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DIAGNOSIS   AND  TREATMENT 


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DISEASES  OF  THE  CHEST. 


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A  TREATISE 


ON    THE 


DIAGNOSIS  AND   TREATMENT 


OP 


DISEASES  OF  THE  CHEST. 

PART  I. 

DISEASES   OF   THE   LUNG  AND   WINDPIPE. 


BY 

WILLIAM    STOKES,    M.D.,    P.R.I.A.,   D.C.L.    Oxon,  F.R.S., 

REGIUS    PROFESSOR   OF    PHYSIC    IN    THE    UNIVERSITY    OF    DUBLIN,    PHYSICIAN 
TO  THE  QUEEN   IN   IRELAND,   ETC.,   ETC.,   ETC. 


WITH 

MEMOIR  BY  DR.  ACLAND,  F.R.S. 


EDITED    FOR    THE    NEW    SYDENHAM    SOCIETY 

BY 

ALFRED  HUDSON,  M.D.,  M.R.I.A., 

REGIUS  PROFESSOR  OF  PHYSIC  IN  THE  UNIVERSITY  OF  DUBLIN. 


|ronuon : 
THE    NEW     SYDENHAM     SOCIETY. 

MDCCCLXXXII. 


INTRODUCTION  BY  DR.  ACLAND, 


The  volume  which  is  now  again  given  to  the  world,  with  some 
important  additions,  has  been  for  many  years  out  of  print.  Dr. 
Stokes  was  unwilling  in  advanced  life  to  republish  this  work  of  his 
prime  without  alterations  which  would  have  involved,  in  fact,  re- 
writing. The  treatise  was  at  its  time  as  complete  as  it  was 
masterly. 

On  his  death,  and  in  compliance  with  his  request,  Dr.  Hudson, 
the  valued  friend  of  many  years,  undertook  to  prepare,  as  an 
historical  landmark  in  medicine,  a  reprint  with  additions  which 
Dr.  Stokes  had  himself  prepared  and  put  in  Dr.  Hudson's  hands. 
Dr.  Hudson  made  me  promise  that  if  he  edited  the  book,  I  would 
write  a  brief  memoir  of  our  common  friend  as  a  prefix  to  the 
work.  Death  has  now  removed  Dr.  Hudson  also,  and  what  I 
write  cannot,  alas !  be  revised  by  him.  Had  I  foreseen  this,  I 
probably  should  not  have  undertaken  the  difficult  duty.  As  it  is, 
the  few  pages  that  follow  are  poor  offerings  placed  on  tho  grave 
of  a  beloved  teacher,  at  the  dying  request  of  his  comrade,  who  fell 
while  erecting  a  monument  to  his  friend.  For  the  love  of  both 
would  that  my  offering  were  more  worthy.  I  pray  the  members 
of  the  New  Sydenham  Society  to  accept  the  tribute,  such  as  it  is, 
not  for  the  deed  but  for  the  will. 


VI  INTRODUCTION. 

The  Headers  should  take  note  that  the  aim  of  the  Memoir  is 
to  represent  Stokes  as  a  man  rather  than  to  describe  in  detail 
his  work  as  Physician  and  Author.  The  reprint  of  his  work 
tells  its  own  tale.     "What  like  man  was  he  who  wrote  it  ? 

Henry  "W.  Acland. 

t 

Oxford,  January  6,  1882. 


M  E  M  0  I  K. 


The  Author  of  the  work  to  which  this  Memoir  is  prefixed,  Dr. 
William  Stokes,  was  born  in  July  of  the  year  1804,  in  the  City 
of  Dublin.  His  father,  Whitley  Stokes,  was  Regius  Professor 
of  Medicine  in  the  University  and  Senior  Fellow  of  Trinity 
College.  He  was  a  man  of  lofty  aims  and  untiring  energy, 
and  employed  these  not  only  in  the  work  of  his  profession,  but 
in  promoting  by  various  methods  the  welfare  of  his  country. 
He  was  a  successful  teacher  of  medicine  in  the  University  of 
Dublin  and  in  the  Meath  Hospital.  By  his  exertions  the 
Botanical  Gardens  and  Museum  of  Trinity  College  were  estab- 
lished. He  was  the  first  University  Lecturer  on  Natural  History, 
at  a  time  when  the  conditions  of  society  in  Ireland  were  un- 
favourable to  intellectual  progress.  Indeed,  he  sought  to  develop 
the  resources  of  Ireland  in  many  ways,  and  to  further  the  education 
and  religious  instruction  of  the  people  through  their  native 
language. 

The  early  life  of  William  Stokes  was  much  influenced  by  his 
father.  The  boy  was  his  assistant  in  his  laboratory ;  the  com- 
panion of  his  botanical  and  geological  walks  among  the  Dublin 
hills.  This  companionship  was  of  the  more  value  because 
the  tone  of  Irish  society,  notwithstanding  the  brilliant  talent  and 
energy  of  the  people,  had  not  recovered  the  misfortunes,  excite- 
ment, and  depression  consequent  on  the  revolutionary  movement 
which  closed  the  18th  century.  Trinity  College  had  no  adequate 
museum,  lecture-rooms,  or  laboratories,  such  as  were  to  be  found 
in  Edinburgh,  Paris,  Vienna,  Leyden,  or  Berlin.  No  journal  of 
medical  science  existed  in  Ireland  before  1800.  It  was  no  doubt 
from  these  causes  that  Whitley  Stokes,  the  father,  sought  his 
degree  in  Edinburgh  in  1793,  as  did  William  Stokes  in  1825 ; 


Vlll  MEMOIR. 

hence  it  was  that  Robert  Graves  spent  several  years  working  in  the 
continental  schools.  Whitley  Stokes,  after  his  Edinburgh  degree, 
obtained  a  fellowship  at  Trinity  College,  which,  however,  religious 
scruples  led  him  to  resign.  He  decided,  probably  in  consequence 
of  these  scruples,  that  his  sons  should  go  neither  to  school  nor 
college.  William  received,  however,  a  thorough  classical  education 
from  John  Walker,  also  an  ex-Fellow  of  Trinity  College,  and  a 
learned  scholar  and  mathematician.  It  was  a  source  of  regret 
to  William  Stokes  in  after  life  that  he  had  not  been  allowed 
to  enter  College,  but  this  circumstance  was  compensated  in  his 
case  to  some  extent  by  the  intimate  personal  relations  into  which 
he  was  led  thereby  with  his  father.  This  early  intercourse 
with  so  able  and  active  a  man  led  him,  no  doubt,  to  appreciate 
the  great  opportunities  which  he  had  on  arriving  in  Edinburgh, 
at  that  time  the  most  active  scientific  University  in  the  king- 
dom. He  left  his  home  at  the  age  of  nineteen  for  Glasgow, 
where  he  remained  some  months,  passing  on  to  Edinburgh  in 
the  spring  of  1823.  There  the  circumstance  occurred  which 
exercised  the  deepest  influence  on  his  future  life.  He  became 
the  pupil  of  William  Alison,  the  Professor  of  Medicine,  whose 
name  no  pupil  or  friend  can  write  without  feelings  of  the  deepest 
admiration,  affection,  and  gratitude.  Later  in  life,  Dr.  Stokes 
wrote  of  this  remarkable  man  :  "  Alison  was  the  best  man  I  ever 
knew.  I  wonder  how  it  has  happened  that  men  should  forget 
what  reverence  is  due  to  his  memory — whether  we  look  on  him 
personally  as  a  man  of  science  and  a  teacher,  or  at  his  life  as  that 
of  an  exemplar  of  a  soldier  of  Christ.  It  was  my  good  fortune 
to  be  very  closely  connected  with  him  during  my  student  days  in 
Edinburgh,  and  to  attend  him  by  day,  and  more  often  far  into 
the  night,  in  his  visits  of  mercy  to  the  sick  poor  of  that  city,  to 
whom  he  was  for  many  a  year  physician,  counsel,  and  support." 
William  Stokes  had,  indeed,  just  the  nature  to  be  led  captive  by 
that  noble  man.  He  followed  him  by  day  and  by  night  in  his 
wanderings  through  the  wretched  wynds  and  the  then  miserable 
haunts  of  Edinburgh  ;  he  saw  the  acute  observer  investigating 


MEMOIR.  ix 

every  form  of  the  severest  disease,  whether  in  the  homes  of  the 
poor  or  in  the  wards  of  the  great  Infirmary  ;  and  he  watched  the 
workings  of  the  tender  spirit  whose  goodness  surpassed  even  its 
great  scientific  knowledge,  and  drew  in  the  lessons  to  be  derived 
from  one,  in  whom  the  pursuit  of  intellectual  truth  in  things 
material  or  physiological  was  a  passion,  hut  who  yet  never 
seemed  to  forget  that  the  moral  elevation  of  his  fellow-men 
was  a  worthier  object  than  the  promotion  of  their  material 
interests  and  comforts. 

Of  his  life  as  a  student  I  am  unable  to  find  details,  but  what 
has  just  been  said,  added  to  one  other  fact,  is  sufficient.  Before 
he  left  Edinburgh,  at  the  end  of  two  years  residence,  he  had 
prepared  for  publication  and  published  a  volume  on  the  use  of 
the  stethoscope — for  which  little  work  he  received  the  large  sum 
of  .£70.  No  better  evidence  than  this  can  be  adduced  of  the 
effect  that  the  influence  of  Alison  and  others  had  upon  the 
young  Irish  student.  Yet  I  cannot  forbear  relating  a  story 
of  how  this  influence  began,  as  I  have  heard  it,  not  from 
himself,  but  from  his  family.  He  was  walking  one  wet 
night  down  the  old  Cowgate ;  he  observed  a  crowd  at  the 
entrance  of  a  dark  passage  ;  he  stopped  to  see  what  it  could 
mean  ;  he  entered  a  low  room  filled  with  sick  poor  and  Professor 
Alison  seated  among  them  ;  he  watched  the  scene  ;  a  young  man 
evidently  suffering  from  advanced  fever  stepped  forward.  Alison 
said,  "  My  poor  man  "  (I  can  now  hear  him  say  it),  "  go  to  your 
bed,  and  when  I  have  done  here  I  will  come  to  you."  Young 
Stokes  then  stepped  forward  and  said,  "  Sir,  I  will  take  the  poor 
man  to  his  home."  "  Who  are  you  ?  "  asked  Alison.  "  One  of 
your  pupils  ;  my  name  is  Stokes."  "  I  never  saw  you  before," 
said  Alison.  "  Perhaps  not,  but  I  have  seen  you,  for  I  go  to 
your  lectures.  Let  me  take  the  poor  man  home,  and  I  will  come 
and  tell  you  how  he  goes  on."  "  Very  well,"  said  Alison,  "  you 
may  go."  From  that  time  they  were  companions  and  friends. 
With  this  seed,  scientific  and  human,  I  would  almost  say  Christ- 
like or  divine,  thus  sown,  Stokes  returned  to  Dublin,  to  face  in 


X  MEM0IK. 

his  native  metropolis  the  realities  of  professional  life  in  similar 
scenes.  He  left  Scotland  in  1825.  Before  he  left  he  had  formed 
an  attachment  to  a  lady,  who  in  1828  became  his  wife. 

