This sign announces the rattle to be in the small bronchial ramifications.

GASES. 299

14th. Sputa less sanguinolent, but orthopnea greater. (V. S.
repeated).

15(h. The respiration has become puerile on the anterior and
lateral parts of the chest, but it is not so distinct as before on the
right side anteriorly; a distinct crepitous rattle on the right side.
The chest sounds equally well before, and on both sides. Diag-
nostic: Peripneumony gains the anterior and lateral parts of the
right lung; but remains, on the left, confined to the posterior parts.
He died on the 18th.

Dissection twenty-four hours after death. The pericardium con-
tained about four ouuces of a limpid serum. The walls of both
ventricles were thick, but not so as to constitute disease. An ir-
regular white spot was found intimately adhering to the pericar-
dium on each ventricle. The portion of the aorta contained in the
pericardium was coated exteriorly wilh small firm greyish tuber-
cles, resembling the tubercles of the lungs in their first stage. Tlie
mitral valve was irregular and contained three or four small semi-
cartilaginous tumours.

The cavity of the pleura was entirely obliterated on both sides,
by the universal adhesion of the membranes, by means of a short
and in most places well-organized cellular tissue, except at their
base, where the medium of attachment was a membrane of a
greyish-white colour, semitransparent, of a fibrous texture, and
nearly two lines thick.

The lungs, when detached, floated in water, though heavy and
large. Their surface was livid, and more so behind. The sub-
stance of the lungs was soft and crepitous on their anterior part,
to the depth of two fingers' breadth on the right lung, and font
fingers on the left; but became progressively firmer and less cre-
pitous on tracing it backwards, until, on the whole of the poste-
rior part, their texture was as dense as liver, of a violet red
colour and entirely without crepitation. These portions, when de-
tached, did not float on the water The hepatization was nearly
one third more extended in the right than in the left. The lining
membrane of the bronchia was of a reddish brown colour.

The cavity of the peritoneum contained nearly a pint of yel-
lowish serum.

END OF THE TREATISE

NOTES

BY

THE TRANSLATOR.

Connexion of Tubercles with Inflammation, Page 38.

Hitherto great confusion has existed in our notions respecting
the true character of the appearances found in the lungs after
death. Among others, the common notion of consumption being
merely the consequence of the suppuration of an inflamed lung,
has had a very injurious effect in practical medicine. It is to be
hoped that the more correct knowledge now obtained of the true
nature of the mobid appearances, will establish a more rational
practice. From the anatomical character of tubercular phthisis,
it is evident that we have little or nothing to expect from the em-
ployment of venesection and other antiphlogistic measures, — or,
indeed, from any other; — while the great infrequency of the ter-
mination of simple inflammation of the lungs (peripneumony) in
abcess, that is — in an irremediable condition of parts, — affords us
every chance of this affection yielding to such measures, and
therefore justifies their powerful and long-continued application.
In a practical point of view, therefore, the present work must be
of immense benefit, in settling both the pathology and diagnosis
of the diseases of the chest. Any person accustomed to see many
cases of pulmonary disease must be struck with the confusion
that prevails among medical men respecting them. With many,
every chronic affection of the chest is either Consumption or
Jlsthma, and the same class of remedies, and regimen, is applied
to all. How often are patients sent abroad in a state of health
which is utterly hopeless! and how often do we hear of Consump-

302 NOTES BY THE TRANSLATOR.

tions cured, when the sole merit of the curer was ignorance of the
nature of the disease!

By far the most valuable remarks yet published in England on
this very important matter, of the discrimination of the various
diseases commonly classed under the name of Consumption, are
those in the work of Dr. Armstrong on Scarlet Fever, &c. and
in Dr. Abercrombie's paper in the 66th number of the Edinburgh
Medical and Surgical Journal. To these two essays I would
earnestly call the attention of every practitioner who values
either the welfare of his patients, or his success in his professional
career. To Dr. Armstrong the profession is already under
very great obligations; and the several late papeis by Dr. Aber-
crombie in the Edin. Jour., written in a true philosophical spirit,
lead us to anticipate the most important advantages to medicine
from his future labours.

Tubercular infiltration of the Lungs, Page 38.

This is noticed by Baillie, Page 76.

Extensive distribution of Tubercles, Page 39.