Thus  prepared,  Mr.,  now  Doctor,  Stokes,  of  the  University  of 
Edinburgh,  settled  in  Dublin  to  enter  on  his  professional  life. 
He  brought  with  him  the  reputation  of  having  already,  while 
still  a  student,  published  an  important  treatise  on  Diseases  of 
the  Chest,  fully  abreast  with  the  most  advanced  knowledge  of 
the  day,  and  a  subject  the  development  of  which  has  marked  one 
of  the  greatest  epochs  in  the  history  of  medicine.  He  was  at  once 
elected  Physician  to  the  great  Meath  Hospital,  in  the  place  of 
his  father,  who  had  resigned.  He  became  the  colleague  of  Dr. 
Robert  Graves,  one  of  the  most  remarkable  men  that  Ireland 
has  produced  in  the  profession  of  medicine ;  nay  more,  one  of 
the  truest  geniuses  which  that  profession  has  seen  in  any 
country.  The  two  henceforward  were  friends ;  and  being  friends, 
were  comrades  in  what  they  both  felt,  and  properly  felt,  to  be  a 
hard  fight  with  actual  evils,  physical  and  moral.  Hence- 
forward Stokes  is  to  be  thought  of  as  above  all  else  the 
Physician  of  the  poor,  working  in  a  great  and  famous  Hospital, 
surrounded  by  pupils  hanging  on  his  lips,  and  who  himself 
remained  through  life  the  most  devoted  student  and  keenest 
observer  of  his  whole  class.  Whatever  he  acquired  of  duty, 
honour,  or  place  in  after  life,  was  engrafted  on  this  fundamental 
office  and  character.  He  began  at  once  to  lecture.  About  this 
time,  August,  1826,  when  he  was  22  years  of  age,  he  writes  : 
"  I  rise  early,  write  until  breakfast,  then  go  to  dispensary, 
where  I  sit  in  judgment  on  disease  for  an  hour;  then  to  the 
hospital,  where  I  go  round  the  wards  attended  by  a  crowd  of 
pupils ;  from  the  hospital  I  return  home,  write  again  till  two, 
and  then  go  round  and  visit  my  patients  through  different  parts 
of  the  town  attended  by  a  pupil.  My  patients  have  all  one  great 
defect,  viz.,  that  instead  of  giving  money,  they  too  often, 
unfortunate  beings,  have  to  solicit  it  from  their  medical  atten- 
dant ;  and  who,  with  the  heart  of  a  man,  would  refuse  to  relieve 


MEMOIR.  XI 

their  sufferings  when  he  has  a  shilling  in  his  pocket  ?  A  poor 
woman  whom  I  attended  for  long,  and  who  ultimately  recovered, 
said,  '  Oh,  Doctor,  you  have  given  me  a  good  stomach,  but  I  have 
nothing  to  put  into  it.'  " 

In  the  autumn  and  winter  of  this  same  year,  1826,  fever  was 
raging  in  Dublin  in  consequence  of  the  great  distress  caused  by 
the  failure  of  the  potato  crop  in  summer.  He  writes,  September 
17th,  "Were  you  in  Dublin  just  now  you  would  be  shocked  at 
the  distress,  aggravated  by  disease,  under  which  the  lower  classes 
are  labouring.  They  are  literally  lying  in  the  streets  under  fever, 
turned  by  force  out  of  their  wretched  lodgings,  their  bed  the  cold 
ground,  and  the  sky  their  only  roof.  We  have  now  240  cases  in 
the  Meath  Hospital  of  fever,*  and  yet  we  are  daily  obliged  to 
refuse  admittance  to  crowds  of  miserable  objects  labouring  under 
the  severest  form  of  the  disease.  God  help  the  poor !  I  often 
wonder  why  any  of  them  who  can  afford  it  should  remain  in  this 
land  of  poverty  and  misrule.  Government  has  now  opened  in 
different  parts  of  the  town  hospitals  with  accommodation  for 
1,100  patients,  and  yet  this  is  not  half  enough.  I  walked  out 
the  other  night,  and  on  passing  by  a  lane  my  attention  was 
arrested  by  a  crowd  of  persons  gathered  in  a  circle  round  a  group 
which  occupied  the  steps  of  a  hall  door.  This  was  a  family,  con- 
sisting of  a  father,  mother,  and  three  wretched  children,  who  had 
been  just  expelled  from  their  lodgings  as  having  fever.  The 
father  was  in  high  delirium,  and  as  I  approached  him  started 
off  and  ran  down  the  street ;  the  mother  was  lying  at  the  foot  of 
the  door  perfectly  insensible,  with  an  infant  screaming  on  the 
breast,  where  it  had  sought  milk  in  vain,  and  the  other  two  filled 
the  air  with  their  lamentations.  It  was  a  shocking  sight  in- 
deed. No  one  would  go  near  them  to  bring  them  even  a  drop 
of  cold  water.  In  a  short  time,  however,  I  succeeded  in  having 
them  all  carried  to  the  hospital,  where  they  have  since  recovered." 

Thus,  by  hospital  practice,  by  attendance  on  the  poor  in  their 
own  homes,  and  by  constant  teaching  in  both,  he  acquired,  and 

*  Shortly  afterwards  this  hospital  accommodated  300  fever  patients. 


Xll  MEMOIR. 

continued  to  acquire,  the  material  which  through  a  long  lifa 
■was  freely  distributed  by  writing,  by  lectures,  and  by  personal 
intercourse.  The  printed  systematic  works  which  he  published 
during  the  next  forty-five  years  were  not  as  numerous  as  those 
of  many  other  great  practitioners,  but  as  naturally  the  case  with 
one  who  had  gone  through  such  a  course  of  training,  every 
utterance  of  his  was  weighty  and  full.  The  circumstances  of 
the  time  had  specially  directed  his  attention  to  the  works  of 
Laennec,  and,  as  we  have  already  seen,  to  the  use  of  the  stetho- 
scope. Accordingly,  although  he  lectured  on  medical  practice 
generally,  he  was  specially  storing  his  mind  with  every  fact  and 
inference  bearing  on  pulmonary  disease.  This  knowledge  cul- 
minated in  the  work  reprinted  in  this  volume.  It  was  published 
in  1837,  twelve  years  after  his  return  from  Edinburgh.  But 
prior  to  that,  in  1828,  he  printed  two  lectures,  dedicated  to  the 
class  of  the  Meath  Hospital,  on  the  application  of  the  stethoscope 
to  the  diagnosis  and  the  treatment  of  thoracic  disease.  That 
which  appears  now  so  obvious  as  to  be  of  the  nature  of  truism 
then  required  argument.  In  his  own  words,*  "  a  new  source 
of  knowledge  has  been  lately  added  to  medicine ;  the  sense  of 
hearing  has  been  called  to  our  assistance,  and  has,  I  will  affirm, 
added  more  to  the  facility,  certainty,  and  utility  of  diagnosis 
than  anything  which  has  been  done  for  centuries.  By  the 
stethoscope  we  substitute  the  ear  for  the  eye ;  penetrate  into  the 
mysteries  of  hidden  disease,  and  throw  light  on  a  class  of 
affections  perhaps  more  important  than  most  of  those  to  which 
the  human  frame  is  liable."  And  it  is  worth  noticing  by  the 
way  that  in  these  technical  lectures  he  takes  the  opportunity  of 
reminding  the  surgical  students  of  that  day  to  avoid  the  error  of 
neglecting  what  were  termed  medical  diseases.  The  line  of 
distinction  in  the  study  of  the  two  professions  of  medicine  and 
surgery  is  now  looked  upon  by  the  liberal  and  enlightened  to 
serve  neither  and  to  injure  both,  and  he  tells  all  the  students  in 
his  faithful  and  graphic  way  that  "  the  stethoscope  is  an  instru- 
*  Two  lectures  on  the  Application  of  the  Stethoscope.    Dublin,  1828,  p.  12. 


MEMOIR.  xiii 

ment,  not,  as  some  represent  it,  the  bagatelle  of  a  day,  the  brain- 
born  fancy  of  some  speculative  enthusiast,  the  use  of  which,  like 
the  universal  medicine  of  the  animal  magnetism,  will  be  soon 
forgotten,  or  remembered  only  to  be  ridiculed.  It  is  one  of 
those  rich  and  splendid  gifts  which  Science  now  and  then 
bestows  upon  her  most  favoured  votaries,  which,  while  they 
extend  our  views  and  open  to  us  wide  and  fruitful  fields  of 
inquiry,  confer  in  the  meantime  the  richest  benefits  and  blessings 
on  mankind.  This  instrument  was  first  introduced  by  one  whose 
works  will  ever  remain  as  an  example  of  patient  investigation, 
philosophical  research,  and  brilliant  discovery,  and  its  use  is  now 
supported  by  the  liberal  and  enlightened  and  the  scientific 
portion  of  the  medical  world."  I  cannot  but  remember  now 
that  more  than  ten  years  after  this  passage  was  written,  I 
myself  being  a  clerk  in  a  great  hospital,  had  to  withstand  the 
ridicule  of  an  able  teacher  for  devoting  myself  to  the  mastery  of 
the  instrument. 

Nine  years  elapsed  before  he  published  the  present  volume. 
As  the  volume  is  in  the  hands  of  the  reader  it  is  hardly  desirable 
to  offer  an  analysis  of  its  contents,  or  to  give  any  judgment  upon 
them.  It  is  perhaps  sufficient  to  say  that  it  at  once  placed  him, 
in  the  opinion  of  the  whole  medical  profession,  in  the  front  rank 
of  observers  and  thinkers. 

The  terseness  of  his  language  and  clearness  of  his  statements 
produced  a  profound  impression  on  vigorous  and  active  young 
minds  at  the  time.  The  precise  summaries  at  the  end  of  the 
various  chapters,  notably  that  of  the  physical  signs  of  diseases 
of  the  pleura,  seemed  almost  a  revelation  both  in  statement  of 
fact  and  drawing  of  inference. 