The extensive distribution of tubercles mentioned by our au-
thor, and very generally admitted by other writers, I consider as
throwing light on many obscure affections. Is it really true, as
MM. Laennec and Bayle assert, that the diarrhoea of consump-
tion is the direct consequence of their presence in the intestinal
tunics?

Cicatrization of Pulmonary Fistula, Page 42.

Dr. Young, in giving an account of the Historia Anatomica of
Lieutaud, notices a case " of a cicatrix found in the lungs,
where a consumption had been cured, from Valsalva." Young,-
p. 225. The facts detailed in this section are extremely interest-
ing; if they destroy the hope entertained by many, of the curabi-
lity of consumption in the early stage, they give us hopes, where
in general no hope has hitherto existed, in the latter stage of the
dis< ase. These facts seem to afford a better reason for sending
our confirmed consumptives to warm climates, than could have
previously been offered by most of those who were in the habit
of doing so. — I have no doubt that many of the readers of this
work, of more extensive information than the Translator, can

NOTES BY THE TRANSLATOR. 303

corroborate many of the author's statements by facts adduced
from other writers.

Expectoration in Phthisis, Page 55.

For an extensive and minute chemical account of the different
kinds of expectorated matter, see Dr. Pearson's papers in the
Philosophical Transactions for 1809 and 1810. The question of
the mere purulency or non-purulency of the sputa is of very in-
ferior value in a diagnostic point of view, to what it was once
considered; since it is now well known that the expectorated
matter may be purulent in* other diseases besides Phthisis.

Tubercles on the surface of the Peritoneum and Pleura, Page 39.

" In these situations they are found small and very numerous,
usually in their first stage, and occasion death by dropsy before
they can reach the period of maturation." This is the disease
described by Dr. Baron, and is mentioned in many parts of the
present treatise. As a cause of dropsy, it must often at once in-
dicate the employment of antiphlogistic measures, and prove their
perfect inutility.

Tubercles in the substance of the Vertebrae,, or the point of union be-
tween these and the Ligaments, Page 39.

In many chronic affections of the spine, in strumous subjects,
unattended by curvature, I am disposed to attribute the symptoms
to this cause.

Vomica, Page 56.

Among others see the work of Dr. Baron on Membranes. I
apprehend this author confounds three different diseases under
one head.

Peripneumony, Page 59.

All the appearances mentioned by our author in this disease
have been noticed by other writers; but he is entitled to the ho-
nour of having first ascertained their relations to each other, of
having united them all in one connected and distinct view, and
fixed their true characters as different stages of the same disease

304 NOTES BY THE TRANSLATOR.

Hepatization of the Lungs is noticed by almost every writer oil
the Lungs, but its true character has been misunderstood even by
some of our best and very recent authors It is considered as
an inflammatory affection in the very short notice of it given by
Baillie. But it is singular that it is said to be of such rare oc-
currence, see Morb. Anat. page 80. See also Hastings on Bron-
chitis, and many cases in the various medical Journals.

One great advantage of the anatomical knowledge of diseases
is, that, whatever system of nosology we follow, in the treatment,
our ideas will always be attached to some fixed and intelligible
condition of parts, the removal of which will form the object of
all our remedial measures; while, without this knowledge, we
shall be the sport of theory, and combat often words in place of
things. How often I have heard of effusion into the lungs as a
frequent cause of death, without being able to attach any precise
idea to the expression!

Jlbscess of the Lungs, Page 61.

The assertions of our author respecting the relative infrequen-
cy of this termination of peripneumony is very opposite to the
best English authorities. I have no doubt that a great many
supposed abscesses have been merely softened tubercles, as de-
scribed by our author in the chapter on Phthisis.

In page 56 he states an abscess of the lungs from simple inflam-
mation to be a thousand times less frequent than a case of Em-
pyema.

For some excellent observations on Chronic Peripneumony see
Dr. Armstrong's work on Scarlet Fever; also dr. Duncan's on the
three varieties of Consumption.

A most striking instance of the evils of a symptomatica! classi-
fication of diseases is exhibited in the conjunction, by Dr. Cullen,
of Pleurisy and Peripneumony under one name and species (Pneu-
monia). Many of their symptoms are undoubtedly the same, and
it may often not be easy to distinguish the two diseases when exist-
ing separately; yet it is evident, no two affections can be really
more distinct in their nature than an inflamed pleura with effusion
in the chest, and an inflamed lung with thickening of its paren
chyma.

NOTES BY THE TRANSLATOR. 305

Tenacious Sputa in Peripneumony, Page 63.

This character of the sputa is very characteristic: it shows the
importance of examining the expectorated matter in all cases of
diseased lungs. Indeed a crachoir ought to form an invariable part
of the furniture of a pulmonary invalid.

The third variety of Peripueumony is confounded by many ob-
servers with Phthisis. See Portal, Morgagni, Soulhey, &c.

Haemoptysis, or Pulmonary Apoplexy, Page 69.

Mr. Burns I think cursorily notices, and perhaps accounts for,
the condition of the lungs named Pulmonary Apoplexy by our
author. He considers it as always the consequence of disease of
the heart, viz. dilatation of the right side. " The pulmonic ves-
sels by the congestion and continued vis a tergo are ruptured; blood
is forced into the air-cells; haemoptysis is produced; or if urged
still further, all the cellular structure of the lungs is crammed
with blood; these organs cut like liver, and sink when put into
water. This I am convinced from repeated observations is a fre-
quent cause of hemorrhage from the lungs, and I have seen several
who have lost their lives from not preserving the muscular action
within proper limits." Burns on the Heart, p. 53. Mr. Burns's
view of the matter is highly important, and, like all pathological
facts, tends directly to the improvement of practical medicine.
Certainly his idea receives countenance from the general fact
(noticed by him) of haemoptysis being mentioned by almost all
writers as a symptom of enlarged heart. It is worthy of notice
that the two cases (15 and 16) of Haemoptysis given by our author
are complicated with disease of the heart, but only in one of these
was this in the right side. What further enhances the probability
of this explanation of the phenomenon, is the fact of occasional
rupture of the pulmonary substance in these cases, as mentioned
by M. Laennec, page 71.

Pulmonary Catarrh, Page 74.

For a much fuller account of all the varieties of this disease
see the excellent Treatise on Bronchitis by Dr. Hastings. See
also, the valuable little work of Dr. Badham on the same subject,

39

,j()(j NOTES BY THE TKANbLATOh

and the treatise of Dr. Cheyne on the Pathology of the Larynx
and Bronchia.

M. Laennec perhaps exhibits this affection in a simpler stall
than it is often met with in practice, especially in severe cases
Unquestionably the inflammation often extends to the substance
of the lungs. Dr. Hastings particularly notices this, page 282,
where he states the inflammation of the lungs as frequently reach-
ing the degree of hepatization. This is also noticed in many
cases of chronic Bronchitis given by Dr. Hastings. For instance,
see Case 1, 2, 5 (particularly), 8, 18, and 22. It is worthy of
remark that out of the 19 cases of the acute disease given by the
same author, only one or two exhibit the complication of perip-
neumony — viz. No. 3, and 19, and these only in a slight degree.

However different Bronchitis and the true tubercular Phthisis
are in their nature, it will readily be admitted by every prac-
titioner of experience, that, in certain cases, it is impossible to
distinguish them by any or all the usual symptoms. This is
acknowledged by almost all writers on the subject of these diseases.
Among others, see Armstrong, page 184; Young, page 31; Has-
tings, page 290. Of the great importance, however, of a distinc-
tion between these diseases there can be no doubt, when we con
sider their very different pathological character; and on this
account, the new method of diagnosis of our author is unquestiona-
bly of the greatest, value to these two diseases.

More than one half the miners of Cornwall die of varieties oi
this disease. In them it is very often complicated with disease
of the heart; and is to be attributed to a great complication of
causes. I hope to lay before the public an account of this affection
so dreadfully destructive of human life.

Dilatation of the Bronchia, Page 79,

Perhaps this ought not to be considered as a distinct disease, but
rather as an accident or symptom of Bronchitis or some other dis-
eases of the lungs accompanied by cough. I know of no authoi
who has previously noticed this affection, except Slorck, See his
Biennium Medicum. Leyd. 1761.

Emphysema of the Lungs, Page 82.