Such  was  the  book  which  raised  Stokes  to  the  high  position 
which  he  ever  after  maintained.  It  is  worthy  of  note  in 
the  present  day  that  one  of  his  settled  beliefs  was  that  true 
progress  in  any  art  is  gradual  and  cautious,  and  that  the  wisest 
worker  carefully  and  thankfully  uses  all  good  material  left  by 
predecessors.     "If  you  would  advance  a  knowledge,"  he  would 


XIV  MEMOIR. 

say,  "  be  content  to  take  up  the  thread  where  the  last  investigator 
laid  it  down,  and  set  yourself  to  carry  on  his  work."  In  this 
temper  he  lived ;  in  this  he  worked.  He  looked  on  himself  as 
promoting  the  objects  of  his  predecessors  and  his  fellow- workers, 
ever  using,  ever  adding,  never  detracting. 

In  a  very  few  years  from  this  period  the  degree  of  M.D.  was 
conferred  upon  him,  honoris  causa,  by  the  University  of  Dublin  ; 
he  was  elected  a  Fellow  of  the  King's  and  Queen's  College  of 
Physicians  of  Ireland  ;  honorary  member  of  the  Imperial  College 
of  Vienna;  of  the  Boyal  Medical  Societies  of  Berlin,  Leipsic, 
Edinburgh,  and  Ghent ;  of  the  Medical  Societies  of  the  Grand 
Duchy  of  Baden,  the  National  Institute  of  Philadelphia,  and 
many  others.  In  1842  he  became  Kegius  Professor  of  Physic 
in  the  University  of  Dublin,  succeeding  his  father,  who  had 
occupied  the  chair  for  many  years.  Dr.  Stokes  published  no 
great  work  from  this  time  for  eighteen  years,  when  another  volume, 
of  a  very  different  character,  but  of  equal  merit,  that  on  Diseases 
of  the  Heart,  confirmed  the  general  impression  of  all  physicians 
of  the  great  powers  of  the  now  veteran  teacher.  This  work  was 
translated  into  German.  The  translator,  Dr.  Lindwurm,  makes 
this  pregnant  remark  in  his  introduction,  "  Our  more  modern 
German  works  are,  to  a  greater  or  less  extent,  only  treatises  on  the 
physical  diagnosis  of  organic  affections  of  the  heart ;  Stokes,  on 
the  contrary,  resists  this  one-sided  tendency,  which  bases  the 
diagnosis  solely  on  physical  signs  and  disregards  the  all-important 
vital  phenomena ;  he  lays  less  weight  on  the  differential  diagnosis 
of  lesions  of  the  several  valves,  and  on  the  situation  of  a  sound, 
than  on  the  condition  of  the  heart  in  general,  and  especially  on 
the  question  as  to  whether  a  murmur  is  organic  or  inorganic, 
and  whether  the  disease  itself  is  organic  or  functional ;  and  he 
devotes  especial  attention  to  functional  disturbances  of  the  heart, 
such  as  occur  in  typhus,  in  anemia,  and  in  nervous  conditions 
of  that  organ."  The  book  is  illustrative  of  one  of  the  most  re- 
markable features  of  Stokes'  character.  In  talking  over  a  case 
with  him,  it  was  hard  to  say  which  was  the  more  striking,  his 


MEMOIR.  XV 

power  of  observation  and  sagacity,  or  his  modesty;  and  in  no 
cases  was  this  more  remarkable  than  in  that  class  of  diseases  in 
which  he  was  confessedly  a  supreme  master.     The  reason  of  this 
is  found  in  a  passage  of  the  volume  on  the  heart :  "  The  diagnosis 
of  the  combinations  of  diseases,  even  in  so  small  an  organ  as 
the  heart,  is  still  to  be  worked  out ;  and  until  this  be  done  the 
rules  of  physical  diagnosis  founded  on  the  presumed  isolation  of 
disease  must  be  used  with  great  caution.      I  cannot,  even  at  the 
risk  of  being  charged  with  understating  the  position  of  physical 
investigation  at  the  present  day,    avoid  expressing  my  opinion 
that  a  too  great  positiveness  marks  some  of  the  statements  in 
our  standard  works,  and  that  the  difficulties  of  special  diagnosis 
are  still  infinitely  greater  than  many  might  be  led  to  suppose. 
I  desire  to  enter  a  protest  against  the  tendency,  still  too  prevalent 
in  many  schools,  which  would  base  the  diagnosis  of  disease  in 
great  part,  if  not  entirely,  on  the  consideration  of  purely  physical 
signs,  to  the  exclusion  of  that  important  class   of  phenomena 
which,  for  want  of  a  better  name,  we  are  obliged  still  to  call 
Vital.     For  there  is  nothing  more  calculated  than  this  to  cause 
the  neglect  of  that  first  and  greatest  lesson  in  medicine,  which, 
while  inculcating  modesty  and  caution  in  diagnosis,  makes  us 
bring  every  possible  light  to  bear  on  the  case  before  us.     As  the 
student   fresh  from  the   schools,    and   proud  of    his    supposed 
superiority  in  the  refinements  of   diagnosis,  advances  into  the 
stern  realities  of  practice,  he  will  be  taught  greater  modesty,  and 
a  more  wholesome  caution.     He  will  find,  especially  in  chronic 
disease,  that  important  changes  may  exist  without  corresponding 
physical  signs — that   as   disease    advances    its    original    special 
evidences  may  disappear— that  the  signs  of  a  recent  and  trivial 
affection  at  one  portion  of  the  heart  may  altogether  obscure,  or 
prevent,  those  of  a  disease  longer  in  standing  and  much  more 
important — that  functional  alteration  may  not  only  cause  the 
signs  of  organic  lesion  to  vary  infinitely,  but  even  to  wholly  dis- 
appear—that the  signs  on  which  he  has  formed  his  opinion  to- 
day may  be  wanting  to-morrow — and,  lastly,  that  to  settle  the 


XVI  MEMOIR. 

simple  question  between  the  existence  of  functional  and  that  of 
organic  disease,  will  occasionally  baffle  the  powers  of  even  the 
most  enlightened  and  experienced  physicians." 

This  volume'on  the  Diseases  of  the  Heart  was  at  once  accepted, 
and  since  has  been  received,  as  one  of  the  most  acute,  graphic, 
and  complete  accounts  of  the  clinical  aspects  of  the  organ 
under  discussion.  It  exemplifies,  in  a  very  remarkable  way,  the 
several  characteristics  of  Dr.  Stokes'  mincl,  at  once  so  purely 
scientific  and  so  eminently  practical.  No  practitioner  can  open 
the  volume  without  feeling  it  to  be  a  store-house  of  knowledge 
obtained  at  the  bed-side.  It  is  sufficient  to  refer  to  the  table  of 
cases  at  the  close  of  the  volume,  and  to  the  several  summaries 
at  the  end  of  the  discussion  of  the  various  forms  of  heart- 
disease,  to  satisfy  oneself  of  the  truth  of  this  observation ;  but 
two  illustrations  of  his  acuteness  and  care  may  be  here  given. 

"  We  read  that  a  murmur  with  the  first  sound,  under  certain 
circumstances,  indicates  lesion  of  the  mitral  valves.  And  again, 
that  a  murmur  with  the  second  sound  has  this  or  that  value. 
All  this  may  be  very  true,  but  is  it  always  easy  to  determine 
which  of  the  sounds  is  the  first,  and  which  the  second  ?  Every 
candid  observer  must  answer  this  question  in  the  negative.  In 
certain  cases  of  weakened  hearts  acting  rapidly  and  irregularly, 
it  is  often  scarcely  possible  to  determine  the  point.  Again  even 
where  the  pulsations  of  the  heart  are  not  much  increased  in 
rapidity,  it  sometimes,  when  a  loud  murmur  exists,  becomes 
difficult  to  say  with  which  sound  the  murmur  is  associated.  The 
murmur  may  mask  not  only  the  sound  with  which  it  is  properly 
synchronous,  but  also  that  with  which  it  has  no  connexion,  so 
that  in  some  cases  even  of  regularly  acting  hearts,  with  a  distinct 
systolic  impulse,  and  the  back  stroke  with  the  second  sound, 
nothing  is  to  be  heard  but  one  loud  murmur. 

"  So  great  is  the  difficulty  in  some  cases,  that  we  cannot  resist 
altering  our  opinions  from  day  to  day  as  to  which  is  the  first  and 
which  the  second  sound. 


MEMOIR.  xvii 

"  To  the  inexperienced  the  detailed  descriptions  of  such  phenomena 
as  the  intensification  of  the  sounds  of  the  pulmonary  valves ;  of 
constrictive  murmurs  as  distinguished  from  non-constrictive ;  of 
associations  of  different  murmurs  at  the  opposite  sides  of  the 
heart ;  of  presystolic  and  post-systolic,  prediastolic  and  post- 
diastolic murmurs,  act  injuriously — first,  by  conveying  the  idea 
that  the  separate  existence  of  these  phenomena  is  certain,  and 
that  their  diagnostic  value  is  established — and  secondly,  by 
diverting  attention  from  the  great  object,  which — it  cannot  be 
too  often  repeated — is  to  ascertain  if  the  murmur  proceeds  from 
an  organic  cause  ;  and  again,  to  determine  the  vital  and  physical 
state  of  the  cavities  of  the  heart. 

•    ■  •  •  •  •  •  * 

"If  the  question  as  to  the  practicability  of  the  negative  diagnosis, 
with  reference  to  either  orifice,  be  raised,  it  appears  probable 
that  where  a  mitral  murmur  is  manifest,  it  will  be  easier  to 
determine  the  absence  of  disease  of  the  aortic  valves  than  to 
declare  the  integrity  of  the  mitral  valves  in  a  case  of  aortic 
patency.  The  experience  of  each  succeeding  day  devoted  to  the 
study  of  diseases  of  the  heart  will  make  us  less  and  less  confident 
in  pronouncing  as  to  the  absence  of  disease  in  any  one  orifice, 
although  no  physical  sign  of  such  a  lesion  exist,  if  there  be 
manifest  disease  in  another,  or  again,  if  there  be  symptoms  of 
an  organic  affection  of  the  heart." 