This is a new disease, at least in practical medicine. It is only
by the progress of pathological knowledge that we can hope for a
true nosology. Under the term Asthma, as many very different

NOTES BY T1IK TRANSLATOR, 307

ceases are confounded as under the term Consumption. It is
hoped that the present work will be of no small use in leading to
the discrimination of diseases, which cannot be confounded with-
out the greatest injury to the subjects of them. Our author, unlike
some of his countrymen, does not range all asthmatic affections as
consequences of disease of the heart, although he evidently con-
siders the disease as much more frequently symptomatic than idio-
pathic. If the term is to be retained in medicine, it ought to be
restricted to the idiopathic or spasmodic variety; or used as the
generic name comprehending the various species symptomatic of
Bronchitis, Diseased Heart, Emphysema and (Edema of the
Lungs, &c. as well as the nervous or the idiopathic, so well de-
scribed by Dr. Bree. See his Treatise on Disordered Respira-
tion.

CEdtma of the Lungs, Page 92.

This condition of the lungs is noticed by many English authors.
Dr. Baillie says he has not seen any well marked example of it.
Morb. Anat. page 77. Dr. Parry considers it (Elements, page
106) as a frequent, and indeed necessary consequence of perip-
neumony, and in this he seems corroborated by the experience of
our author, page 93. Dr. Darwin notices it among other dropsies
under the title Anasarca Pulmonum. SeeZoonom. vol. iii. page
172, London, 1801. See also Dr. Perceval's Essays, Med. and
Exper. vol. ii. page 177. He says, " The difficulty of respiration
is constant, and increased by the least motion, though not much
varied by different attitudes of the body, the patient complains of
great anxiety about the precordia, and when he attempts to take a
deep inspiration, he finds it impossible to dilate his chest, and his
breath seems to be suddenly stopped." It is obvious that these re-
marks afford only a very imperfect diagnosis of this disease-
It is somewhat singular that this affection does not seem to oc-
cur in those cases of general dropsy which are consequent on
Bronchitis. See Dr. Hastings's Treatise, page 352.

Bony Concretions in the Lungs, Page 104.

These generally consist of a large proportion of phosphate of
lime, a small proportion of carbonate, and animal matter. See
Thomsons's Chemistry, 5th edit. vol. iv. page 572. See also Dr
Prout's Analysis, Lon. Mrd. ftepos. vol. xii. page 352.

308 NOTES BY THE TRANSLATOR

Black Pulmonary Matter, Page 1 12

In the Philosophical Transactions for 1813, Dr. Pearson lias
given an account of this matter, and a chemical analysis of it,
which, as usual, are overlooked by our author. I give the result
cf Dr. P.'s examination in the words of Dr. Young: — " He [Dr.
Pearson] considers the bronchial bodies as true lymphatic glands,
and thinks the black substance which often tinges them, consists
of charcoal, derived from small particles of dust, floating in the
atmosphere, which have been taken in by the absorbents, and de-
posited in their glands : and he has found some of the lymphatics
occasionally filled with a similar substance. He supports his
opinion by chemical experiments, which show the insolubility of
the black substance in nitric acid, while he has been unable to
find any other animal substance, the ink of the . cuttle-fish not
excepted, that resists the action of the acid. The glands of the
mesentery, he says, are also sometimes black, but their blackness
disappears upon immersion in the nitric or muriatic acid."*

Medullary Tumour, Page 1 1 7.

It is extremely discreditable to M. Laennec not only to have
taken no notice of the English works that mention this species of
tumour, but to have claimed the discovery of it to his own country.
He may certainly plead the custom of his country in excuse; but he
might have had sufficient candour to consider this as a custom more
honoured in the breach than the observance. It is scarcely necessary
to refer the English reader for an account of this affection to the
works of Burns, Hey, and Abernethy, and more especially to the
treatise of Mr. Wardrop on Fungus Ho&matodes, or Soft Cancer;
Edin- 1809 A remarkable case of this disease existing in many
organs at the same time, and among others the lungs, is given by Mr,
H. Earle in the third vol. of the Med. Chir. Trans, page 59.

Pleurisy, Page 122.

The chapter on Pleurisy offers an admirable specimen of Pa
thology. It contains much that is novel; and much that must
tend to the improvement of practical medicine.

* Young on Consumption, page 468.