About  this  time,  1854,  he  published  the  lectures  on  Fever  in 
the  Medical  Times  and  Gazette.  These  were  afterwards  col- 
lected, but  not  before  the  year  1874,  into  a  single  volume  with 
additions.  In  this  volume  he  did  not  pretend  to  give  even  a 
sketch  of  all  that  is  known  or  believed  to  be  known  respecting 
fever.  "  Nothing  will  be  found  in  them  relating  to  histological 
research,  the  chemico-vital  states,  of  the  fluids,  or  organs,  or 
the  analysis  of  the  laws  of  crisis."  He  does  not  even  attempt 
to  weigh  the  evidence  concerning  the  separate  identity  of  fevers, 
and  in  these  respects  surprised  some  who  leant  on  his  judgment 
in  the  most  absolute  manner.     But,  as  was  his  wont,  he  confined 

b 


Xvili  MEMOIR. 

himself  to  that  which  he  seemed  to  himself  to  know,  and  he 
would  not  allow  himself  to  go  beyond  his  convictions.  In  one  of 
his  early  lectures  he  speaks  of  the  difficulty  of  changing  ideas  in 
which  one  has  been  educated.  "  There  is  nothing  more  difficult," 
he  says,  "than  for  a  man  who  has  been  educated  in  a  particular 
doctrine  to  free  himself  from  it,  even  though  he  has  found  it  to 
be  wron^.  There  is  something  in  the  human  mind  which 
renders  the  reception  of  a  doctrine,  if  it  be  a  bad  one,  a  most 
dangerous  circumstance  ;  it  is  like  the  imbibition  of  a  particular 
poison  or  miasma.  We  find  that  some  men  who  have  once  been 
exposed  to  the  miasmatic  influences  which  cause  intermittent 
fever  will  for  nearly  the  whole  course  of  their  lives  be  incapable 
of  getting  rid  of  that  influence  which  has  been  once  received  ; 
and  thus  it  is  not  only  with  physical  but  with  moral  or  intel- 
lectual impressions."  Whether  he  had  in  mind  when  he  wrote 
these  words  his  own  unwillingness  to  accept  in  full  the  modern 
distinctions  between  fevers  cannot  be  positively  said,  but  he  dis- 
cusses the  subject  in  his  sixth  lecture  with  great  care,  and  he 
seems  quite  unwilling  to  admit  the  modern  accepted  distinctions. 
"  I  have  said,"  he  writes  in  the  seventh  lecture,  "  that  I  hold  the 
study  of  the  marks  or  points  of  agreement  amongst  these  diseases 
to  be  of  more  value  than  that  of  their  differences,  and  for  this 
reason,  that  the  former  bears  on  the  question  of  treatment  much 
more  than  does  that  of  their  distinctions."  He  had  seen, 
studied,  and  treated  fever  on  a  great  scale  for  fifty  years,  and 
like  his  great  master,  Alison,  was  familiar  with  it  in  all  its  forms 
and  under  all  the  conditions  which  appear  to  cause  it.  He 
seemed  never  to  have  satisfied  himself  that  there  were  generic 
differences  in  these  forms,  but  was  inclined  to  consider  them 
varieties.  This  I  learn  on  the  authority  of  Sir  William  Gull  to 
have  been  the  belief  of  Dr.  Alison  to  the  last.  Again  and 
a^ain  this  impression  seems  to  be  ineffaceable  from  Stokes' 
mind.  He  reasoned  on  the  data  he  had  in  Ireland,  as  did 
Alison  in  Scotland,  or  Jenner  in  London.  "  I  have  told  you," 
he  says,   "  that  no  two  epidemics  are  exactly  alike,  eilker  as 


MEMOIR. 


XIX 


regards  their  essential  symptoms  or  local  complications.  .  .  . 
I  have  said  that  this  is  not  the  place  to  go  into  the  history  of 
every  observed  form  of  fever  and  into  various  controversial 
questions  that  have  arisen  regarding  them.  Study  the  excellent 
works  of  Dr.  Murchison,  Dr.  Hudson,  Sir  Wm.  Jenner,  and 
Dr.  Stewart,  and  use  your  own  judgment  as  to  how  far  your 
experience .  bears  on  the  great  questions  therein  discussed ;  in 
the  meantime  let  us  continue  to  study  the  local  complications, 
after  which  we  shall  be  in  a  position  to  deal  with  the  question 
of  the  treatment,  if  not  the  prevention  of  the  disease."  The 
volume  will  always  be  worthy  of  careful  attention  in  historical 
relation  to  the  writings  of  Alison  and  Graves,  Murchison  and 
Jenner,  as  the  observations,  for  preventive  and  therapeutical 
purposes,  of  a  most  acute  physician.  Many  passages  ring  in  it 
as  if  they  had  been  written  by  Sydenham  or  by  Hunter  in  their 
best  moods. 

In  the  year  1863  Dr.  Stokes  edited  a  volume  containing  studies 
in  physiology  and  medicine  by  Dr.  Kobert  Graves,  who  had 
become  Professor  of  the  Institutes  of  Medicine  and  the  School 
of  Physics  in  Ireland.  Of  the  influence  which  these  two  men, 
Graves  and  Stokes,  exercised  on  one  another  for  good  it  would 
not  be  possible  to  speak  too  strongly.  Those  who  remember  the 
effect  which  Graves'  Clinical  Lectures  produced  when  they 
appeared  will  readily  understand  this.  Stokes,  in  writing  of 
him  after  his  death,  calls  him  "the  most  remarkable  man,  from 
his  erudition,  the  variety  of  his  mental  powers,  his  industry, 
and  from  the  multitudinous  additions  which  he  made  to  practical 
medicine,  of  which  the  profession  in  this  country  can  boast." 
He  was  a  man  who  in  a  marked  degree  combined  the  scientific 
mind  of  the  physiologist  with  the  intensely  practical  quickness  of 
the  clinical  observer.  Stokes  used  to  tell  with  delight  a  saying 
of  Graves'.  He  was  going  round  the  hospital,  when  on  entering 
the  convalescent  ward  he  began  to  expatiate  on  the  healthy 
appearance  of  some  who  had  recovered  from  severe  typhus. 
"This   is  all  the   effect  of  our  good  feeding,"  he  exclaimed; 

62 


XX  MEMOIK. 

"  and  lest  when  I  am  gone  you  may  be  at  a  loss  for  an 
epitaph  for  me,  let  me  give  you  one  in  three  words,  '  He  fed 
Fevers.'  "  * 

"  He  was  a  man,"  he  also  said,  "  besides  with  a  warm  and 
sensitive  heart ;  loving  truth  for  its  own  sake,  he  held  in  uncon- 
cealed abhorrence  all  attempts  to  sully  or  distort  it,  and  he  never 
withheld  or  withdrew  his  friendship  from  any,  even  those  below 
him  in  education  and  social  rank,  if  he  found  in  them  the  quali- 
ties which  he  loved,  and  which  he  never  omitted  to  honour." 

And  again :  "  The  world  never  spoiled  him,  so  that  he  pre- 
served most  of  the  youthful,  and  all  the  kindly  and  better 
qualities  of  his  mind  up  to  the  hour  of  his  death." 

His  volumes  of  clinical  medicine,  and  his  remarkable  powers 
as  a  clinical  teacher  will  never  be  forgotten  in  the  history  of 
Ireland.  His  Physiological  Essays,  edited  by  Dr.  Stokes,  derive 
their  chief  present  interest  from  the  personal  characters  of  the 
author  and  editor. 

During  the  three  epochs  of  Dr.  Stokes'  life  marked  out  by  the 
intervals  between  the  publication  of  his  principal  works, — viz., 
his  volume  on  the  Stethoscope  in  1825  at  Edinburgh ;  that  on 
Diseases  of  the  Chest  in  1837  ;  on  the  Heart  in  1854  ;  and  on 
Fever  in  1874, — each  of  them  evidencing  in  different  ways  the 
mixed  scientific  and  practical  nature  of  his  professional  life, — a 
tide  of  other  medical  writing  was  flowing  in  full  force  from  his 
pen.  These  writings  were  very  various.  A  series  of  Lectures 
on  the  Practice  of  Physic,  written  between  1832  and  1835,  and 
delivered  in  the  Meath  Hospital  and  the  Park  Street  School, 
appeared  in  the  London  Medical  and  Surgical  Journal  (vols. 
3,  4,  5,  6).  They  were  reprinted  in  America;  and  the  volume 
was  edited  afterwards,  with  additional  matter,  by  Dr.  Bell,  and 
became  one  of  the  standard  medical  treatises  of  the  United 
States.  He  was  at  this  time  only  twenty-eight  years  of  age. 
He  wrote  seven  articles  for  the  Cyclopaedia  of  Medicine  between 
1832  and  1835.  The  subjects  were,  Derivatives,  Dysphagia, 
Enteritis,  Gastritis,  Gastroenteritis,  Inflammation  of  the  Liver ; 


MEMOIR. 


XXI 


and  in  conjunction  with  Dr.  Mac  Adam,  Peritonitis.  Under  what 
circumstances  this  particular  class  of  subjects  was  assigned  to 
Dr.  Stokes  I  have  no  evidence.  In  the  Dublin  Medical  Journal 
there  are  various  important  papers.  One  in  the  volume  for 
1832  is  on  the  use  of  large  doses  of  opium  in  certain  cases 
of  disease,  a  paper  of  great  practical  value.  It  will  interest 
pupils  of  his  revered  teacher  Alison,  with  whom  this  subject 
was  one  of  cardinal  importance.  This  was  followed  by  two  of 
not  less  moment  from  the  point  of-  view  of  practice  and  treat- 
ment. One  in  1833  is  on  the  Diagnosis  of  Pericarditis.  The 
other  paper  in  1839  is  on  the  "  State  of  the  Heart,  and  the  Use 
of  Wine  in  Typhoid  Fever."  His  words  at  the  outset  of  this 
treatise,  written  more  than  forty  years  ago,  are  so  graphic  that 
they  may  be  quoted  here  for  the  sake  of  younger  readers  who  do 
not  know  the  story  of  the  past. 