NOTES BY THE TRANSLATOR. 3Q9

The fact of the inflammation of serous membranes being always
accompanied with a serous effusion, although noticed by patholo-
gists for a good many years, since the publications of Carmichael
Smyth and Bichat, appears to be stil! very imperfectly known to
the profession in general. The phenomenon has been stated by
no writer more distinctly than by Dr Parry in his late most ela-
borate work on Pathology. See page 107 et sequent. With (he
knowledge of this fact before our eyes, it is surprising that the
recent doctrines respecting the inflammatory character of many
dropsies, did not arise among us sooner. In the cure of acute
pleurisy, ought the knowledge of the fact of serous effusion to in-
fluence our practice in ordinary circumstances? Of course, the
best remedies for checking or preventing it are those which tend
directly to reduce the inflammation; but when the inflammation is
checked, or while we are endeavouring to check it, will it be well
to keep in view the dropsical affection (for it is truly such) which,
though a mere consequence of the original disease, is now itself a
disease? On this principle ought we to follow up the antiphlogistic
treatment with means calculated to promote the action of the ab-
sorbents and the kidneys.

Thickening of the Pleura, Page 123.

This is asserted by Dr. Baillie, page 54, although denied by
our author, page 123. I think the very definition of inflamma-
tion (redness, sivelling, &c.) necessarily involves some degree of
thickening.

Where so many cases of Acute Pleurisy are on record, and so
many must have been met with by every practitioner of experi-
ence, it may seem useless to refer to any individual case. Owing
to its conciseness, however, and its .perfect accordance with what
I have myself seen, I must refer to the appearances on dissection
in a case detailed in the Lond. Med. Repos. vol. v. page 479.

Cartilaginous thickening of the Pleura is mentioned by Parry.
Elements, page 114.

Chronic Pleurisy, Page 129.

No disease has been more misunderstood than this, both in a
pathological and practical point of view. For an excellent ac-
count of the external symptoms of this affection see Dr. Armstrong's
treatise on Scarlet Fever, &c. page 193: see also Dr. Abercrombie's
paper already referred to in the Edinburgh Journal. i

310 NOTES 1JY THE TRANSLATOR.

Contraction of the Chest, Page 131.

M. Larrey in a late number of the Journal Compliment, des
Sc. Med. for May 1820, details several very interesting cases of
Chronic Pleurisy and Empyema, resulting from wound, in some
of which this contraction of the chest was very strongly marked.
See Medico-Chir. Review for Dec. 1820 It would appear that
this condition of parts existed in some of the cases called Tubercu-
lous Accretions by Dr. Baron. See page 173-4, &c. of his work.

Empyema, Pages 130 and 149.

This operation has often been performed, and with much ad-
vantage, in this country. A very interesting case of chronic
pleurisy, in which this operation was performed, has been lately
published by Dr. Hennen in the 65th No. of the Edin. Journal.
It is to be remarked as a most striking instance of the want of
precision in our ideas respecting diseases of the chest, that this
learned and experienced gentleman should have denominated this
most decided case of Pleurisy — Hydrothorax.

In the cases of M. Larrey above referred to, he mentions an
oedematous state of the teguments behind the hypochondrium of
the affected side as an invariable pathognomonic sign of effusion
of blood into the chest. The same condition of the chest is
noticed by our countryman Mr. Sharp in the case of Empyema
(Crit. Inquiry, § Empyema); and also by Mr. Hey, (Surgery, page
476.)

Fluctuation in Empyema, Pages 142 and 249.

Many English authors mention this symptom. In many of the
cases recorded we have not sufficient data to enable us to ascer-
tain the correctness of M. Laennec's idea of the uniform coexist-
ence of pneumo-thorax with empyema in all cases wherein succus-
sion produces the sound of fluctuation. In Mr. Hennen's case
this effect was very perceptible, and from some parts of the
narrative it would seem probable that there was here an effusion
of air also.

NOTES BY THE TRANSLATOR. 3\\

Place of Election, Page 149.

In one cast, contrary to the usual practice, Mr. Hey operated
between the fifth and sixth ribs.

Idiopathic Hydrothorax, Page 151.

The great rarity of the true hydrothorax ought to make us
cautious how wc give this name to so many affections as we are
accustomed to do; and the undoubted fact of a serous effusion
being an almost uniform attendant on the inflammation of serous
membranes, ought to make us slow to trust to mere diuretics and
other similar remedies in cases wherein we have strong reason
for suspecting dropsical effusion, especially in the chest. The
now very generally allowed connexion between dropsy and inflam-
mation, mentioned by our author in many parts of this treatise, is
still much better understood in England than France. It is there-
fore hardly necessary to refer the English reader to the works of
Blackall and Parry, and especially Crampton, for the practical
and pathological illustration of this important doctrine.

Symptomatic Hydrothorax from tubercles on the Pleura, Page 153.

In this and many other parts of the treatise, our author notices
the tuberculous affections of serous membranes lately so ably
illustrated by Dr. Baron. It must be very satisfactory to that
gentleman to have his statements corroborated by so great an au-
thority; more especially as they were evidently unacquainted
with each other's inquiries. Dr. Baron's work is a most valuable
addition to our pathological knowledge; although the author appears
occasionally to have extended his peculiar views to some morbid
appearances which might perhaps be explained on the principlr
of ordinary inflammation.

Hcema-ihorax, Page 155.

This is noticed by Dr. Parry, page 1 19, and sanguineous effusion
mentioned as an occasional consequence of inflammation in all
textures.

312 sUTES b\ the translator,

Pneumothorax, Page 159.

Dr. Duncan, Jun. informs me that he has often met with this
ifTection in cases of empyema. Where he suspects it before
opening the thorax, he examines the diaphragm from the abdo-
men. — " In one case lately," he says, " as I predicted, we found
the diaphragm on one side convex upwards, and on the other
convex downwards: on puncturing an intercostal space on this
side, the air rushed out and the diaphragm rose into the chest."

Diseases of the Heart, Page 165.

It is not very creditable to M. Laennec not to have noticed
some of the English authors on disease of the heart, especially
Mr Burns and Dr. Farre, and also Dr. Warren's little work.
In the excellent treatise of the former, much very valuable matter
is contained. For many valuable observations respecting the
affections of both the lungs and heart, the reader is referred to Mr
Howship's Pract. Obs. on Surg. &c.

Hypertrophia, Page 165.

This is excellently described by Mr. Burns, page 40.

Dilatation of the heart, Page 167.

Mr. Burns states this condition of the heart to terminate very
commonly in chronic inflammation. I fear M. Laennec is occa-
sionally too exclusive in his distinctions.

Dilatation of the heart is considered by Mr. James (Med. Chir.
Trans, vol. viii.) as frequently caused by obstruction in the mi-
nute secerning and nutrient vessels.

Ossification of the Heart, Page 176.

In addition to the few eases of this mentioned by our author,
a remarkable case is noticed by Mr. Burns, page 131, in which
there was abroad belt of bone round both ventricles. In another
case he found both ventricles " mere calcareous moulds " — It is
singular that M, Laennec no where notices the ossification of the

NOTES BY THE TRANSLATOR. 313

coronary arteries, considered by Dr. Parry as the usual cause of
Jlngina Pectoris. See Dr. Parry's treatise.

Carditis, Page 177, and Pericarditis, Page 197.

These two diseases have been commonly confounded in dissec-
tion, and they cannot be separated in practice. For an excellent
account of this see Dr. Baillie's Morbid Anat. See, also, the much
less satisfactory work of Dr. Davis on Carditis. I have already
mentioned Mr. Burns's opinion of this disease frequently super-
vening to dilatation of the heart.

Globular Excrescence, Page 187.

This is noticed by Mr. Burns, page 194. In a case of Po-
lypus mentioned by Mr. Burns, page 200, he states perfectly
formed pus to have been contained in it: — was this an instance of
M. Laennec's Globular Excrescence?

Red colour of internal Membrane, Page 188.

Some recent attempts have been again made to connect this
appearance with inflammation, and to make a general affection of
the arteries of this kind to act an important part in the pathology
of febrile diseases, — how truly, I am very sceptical.

Malformation of the heart, Page 192.

For a much more complete view of affections of this nature see
the works of Mr. Burns and Dr. Farre.

Hydro-Pericardium, Page 201.

For some curious cases of this affection, in some of which tap-
ping was successfully performed by Dr. Romero, a Spanish phy-
sician, see Dr. Johnson's Review for Dec. 1820, page 477.

The Pulse, Page 263.