"  If  we  compare  the  inexperienced  man  with  him  who  has 
had  a  long-continued  practice  in  fever,  we  may  often  observe  that 
the  former  employs  a  too  vigorous  antiphlogistic  treatment  in 
the  commencement  of  the  disease,  and  delays  the  exhibition  of 
stimulants  until  the  powers  of  life  are  sunk  too  long,  while  the 
latter  is  much  more  cautious  in  husbanding  the  strength  of  his 
patient,  and  shews  much  less  fear  of  resorting  to  wine  and  other 
stimulants.  It  is  in  determining  on  the  use  of  wine  in  fever 
that  the  junior  or  inexperienced  man  feels  the  greatest  difficulty  ; 
•it  is  in  its  exhibition  that  he  betrays  the  greatest  uncertainty 
and  fear.  This  is  to  be  explained  by  referring  to  the  general 
character  of  the  doctrines  which  have  prevailed  within  the  last 
quarter  of  a  century,  and  which  are  only  now  beginning  to  yield 
to  a  more  rational  pathology.  The  doctrine  of  an  exclusive  or 
almost  exclusive  solidism  which  referred  all  diseases  to  visible 
changes  of  organs,  which  taught  that  inflammation  was  the  first 
and  principal  morbid  phenomenon,  and  that  fevers  were  always 
the  result  of,  or  accompanied  with,  some  local  inflammation,  was, 
however  disguised  under  various  denominations,  the  doctrine 
taught  to  the  majority  of  our  students.     Their  ideas  were  thus 


XX11  MEMOIR. 

exclusively  anatomical ;  inflammation  formed  the  basis  of  their 
limited  pathology,  and  thus  instructed,  they  entered  on  the  wide 
field  of  practice,  most  of  them  having  never  even  attended  a 
fever  hospital ;  utterly  ignorant  of  the  nature  of  essential  fevers, 
tbey  applied,  in  the  diseases  of  debility,  the  treatment  of  acute 
local  inflammation,  and  delayed  stimulation  until  nature  could 
not  be  stimulated.  Let  it  not  be  supposed  that  in  this  picture 
I  seek  to  make  a  favourable  contrast  between  the  education 
which  I  myself  received,  and  that  given  to  others — far  from  it, 
I  confess  that  it  was  not  until  several  years  after  I  commenced 
practice  that  I  became  fully  aware  of  the  erroneousness  of  what 
is  termed  the  anatomical  theory  of  disease ;  and  I  feel  certain, 
humiliating  though  the  confession  may  be,  that  the  fear  of 
stimulants  in  fever  with  which  I  was  imbued,  was  the  means  of 
my  losing  many  patients  whose  lives  would  have  been  saved,  had 
I  trusted  less  to  the  doctrine  of  inflammation,  and  more  to  the 
lessons  of  experience,  given  to  us  by  men  who  observed  and 
wrote  before  the  times  of  Bichat  or  of  Hunter. 

"  The  hospital  physician  will  be  frequently  asked  by  students  to 
state  the  principle  on  which  he  administers  wine  in  fever.  I 
conceive  the  question  may  be  thus  answered.  Typhus  fever  is 
a  disease  which  has  a  tendency  to  a  spontaneous  and  favourable 
termination,  but  one  in  the  course  of  which  the  powers  of  life 
are  attacked  by  a  most  malignant  influence.  By  wine,  food,  and 
other  stimulants  we  support  nature,  until  the  struggle  is  past,  so 
that,  to  use  the  words  of  an  ancient  author,  which  embody  a 
more  profound  principle  than  appears  at  first  sight,  we  '  cure 
the  patient  by  preventing  him  from  dying  ' ;  that  is  to  say,  we 
prolong  his  existence  until  the  natural  and  favourable  termination 
of  the  disease  arrives.  We  do  not  allow  our  patients  to  die  of 
exhaustion,  and  bearing  in  mind  the  depressing  influence  they 
have  to  struggle  with,  we  give  stimulants  at  the  proper  time  and 
with  a  bold  hand.  We  give  our  patients  an  artificial  life  till  the 
period  arrives  when  nature  and  health  resume  their  sway." 

Between  these  papers  was  one  on  the  Pathology  of  Aneurism 


ilEMOIR.  XX111 

« 

(1834),  aud  one  on  Emphysema  (1836),  besides  others  on  points 
of  Thoracic  Pathology,  shewing  the  clear  purpose  for  which  his 
mind  was  being  stored  with  the  knowledge  that  was  to  bear  fruit 
in  his  mature  life.*  He  was  now  only  thirty-three  years  of  age. 
His  great  work  on  the  Diseases  of  the  Chest  was  published.  He 
became  overwhelmed  with  private  practice.  At  the.  Meath 
Hospital  he  worked,  thought,  and  taught.  Henceforward, 
wherever  he  spoke  or  wrote,  men  felt  that  there  was  one  who 
spoke  and  wrote  only  when  there  was  something  which  should 
not  be  withheld.  Of  such  utterances  there  is  a  remarkable  illus- 
tration in  a  paper  by  himself  and  Dr.  Cusack  on  the  mortality  of 
medical  men  in  Ireland.  They  only  who  know  Ireland  can  fully 
estimate  either  the  sufferings  of  the  people,  or  the  devotion 
of  such  active  and  able  men  as,  loving  their  country,  live  for  it ; 
and  who,  living  there,  work  with  discretion  and  steadiness.  The 
occasion  of  this  document  was  the  deep  sense  he  entertained  of 
the  hardships  and  dangers  to  which  the  medical  men  in  Ireland 
are  exposed  in  attending  on  Fever  Hospitals  and  Dispensaries. 
Many  old  pupils  had  fallen  victims ;  they  had  perished  while 
living  on  the  poorest  pittance  from  the  Government,  and  their 
widows  were  unprovided  for.  Ireland,  from  whatever  cause,  is 
most  productive  of  fever.  In  ten  years  prior  to  June,  1841,  a 
period  not  characterized  by  any  remarkable  epidemic,  nearly  one- 
tenth  of  all  deaths  in  the  province  of  Leinster  was  from  fever.  In 
Ireland,  he  said,  few  medical  men  escape  fever,  and  they 
generally  have  it  with  great  malignity.  It  was  rarely  absent 
from  the  rural  districts,  in  which,  owing  to  the  nature  of  the 
dwellings  and  the  condition  of  the  peasantry,  and  the  distances 
to  be  travelled,  the  dispensary  surgeon  has  to  meet,  in  cold  and 
wet,  fatigue  and  hunger,  the  most  concentrated  contagion.  A 
cholera  epidemic  is  far  less  dangerous  than  the  ordinary  typhus. 
Of  1,220  medical  men  in  charge  of  406  Medical  Institutions,  568 
had  fever  between  1818  and  1843.  These  facts,  among  which  he 
lived,   and  which  he    collected   with  care,  became  the  subject 

*  For  a  list  of  his  minor  papers  see  Note,  p.  xlii. 


XXIV  MEMOIE. 

of  Parliamentary  inquiry.     Though  so  recent,  they  seem  now  as 
the  ghastly  tale  of  some  dark  bygone  age. 

The  keen  interest  which  Dr.  Stokes  had  in  all  that  concerned 
the  condition  and  happiness  of  the  medical  profession  is  illus- 
trated by  the  paper  just  discussed.  One  of  the  methods  in  which 
through  life  this  strong  feeling  was  displayed,  is  seen  in  the 
efforts  which  he  made  to  advance  the  culture  of  the  profession. 
His  opinion  on  this  subject,  in  the  year  1861,  should  be  told  in 
his  own  words  :  "  The  chief,  the  long  existing,  and,  I  grieve  to 
say  it,  the  still  prominent  evils  among  us  are  the  neglect  of 
general  education,  the  confounding  of  instruction  with  education, 
and  the  giving  a  greater  importance  to  the  special  training  than 
to  the  general  culture  of  the  student."  And  the  reason  of  this 
he  gives  in  these  words  :  "  Let  us  now  ask,  What  is  medicine  ? 
Is  it  an  isolated  science ;  an  exception  to  all  other  branches  of 
human  knowledge  ;  a  study  having  no  use  for  the  great  weapons 
of  the  human  mind,  observation,  and  the  reasoning  power  ?  Are 
the  studies  of  letters,  the  influence  of  history,  ethics,  and  the  laws 
of  physical  science  nothing  to  it  ?  I  will  not  dwell  on  such 
questions,  from  my  respect  for  your  understandings.  But  what 
it  is  not,  it  may  be  wholesome  to  declare.  It  is  not  the  result  of 
a  poor  seed,  sown  on  a  raw  and  sterile  soil.  It  is  not  a  handi- 
craft, governed  by  a  fixed  rule,  or  any  set  of  rules,  that  you  may 
learn  by  rote ;  it  is  not  a  study  of  fixed,  but  of  varying  con- 
ditions. It  is  no  solitary  science,  but  rather  a  complex  system 
of  knowledge  of  many  lands,  derived  from  many  sources — from 
the  observations  of  bygone  years,  and  the  multiplied  discoveries 
of  the  present  day.  It  is  related  to,  and  inseparable  from,  all 
other  branches  of  human  knowledge,  from  which  it  largely 
borrows,  and  to  which  it  pays  back  with  interest."  .  .  .  .  "  The 
old  Universities  of  England  and  Ireland  have  ever  kept  up  the 
dignity  and  the  reality  of  their  medical  degrees.  They  have  not 
sought  to  create  revenue  for  their  schools,  and  increase  the  mem- 
bers attending  in  their  medical  classes,  by  lowering  the  degree 
in  Medicine  below  that  in  Divinity  or  in  Law.  .  .  .  They  have 


MEMOIR.  XXV 

taken  a  right  view  of  the  first  objects  of  their  foundation, 
which  are  the  general  mental  culture  and  moral  training  of  all 
over  whom  their  powers  may  extend.  With  them  the  general 
culture  has  been  the  leading  object,  and  has  been  fostered  and 
valued,  first,  for  its  own  sake,  and  next,  as  giving  the  only  safe 
ground  for  such  special  instruction  as  may  be  requisite  for  this 
or  that  calling."  .  .  .  "  The  Medical  Council  have  marked  their 
sense  of  the  predominating  importance  of  general  culture  in  this 
wise — that  their  Eeport  on  Medical  Education  deals  almost 
wholly  with  the  subject  of  general  or  extra-professional  training. 
It  hardly  touches  on  special  education  except  so  far  as  relates 
to  the  mode  of  conducting  examinations.  The  Council  have 
obviously  felt  that  the  greater  question  claimed  their  first  care." 
And,  speaking  of  the  modern  system  of  cramming  for  examina- 
tions, he  says:  "  It  is  a  system  the  evils  of  which  have  increased, 
in  place  of  diminishing.  The  overloading  of  special  instruction 
will  not  help  but  really  retard  the  production  of  the  higher  class 
of  men.  ...  It  was  not  in  this  fashion  that  the  fathers  of 
British  Medicine  were  moulded ;  nor  our  great  Jurists,  or  our 
learned  and  pious  Theologians  were  trained.  Will  not  its  result 
be,  at  the  best,  to  produce  a  crowd  of  mediocrities,  with  no 
chance,  or  but  a  little  one,  of  the  development  of  the  larger  man?" 
And  then  he  ends  this  address,  delivered  at  the  Meath  Hospital, 
from  which  these  passages  have  been  quoted,  thus :  "  Let  us 
labour  to  place  the  teaching  of  medicine  in  its  true  position. 
Let  us  emancipate  the  student,  and  give  him  time  and  oppor- 
tunity for  the  cultivation  of  his  mind,  so  that  in  his  pupilage  he 
shall  not  be  a  puppet  in  the  hands  of  others,  but  rather  a  self- 
relying  and  reflecting  being.  Let  us  ever  foster  the  general 
education  in  preference  to  the  special  training,  not  ignoring  the 
latter,  but  seeing  that  it  be  not  thrust  upon  a  mind  uncultivated 
or  degraded.  Let  us  strive  to  encourage  every  means  of  large 
and  liberal  education  in  the  true  sense  of  the  term,  and  so  help  to 
place  and  sustain  our  noble  profession  in  the  position  which  it 
ought  to  occupy." 


XXVI  MEMOIR. 

I  must  repeat  once  more  that  nothing  impresses  me  more 
on  looking  through  his  various  utterances  in  relation  to  the  con- 
dition of  medicine  in  this  country  than  the  intensity  with  which 
he  feels  the  importance  not  only  of  training  the  faculties  of 
reason  and  observation,  but  also  at  promoting  the  general  culture 
of  the  mind.  He  breaks  out  from  time  to  time,  apparently 
with  horror,  of  the  opposite  views.  In  one  address  concerning 
the  effect  of  small  professional  corporations  he  says  :  "  The 
student  was  taught  not  only  in  private,  but  in  public  lectures, 
that  he  should  make  his  special  training  the  great  object.  He 
was  taught  to  neglect  the  larger  culture  of  his  mind,  and  the 
lower  aim  was  ever  kept  before  him.  No  wonder  that  in  course 
of  time  the  claims  of  medicine  to  be  considered  as  one  of  the 
leading  professions  were  lowered.  It  is  plain  that  unless  all 
this  be  changed,  unless  this  cancer  be  eradicated,  the  time 
will  come  when  we  shall  be  shamed  by  seeing  the  more  difficult 
problems  of  medicine  attempted  and  solved  by  men  outside  the 
profession  ;  men  of  large  and  liberal  education,  who  will  succeed 
in  doing  that  which  its  proper  members  were  unable  to  perform. 
Among  the  many  errors  which  Ave  must  try  to  get  rid  of  in 
dealing  with  this  matter,  this  is  one  of  such  magnitude  that  to 
its  existence  may  be  traced  most  of  the  evils  that  beset  the 
student  of  medicine." 

I  am  bound  to  record,  in  connexion  with  this  subject,  the 
deep  interest  which  he  took  in  the  progress  of  opportunities  for 
scientific  education  in  Oxford,  whether  in  its  bearing  on  the 
general  Education  of  the  Country,  or  the  Education  of  the 
Medical  Profession.  He  shewed  in  his  writings  and  speeches 
how  he  desired  chiefly  for  his  profession  that  its  youth  should 
have  access  to  the  same  culture,  should  enjoy  the  same  thorough 
education  of  their  higher  faculties,  and  should  be  placed  in  the 
same  circumstances  for  the  elevation  of  their  personal  character, 
as  our  Statesmen,  our  Clergy,  or  the  members  of  the  liar.  He 
looked,  therefore,  with  much  interest  at  the  modern  exertions 
which  were  made  by  the  ancient  Universities  to  give  that  kind 


MEMOIR.  XXvii 

of  fundamental  scientific  training  which  should  be  useful  to  the 
members  of  his  own  profession,  prior  to  their  introduction  to 
the  great  schools  for  studying  pathological  phenomena  and 
pursuing  therapeutical  observation,  which  are  supplied  by  our 
great  metropolitan  Hospitals. 

His  conversation  and  his  addresses  were  full  of  observations 
bearing  so  forcibly  on  medical  education  that  a  few  of  them  must 
here  be  quoted.  For  instance,  "It  is  with  societies  of  men,  as 
well  as  with  individuals,  that  which  commands  scientific  respect 
does  not  so  much  depend  on  the  successful  teaching  of  what  has 
already  been  discovered,  as  upon  the  production  of  original  work 
by  the  society  or  individuals." 

2.  "  It  is  with  the  living  that  medicine  has  to  do.  The  living 
man  must  be  studied  in  health  as  in  disease  ;  to  the  ph}  sician  or 
surgeon  the  sick  or  wounded  man  is  as  the  mineral  to  the 
geologist,  as  the  star  to  the  astronomer." 

3.  "  Other  schools  have  earned  a  reputation  in  physiology  and 
comparative  anatomy,  and  those  branches  of  medicine  which  are 
termed  theoretic  ;  but  the  enduring  fame  of  the  Dublin  contribu- 
tions to  science  arises  from  their  essential  practicality  and  truth- 
fulness. They  are  records  of  unbiassed  observation  made  by 
men  originally  well  educated  and  brought  up  in  a  practical  school." 

4.  "  There  can  be  no  greater  error  than  to  compel  a  medical 
officer  to  attend  to  a  number  of  patients  beyond  that  which  his 
mental  or  physical  powers  can  reach.  I  speak  from  experience 
when  I  say  that  no  physician  or  surgeon  ought  to  be  called  on  to 
attend  more  than  fifty  hospital  patients  daily ;  to  treat  more  than 
this  proportion  causes  exhaustion  both  of  body  and  mind,  and  he 
is  rendered  unfit  to  perform  duties  which  of  all  others  require  a 
quiet  mind  and  a  vigorous  frame." 

5.  "  Additional  encouragement  must  be  given  to  the  students 
to  obtain  that  education  which  can  alone  fit  them  to  preserve 
the  social  position  and  rank  of  their  profession,  to  use  the 
words  of  a  great  surgeon,  to  keep  it  from  degenerating  into  a 
trade,  and  the  worst  of  trades.     To  me  the  real  patriot  is  he  who, 


XXV111  MEMOIR. 

in  a  life  of  labour  and  of  trial,  with  integrity,  practical  wisdom, 
and  far-seeing  intelligence,  labours  onward  to  no  other  end  but 
that  his  country  shall  rise,  and  with  the  honourable  and  justifiable 
ambition  that,  loving  her,  he  may  rise  with  her  also." 

6.  "In  the  wards  of  the  hospital  the  student  learns  that  which 
cannot  be  taught  in  the  dissecting  room  or  in  the  theatre  ;  he 
learns  to  teach  himself  to  act  and  to  discover ;  and  he 
does  much  more  ;  the  kindlier  feelings  of  his  heart  are  stirred, 
and  he  becomes  so  trained  to  works  of  charity  and  mercy  that 
their  practice  is  at  last  a  second  nature  ;  he  acquires  that  moral 
courage  by  which  at  the  call  of  duty,  or  of  mercy,  which  is  duty, 
he  learns  to  despise  danger,  and  to  meet  death  whether  it  comes 
by  pestilence  or  by  the  sword." 

7.  "  Medicine  cannot  be  taught  in  a  purely  medical  hospital, 
any  more  than  surgery  in  a  purely  surgical  one." 

8.  "  Medicine  is  essentially  a  progressive  science,  and  avails 
itself  of  almost  every  branch  of  knowledge  in  its  progress. 
Medicine  is  an  inexact  science,  but  this  is  no  reproach.  By  this 
very  character  it  enters  into  fellowship  with  the  most  noble  of 
human  inquiries,  with  those  which  have  for  their  objects  the 
relations  of  the  created  to  the  Creator,  the  future  state  of  man, 
his  moral  and  his  intellectual  nature." 

9.  "  We  have  to  do  with  something  which  cannot  be  measured 
or  weighed  ;  something  too  in  which  experiment  can  only  be  used 
within  narrow  bounds  ;  an  element  whose  nature  is  yet  unknown, 
fleeting  in  its  action,  and  every  day  producing  new  combinations, 
not  merely  new  because  they  were  never  observed  before,  but 
really  new  as  appearing  for  the  first  time." 

10.  "Every  connexion  that  can  be  established  between  the 
mathematical  and  physical  sciences  and  medicine  will  impart  to 
it  more  or  less  of  certainty." 

11.  "  Medicine,  in  its  great  quality  as  a  practical  art,  advances 
in  many  directions ;  of  which  two  may  be  indicated  as  the  most 
important.  One  is  the  discovery  of  new  facts,  whether  relating 
to  physiology,  pathology,  or  therapeutics,  each  of  which,  even 


MEMOIR.  XXIX 

although  its  practical  bearing  be  not  apparent,  enlarges  the 
boundaries  of  the  field  of  certainty.  The  second  is  the  applica- 
tion of  those  new  facts,  on  the  one  hand,  to  testing  the  value 
of  methods  long  in  use ;  and,  on  the  other,  as  a  guide  in 
the  wilderness  of  the  unknown  which  stretches  around  us, 
which  we  are  seeking  to  explore,  and  which  we  hope  in  time  to 
reclaim." 

12.  "Do  not  be  misled  by  the  opinion  that  a  University 
education  will  do  nothing  more  than  give  you  a  certain  pro- 
ficiency in  classical  literature,  in  the  study  of  Logic  and  Ethics, 
or  in  Mathematical  or  Physical  Science.  If  it  does  these  things 
for  you,  you  will  be  great  gainers,  for  there  is  no  one  branch  of 
professional  life  in  which  these  studies  will  not  prove  the  most 
signal  helps  to  you.  But  it  has  other,  and  equally  important 
results ;  it  enforces  respect  for '  the  ordinances  of  religion  ;  it 
habituates  the  mind  to  the  humility  of  prayer ;  it  enlarges  it  by 
communion  with  contemporaries  who  are  preparing  for  their 
varied  walks  in  life;  and  it  excites  the  best  ambition,  by 
presenting  so  many  examples  of  successful  exertion." 