The remarks on the Pulse are extremely important. The in-
sufficiency of this as a test of disease must be acknowledged by
every practitioner of experience. Yet it is surprising to perceive

40

3H NOTES BY THE TRANSLATOR.

the effect of habit and early associations in this matter. How
often do we hear of a pulse being half a dozen or half a score of
pulsations above or below par, and indications of cure founded on
this important alteration! For some excellent observations on
this subject see Dr. Parrry's Elements, page 48 and seq. " II
these things are so, surely we ought to wonder at the confidence
with which physicians look to the condition of the pulse in the
radial arteries as the general evidence of the state of disease, and
the chief rule of (he administration of remedies." Parry, page 50.

Tht purring sensation mentioned by M. Corvisart and our au-
thor, page 272, is attributed by Dr. Ferriar to simple dilatation
of the heart; and by Mr. Burns to Hypertrophic or to dilatation
with chronic inflammation, or with lessened size of the arteries.

In employing the cylinder in diseases of the'heart, there is one
source of error which I think it the more necessary to point out,
as I was myself more than once misled by it in my earlier explo-
ration. When the instrument has been closely applied for some
time the skin occasionally adheres in some degree to it; and when
the motion of the patient's body, or a deep expiration, detaches it,
in the moment of separation a sound somewhat rosembling that
produced by the tearing of cloth, or by a rasp upon wood, is ex-
cited; and may, without attention, pass for the sound said to cha-
racterise contraction of the valvular orifices.

EXPLANATION OF THE PLATES.

PLATE I.

•

Fig. 1. This represents a section of the superior lobe of the
lung, containing tubercles in different stages, and a vast tubercu-
lous excavation. There are aiso, here and there, some pulmonary
spots, more numerous between the excavation and top of the lung.

a. Very large anfractuous excavation, produced by the soften-
ing of the tuberculous matter, which still lines it partially.

66. Columnar bands crossing from one side of the excavation
to the other, composed of the pulmonary tissue condensed, and
covered with a thin layer of tuberculous matter.

cc. Masses formed by the reunion of several immature tuber-
cles, exhibiting, in the section of their substance, an indented ap-
pearance. The shaded parts represent the grey and semiirans-
parent matter of the incipient tubercle, and the inner white por-
tions point out the same where it has become yellow and opaque.

d. The miliary granulations of M. Bayle.

ee. Bronchial tubes opening into the excavation.

/. Part of the exterior surface of the lungs.

Fig. 2. A section of the upper lobe of the left lung, exhibiting
a vast and very ancient pulmonary fistula, traversed by obliterated
blood-vessels, and lined by a thin semi-cartilaginous membrane.
Between this cavity and the top of the lung are seen spots of black
pulmonary matter, tinging the substance of the lung quite black.

a. Bottom of the fistula lined by the semi-cartilaginous mem-
brane.

666. Bronchial tubes opening into it.

ccc. Obliterated blood-vessels, crossing the cavity and then
ramifying on its walls.

316 EXPLANATION OF THE PLATES.

d. Small«excavations, or ulcerations, occupying only a portion
of the thickness of the semi-cartilaginous membrane,
ee. External surface of the lung.

PLATE II.

Fig. 1. Section of the upper lobe, the exterior of which is
seen in Plate V. fig. 2.

a. Fibro-canilaginous cicatrix surrounded by pulmonary sub-
stance strongly marked by the black matter, yet in other respects
sound and crepitous.

b. A bronchial tube greatly dilated and terminating in a cul-
de-sac at the cicatrix.

c. The same obliterated and continued into the cicatrice.
(Some other bronchial tubes seen open on the surface of the sec-
tion, point out the original diameter of the dilated branch.)

d. Bands of accidental serous tissue uniting the lungs to the
pleura of the ribs.

Fig. 2 Incomplete cicatrization of a tuberculous excavation.

a. Group of incipient tubercles, grey and semitransparent
externally, yellow and opaque in the centre. These and the
whole lung are interspersed with spots of the black pulmonary
matter.

b. Cartilaginous cicatrice, almost linear.

c. Extremity of this, divided into two layers and enclosing a
small portion of dry tuberculous matter.

d. v Blood-vessels cut across.

e. Immature tubercles.

/. Exterior surface of the lung.

PLATE III.