Thus  far  Dr.  Stokes  has  been  spoken  of  partly  as  an  eager 
student  of  medical  science,  partly  as  a  physician.  We  must  now 
look  upon  him  from  a  somewhat  different  point  of  view.  In  one 
of  his  addresses  he  puts  as  the  first  "  great  object  of  our  labours" 
the  prevention  of  disease.  This  proposition,  now  that  "  sanitary 
science  "  has  become  a  fashion,  seems  but  an  obvious  sentiment. 
With  him,  long  before  it  became  popular,  it  was  a  veritable 
passion.  "  Preventive  medicine,  as  distinguished  from  curative 
medicine,  touches  every  hearth  and  home  in  the  country  ;  every 
man,  woman,  or  child,  from  the  highest  to  the  lowest;  every 
institution  in  the  State ;  its  power,  its  defences,  its  education,  its 
manufactures  ;  every  trade,  every  occupation,  domestic  purity, 
domestic  happiness,  national  prosperity,  national  health,  lon- 
gevity, and  morals  ;  the  duties  of  property  ;  the  exercise  of  charity, 
the  blossoming  and  fruit  of  our  common  Christianity.  Its  end  is 
to  improve  and  to  preserve  man's  body  in  the  best  condition,  and 


XXX  MEMOIR. 

through  it  his  immortal  part."  And  throughout  his  various  dis- 
courses and  teaching  on  this  subject  he  takes  the  widest  view  of 
its  nature  and  relations.  He  presses  home  his  idea  with  all  the 
force  of  his  ardent  nature.  "The  list  of  causes,"  he  says, 
"  independent  of  epidemic  disease,  which  damage  the  general 
health  of  the  community  is  a  long  one.  The  parent  of  many 
others  is  destitution  with  its  consequences.  But  to  prevent 
destitution  in  masses  of  men,  and  to  promote  their  prosperity, 
is  the  province  of  the  social  rather  than  the  sanitary  reformer, 
who  has  to  deal  rather  with  the  effects  than  with  the  causes 
of  destitution,  though  it  is  certain  that  disease  and  destitution 
may  be  and  often  are  reciprocally  cause  and  effect."  And 
speaking  of  many  of  the  Poor  Law  surgeons  in  their  relation 
to  this  great  work,  he  quotes  this  passage  from  a  memorandum 
of  the  Sanitary  Commission  :  "  '  They  have  had  a  scientific 
education,  and  are  essentially  benevolent  and  practically  humane. 
Their  life  is  spent  in  striving  to  alleviate  the  greatest  calamities 
of  the  most  suffering,  that  is,  of  those  who,  being  willing  to 
work,  are  disabled  by  enfeebled  health  or  actual  disease.  Pene- 
trating every  corner  of  the  filthiest  districts  at  the  ghastliest 
moments,  succouring  the  vicious  when  they  are  disposed  (if 
ever)  to  repent,  and  tending  the  innocent  who  are  ruined  in 
body  by  the  sins  of  those  who  begat  them  ;  hundreds  of  these 
men  do  their  duty,  their  hearts  beating  with  sympathy,  sighing 
for  power  to  remove  causes  the  effects  of  which  they  are  incom- 
petent to  check.  And,  lastly,  being  themselves  far  from  rich, 
they  are  thrifty,  and  as  little  disposed  to  increase  unnecessary 
taxation  as  the  most  indifferent  or  the  most  incredulous  opponent 
of  sanitary  reform.'  " 

And  he  ends  another  address  thus  :  "  A  time  may  come  when 
the  conqueror  of  disease  will  be  more  honoured  than  the  victor 
in  a  hundred  fights." 

In  the  year  1870,  when  he  was  sixty-six  years  of  age,  and  had 
been  forty-four  years  a  clinical  teacher,  he  urged  his  hospital  to 
erect  a  laboratory  for  the  purpose  of  physical   investigation  in 


MEMOIR.  XXXi 

connexion  with  the  clinical  wards.  This  great  practical  teacher, 
who  had  laid  so  much  stress  upon  tbe  qualities  of  observation 
and  sagacity  shewn  by  the  older  physicians,  now  late  in  life  sees 
how  the  modern  appliances  of  physical  science  must  be  used  for 
the  scientific  study  of  disease.  He  refers  to  the  progress  in  this 
direction  in  London,  in  Edinburgh,  and  on  the  Continent, 
and  says,  "  We  must  henceforward  provide  instruction  in  all 
methods  by  which  physical  science  is  brought  to  bear  on 
the  advance  of  medicine "  ;  that  "  every  hospital  in  Dublin 
should  have  a  physical  laboratory  furnished  with  such  apparatus 
and  appliances  as  the  science  "of  the  present  day  requires  for  the 
investigation  of  disease."  And  with  that  mixture  of  simplicity 
and  sagacity  which  was  so  striking  in  him,  he  says :  "  It  is  not 
to  be  expected  that  the  senior  physicians  and  surgeons  of  a  hos- 
pital could  be  so  conversant  with  the  modern  modes  of  physical 
inquiry  as  to  be  able  to  train  the  students  in  that  direction  "  ; 
but  adds  that  a  specially  trained  officer  must  be  appointed  for 
the  purpose.  And  finding  the  authorities  deficient  in  the  alacrity 
which,  even  at  his  age,  he  desired,  he  says  :  "We  have  not  been 
reading  the  signs  of  the  times,  and  it  is  plain  at  all  events  that 
these  matters  should  be  seriously  considered  by  us  all."  It 
must  not  be,  however,  supposed  that  this  was  the  first  occasion 
on  which  he  had  urged  the  giving  great  facilities  to  the  student 
for  acquiring  precise  physical  knowledge  and  experimental  dex- 
terity; for  nearly  ten  years  before  he  had,  in  an  elaborate  discourse, 
pointed  out  the  different  ways  in  which  such  persons  as 
Virchow,  Helmholtz,  Liebreich,  Beale,  Jellett,  Hoppe-Seyler, 
G.  Gr.  Stokes,  Haughton,  Donders,  and  others  had  in  several 
directions  placed  within  the  reach  of  the  younger  generation  of 
medical  men  knowledge  and  power  wholly  unknown  to  our  fathers, 
and  such  as  it  is  impossible  for  the  present  race  of  men  to  ignore. 
And  it  must  be  borne  in  mind  that  this  was  the  conviction  of  a 
pre-eminent  clinical  observer  and  practitioner. 

It  would  thus  far  seem  that  Dr.  Stokes  was  engrossed  by  the 
study  of  disease,  love  of  his  profession,  and  his  conception  of  the 


XXxii  MEMOIR. 

dignity  of  medicine,  as   the  averter,   alleviator,  and  healer  of 
bodily  and  mental  disorder. 

But  did  nothing  else  lie  hidden  in  the  nature  of  this  large- 
hearted  man  ?  Yes  ;  and  chiefly  two  things.  First,  a  Love  of 
Art.  What  did  Art  convey  to  him?  What  its  attractions, 
and  what  its  link  with  his  nature  ?  This  is  not  hard  to  see  nor 
to  show.  The  study  of  Man  was  with  him  an  instinct,  both  on 
the  material  and  on  the  intellectual  side.  On  the  material  side ; 
for  he  was  a  physiognomist ;  a  great  judge  of  character ;  and 
had  a  keen  perception  of  all  physical  characteristics  ;  qualities 
which  he  obtained  by  intense  observation  of  men  in  disease  ;  of 
men  in  health;  and  of  persons  in  every  class  of  society  and 
every  kind  of  occupation.  On  the  intellectual  side  ;  for  the 
phenomena  of  man's  external  nature  were  to  him  only  expressions 
of  the  mind  working  within  ;  mind  the  result  of  inheritance  ; 
mind  formed  by  itself;  mind  the  result  of  circumstance.  The 
second  thing  to  be  remarked  was  his  intense  interest  in  every 
form  of  human  character,  in  persons  of  every  age,  occupation, 
and  condition.  He  had  that  which  many  accomplished  persons 
have  not,  the  keenest  sense  of  humour,  which  sparkled  up  in  a 
way  quite  indescribable.  He  combined  with  real  delight  in  all 
intellectual  development  the  most  tender  human  interest. 
Some  of  the  stories  of  sorrow  and  of  characteristic  life  among 
the  Irish  poor  were  told  by  him  with  a  pathos  of  voice  and 
utterance  impossible  to  be  imagined :  it  must  have  been 
heard.  When  pressed  he  would  relate  some  story  such  as 
this :  "  An  aged  priest,  Dean  of  Westport,  told  me  a  story 
illustrating  the  deep  religious  feeling  of  the  Irish  peasantry. 
'  I  had  the  largest  parish,'  he  said,  'in  the  diocese,  and  had  no 
less  than  four  curates — God  help  them.  They  were  scattered, 
here  and  there  through  the  mountains.  It  was  a  Sunday 
morning  early,  and  you  never  saw  such  heavy  rain  as  was 
falling,  when  a  boy  on  a  horse  rode  up  to  my  house  with  word 
that  Father  Sheehy  was  taken  very  bad  and  would  not  be  able 
to  celebrate  mass.     All  the  curates  had  their  hands  full ;  I  was 


MEMOIR.  xxxiii 

going  to  breakfast,  but  I  had  to  go  off  without  it,  and  the  rain 
was  so  thick  and  heavy  that  in  five  minutes  I  felt  the  water 
running  down  my  back  as  it  poured  in  through  the  roof  and 
sides  of  the  covered  car  in  which  I  travelled.  Well,  I  went 
on ;  the  blast  and  the  storm  only  seemed  to  increase  as  I  got 
higher  and  higher  among  the  mountains,  for  the  best  part 
of  twelve  miles,  when  the  boy  pulled  up.  "  What  are  you 
stopping  for?"  said  I.  "For  your  reverence  to  say  mass," 
said  he.  "Where?"  said  I.  "There!"  he  said,  pointing 
with  his  whip  to  the  ditch,  where  I  saw  a  large  flat  stone. 
"  That 's  the  altar !  "  he  said.  So  I  got  out  and  put  on  my 
wet  vestments,  and  after  a  while  one  poor  creature  came  out  of 
the  mist  and  then  another,  and  then  a  woman  and  a  man  carry- 
ing the  child,  and  then  more  and  more  till  a  great  crowd  gathered 
round  the  stone,  so  great  you  couldn't  see  the  end  of  it  in  the 
fog  and  the  mist ;  and  they  were  all  wet  to  the  skin  after  walking 
over  the  mountains  in  the  storm.  They  were  all  down  on  their 
bended  knees  when  I  came  to  the  elevation  of  the  Host,  and  with 
one  consent  there  arose  a  great  cry  from  them,  "  Cead  mille 
failthe  !  Christo  mo  Slanach  !  ';  A  hundred  thousand  welcomes  ! 
Christ  my  Saviour  ! '  " 

Though  often  saddened  through  his  boundless  sympathy, 
he  was  never  so  depressed  by  the  gravity  of  things  but 
that  there  might  come,  often  most  unexpectedly,  rays 
of  his  tender  humour,  like  sunbeams  on  a  showery  day. 
This  close  study  of  man  was  perhaps  natural  for  a  great  physi- 
cian practising  largely  among  the  poorer  men  and  women  of 
Ireland,  the  raciest  specimens  of  the  raciest  people.  Ke  was, 
moreover,  passionately  fond  of  the  external  aspects  of  Nature, 
either  in  themselves,  or  as  expressed  by  landscape  painters. 
He  was  a  lover  of  country  life ;  of  country  objects  of  the  sim- 
plest description  ;  of  country  scenes.  He  would  even  take  notes 
of  effects  of  skies,  or  compositions  of  landscapes,  which  had 
struck  him  as  he  went  along,  and  would  cautiously  and  care- 
fully write  what  he  had  seen  and  wondered  at,  whether  in  an 

c 


XXXIV  MEMOIR. 

ordinary  continental  toiir,  or  on  the  splendid  Atlantic  coasts 
of  Ireland. 