Fig. 1. Deep depression on the surface of the lungs corre-
sponding to a cicatrice within,
a. Portion of the upper lobe.
6. Depression corresponding with the cicatrice.

c. Part of the anterior border of the lung overlapping the de-
pressed portion.

d. Part of the posterior border of the lung.

Fig. 2 Cartilaginous fistula, with very unequal walls, in the
upper lobe of the lung.

EXPLANATION OF THE PLATES. 317

a. Surface of the lung.

6.

c. d. The cartilaginous mass.

ee. Part of the pulmonary substance comprised between the
cicatrice and summit of the lung, quite bbck with the black pul-
monary matter.

/. Fistulous excavation in the centre of the mass, with two
bronchial tubes opening into it.

PLATE IV.

Fig. 1. Part of the upper lobe exhibiting several of the air-
cells immensely dilated.

aa. Surface of the lung.

666. Large transparent vesicles full of air, formed by the re-
union of several air-cells.

cc. Air-cells in a lesser degree ofdilatation.

Fig. 2. Part of the upper lobe also emphysematous.

aaa. Air-cells dilated and prominent.

6. A point covered with dilated vesicles corresponding to a
rupture of the substance of the lungs within.

c. Air-cell much dilated and apparently pediculated.

d. Extravasated air between the pleura and lungs.

Fig. 3. Summit of an upper lobe in the state of emphysema,
tied to prevent the escape of the air, and dried in the sun, with a
slice removed to show the dilatation of the cells.

a. Surface of the Lung.

6. c. Slice removed to show the cells.

Fig. 4. Portion of a sound lung tied and dried as fig. 3. with
the view of comparing it with the emphysematous lung.

PLATE V.

Fig. 1. This figure represents different forms of the tuber-
culous matter, and some of its effects.

aaa. Immature or crude tubercles quite yellow.

6. Groups of incipient tubercles, still grey and semitranspa-
rent externally.

c. Small cartilaginous cyst, emptied of its tuberculous con-
tents.

d. Tuberculous excavation entirely empty and lined by two

318 EXPLANATION OF THE PLATES.

membranes, the exterior semi-cartilaginous, the interior soft: a
bronchial tube opens into this excavation.

e. Small empty tuberculous excavation, not lined by any
membrane.

/. Surface of the lung.

g. Tubercle partly softened and evacuated.

h. Incipient tuberculous infiltration of the pulmonary tissue.

Fig. 2. Depression on the surface of the lung, indicative of an
interior cicatrice.

a. The depression.

b. Accidental serous tissue uniting the lungs to the costal
pleura. N. B. A section of this figure is given in Plate II.
fig. I.

PLATE VI.

This figure exhibits the effects of contraction of the chest con-
sequent on pleurisy.
a. The sound side.
6. The contracted side.

PLATE VII.

A back view of the same subject.

PLATE. VIII.

Fig 1. The Stethoscope or Cylinder, reduced to one third
its actual dimensions,
a. The Stopper.
6. The lower end.

c. The upper half.

d. The auricular or upper extremity.
Fig. 2. Longitudinal section of the same,
a. The stopper.

6. Point of union of the two parts,
c. The upper half.

Fig. 3. The same section, with the stopper removed.
Fig. 4. The stopper.

a. The body of it, formed of the same wood as the rest of
the instrument.

EXPLANATION OP THE PLATES. 319

&.«*?J23£l ,ravetsing lhe s,op|)er ' for fai "s " * *•

F 'g -5. Upper half of the stethoscope.
a. Body of it. v

Fi, S fi CreW A ( ! n 'J 16 , W °° d) f ° r fixin » the two P° rti °ns together.
* ig. 6. Actual diameter of the stethoscope.

a. Diameter of the canal of the stethoscope.

*h^3 . An ^. turner wil1 b e able to make the instrument, from
*be above description— Trans. •muiooi, irom

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Laennec, Treatise on the diseases of the chest..., WF L158de 1823 c.2
Condition when received: The full leather binding was in poor condition.
The sewing was intact; however, the leather was broken at the hinges. In
addition, the pastedowns were broken at the inside hinges. The spine leather
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and there were many small losses overall. There was a one inch square
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covers were extremely worn to the extent that the inner paper boards were
exposed and delaminating into layers.

Conservation treatment: Detaching and lifting leather on the spine was
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above adhesive three part mixture. The comers were strengthened using wheat
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