The  following  passage,  describing  a  sunset  seen  from  Sybil 
Head  in  the  County  of  Kerry,  may  be  given  as  an  instance  of 
this  close  study  of  effects  in  Nature.* 

"  Over  the  surface  of  the  great  Atlantic,  and  at  least  a  thousand 
feet  beneath  where  we  stood,  lay  a  boundless  extent  of  mist  or 
vapour,  which,  before  it  became  tinged  by  the  sun's  rays,  had 
assumed  the  appearance  of  an  open  champaign  country,  divided, 
as  it  were,  into  large  fields,  spacious  highways,  broad  pastoral 
plains,  and  extensive  meadows.  Gradually,  however,  this  scene 
changed,  and  as  the  sun  began  to  sink  in  the  far  distance,  his 
sloping  beams  caught  the  upper  portions  of  this  beautiful  vapour, 
and  coloured  them  with  an  exquisite  variety  of  the  richest  hues, 
each  portion  assuming  a  different  tinge,  in  consequence  of  its 
position  with  regard  to  the  sun.  The  effect  of  these  higher 
parts,  thus  lit  up  into  glowing  and  varied  splendour,  as  contrasted 
with  the  calm,  broad  reaches  of  wonderful  country  which  lay 
under  them,  was  inconceivably  fine.  Thus  elevated,  they  looked 
like  towers  of  gold  and  precious  stones,  shining  under  the  evening 
sun,  in  some  enchanted  land. 

"  A  more  wonderful  effect  was  still  to  come. 

"As  the  sun  went  down  into  the  sea  the  whole  expanse  by 
degrees  kindled  into  one  great  flood  of  prismatic  light,  glowing 
in  the  richest  and  most  gorgeous  colours,  all  of  which  now  blazed 
with  the  deep  effulgence  of  what  seemed  his  last  glow. 

"  Then  a  third  change  came  on  the  scene. 

"  All  at  once  the  sun's  disc  dipped  into  the-ocean,  where  it  had 
nearly  disappeared,  leaving  on  this  cloud  scenery  a  golden  haze, 
rich,  warm,  and  transparent.  But  this  was  illusion  ;  for  the  sun, 
which  had  only  set  in  a  deceptive  horizon,  reappeared  in  a  few 
moments,  thus  literally  seeming  to  rise  again.  He  now  shone 
for  a  brief  period  in  mild  and  cloudless  effulgence. 

*  Given  by  "William  Stokes  to  Carleton,  who  printed  it  in  Dublin  University  Magazine, 
April,  1847,  vol.  xxix.  p.  438. 


MEMOIR.  XXXV 

"  The  cliff  from  which  we  contemplated  this  scene  was  covered 
with  lichens  and  mosses  of  various  colours.  It  stood  out  mighty 
and  stupendous  facing  the  crimson  sun,  whose  deep  empurpled 
light  touched  the  whole  magnificent  mass  with  colour.  Then 
the  sun  finally  sank,  and  two  eagles  shot  out  far  below  us  from 
the  side  of  the  cliff,  and  rose  circling  and  wheeling  round  till 
they  disappeared  in  the  darkness.  The  rich  colour  faded  away — 
the  deep-toned  fires  grew  fainter  and  fainter — the  ideal  world 
vanished — darkness  succeeded — the  winds  as  it  were  leaped  into 
motion — the  mighty  waters  began  to  heave,  and  there  remained 
before  us  nothing  but  the  desert  bosom  of  the  dark  Atlantic." 

There  were  other  reasons  also  why  this  close  observation  of 
nature  was  constantly  alive  in  him.  He  was  essentially  an 
Irishman.  In  the  study  of  the  history  of  Ireland  he  thought 
that  nothing  in  its  antiquity  was  too  trifling  to  be  noticed,  or 
too  unimportant  to  be  loved.  And  it  is  quite  true  that  Ireland 
so  considered  is,  in  every  part  of  its  interior  and  its  coast  line, 
full  of  objects  till  lately  too  much  neglected,  and  full  of  interest 
for  the  antiquary,  the  historian,  and  the  Christian  philosopher. 
Not  that  it  would  be  true  that  he  was  blind  to  faults,  or  deaf  to 
tales  of  misgovernment  and  misconduct.  He  deplored  them,  he 
wept  over  them,  he  yearned  for  the  freedom  of  her  people — 
freedom  from  license,  from  folly,  from  superstition,  from  law- 
lessness, from  misguiding  leaders. 

It  happened  that  he  had  from  early  life  an  intimacy  with  two 
remarkable  men  :  one,  Mr.  Burton,  now  Director  of  the  National 
Gallery ;  and  the  other,  Mr.  Petrie,  artist,  antiquary,  musician. 
Of  Mr.  Burton,  so  highly  esteemed,  so  well  known,  so  scholarly, 
it  is  not,  perhaps,  becoming  to  say  more  now  in  his  lifetime. 
Petrie  was  a  man  of  exquisite  refinement,  great  vivacity  and 
tenderness,  a  romantic  admirer  of  the  people,  and  a  collector 
of  national  music.  This  remarkable  person  wandered  through 
the  wildest  districts,  pencil  and  violin  in  hand,  making  at  once 
sketches  of  the  loveliest  scenes,  and  treasuring  up  and  commit- 
ting to  paper  melodies  which,  in  the  remoter  parts,  or  even  in 

c2 


XXXVI  MEMOIlt. 


the  crowded  alleys  of  Dublin,  he  found  to  be  traditional  among 
the  people.  None  who  had  heard  that  genial  man  once  play 
those  Irish  airs  would  ever  forget  either  the  scene  or  the  sound. 
The  influence  of  these  two  persons  on  him  during  a  great  part 
of  his  life,  his  sympathy  in  his  hours  of  leisure  with  what  was 
the  reality  of  their  professional  work,  need  not  be  enlarged  upon. 
Nor  must  it  be  overlooked  that  he  had  a  keen  appreciation  of 
the  drama,  as  embodying,  both  in  writing  and  in  action,  the 
highest  artistic  expressions  of  human  nature ;  and  this  led  him 
at  one  time,  partly  through  the  acquaintance  of  Miss  Helen 
Faucit,  now  the  wife  of  Sir  Theodore  Martin,  to  study  the  con- 
ditions under  which  the  actor  should  learn  and  represent  human 
action  in  disease  ;  and  he  formed  the  distinct  opinion  that  the 
study  of  mental  or  physical  disease  in  asylum  or  in  hospital  was 
not  desirable  for  the  artist.  He  drew  a  clear  line  of  distinction 
between  imaginative  and  realistic  processes  in  art,  and  he  held 
that  the  dramatic  artist  should  trust  to  native  instinct  and  to 
such  knowledge  of  human  life  and  suffering  as  are  to  be  found 
in  his  own  heart  and  drawn  from  his  own  experience. 

In  1842  Dr.  Stokes  wrote  a  review  of  Kugler's  Hand-book  of 
Painting,  passages  from  which  may  be  quoted  as  shewing  the  love 
he  had  even  then  formed  for  the  early  religious  painters.  "  Why 
is  it,"  he  asks,  "that  before  their  works  all  faults  of  painting  are 
forgotten  and  criticism  is  silent  ?  In  works,  the  early  offspring 
of  the  cloister  and  the  cell,  and  of  minds  imbued  with  religious 
love,  we  may  perceive  the  hardness  of  the  outline,  the  bad  per- 
spective, the  unpleasing  backgrounds  and  landscape,  and  the 
manifold  and  glaring  anachronisms  ;  but  yet  there  is  something 
which  elevates  the  work  and  harmonises  it  with  those  high  and 
mysterious  objects  which  it  presents  to  the  outward  and  inward 
eye."  And  he  adds,  speaking  of  the  later  Italian  schools,  "  Yet 
the  change  effected  in  them  was  not  to  be  commended,  if  the 
highest  object  of  art  is  the  effect  on  the  devotional  feeling.  In 
music,  architecture,  in  sculpture,  painting,  oratory,  or  writing, 
the  grand  object  is  to  produce  the  best  effect ;  and  there  are 


MEMOIR. 


XXXV11 


compositions  and  combinations  by  human  genius  which,  analyti- 
cally considered,  are  defective,  but  which  produce  the  most 
ennobling  results  upon  the  mind ;  and  the  merit  is  not  so  much 
in  the  execution  of  the  individual  parts  as  in  their  combination 
for  a  particular  end.  And  with  reference  to  the  devotional 
feeling,  who  will  deny  that  the  ancient  liturgies,  the  old  music, 
the  early  architecture,  all  declare  that  the  nearer  we  approach 
the  times  of  a  more  undoubting  faith,  a  more  intense  devotion, 
the  more  completely  do  we  find  that  these  holy  influences  stamped 
a  character  on  the  creations  of  the  day  ?"  In  another  passage  he 
adds,  "  It  has  been  said  that  the  real  end  and  object  of  art  is  to 
deliver  in  its  varied  language  the  light-imparting  message  of 
God  to  man,  and  for  this  purpose  to  avail  itself  of  every  human 
feeling,  sympathy,  and  perception,  physical  as  well  as  moral. 
And  it  is  plain  that  whosoever  establishes  a  single  new  means  to 
so  great  an  end,  and  adds  it  to  the  bright  apparatus  of  the  poet, 
the  painter,  the  sculptor,  the  architect,  actor,  and  musician, 
must  claim  a  high  place  in  the  world's  esteem." 

In  1874  Dr.  Stokes  was  elected  President  of  the  Royal  Irish 
Academy,  and  as  such  he  received  the  testimony  of  the  most 
cultivated  men  in  Ireland  of  his  fitness  to  preside  over  a  body 
which  represents  the  highest  development  of  literature,  science, 
and  archaeology  in  Dublin.  His  inaugural  address  was  one, 
which,  for  its  breadth  of  view  and  the  genial  interest  shewn  in 
every  department  of  knowledge,  including  some,  as  mathematics, 
in  which  he  was  not  a  proficient,  fully  justified  his  election.  On 
reading  this  address  it  is  hard  to  say  whether  the  character  of 
the  man,  or  the  professional  enthusiasm  of  the  scientific  physi- 
cian, finds  the  more  complete  utterance.  This,  and  the  second 
address  in  the  following  year,  were  the  last  public  utterances  of 
his  laborious  life.  The  ability  and  earnestness  which,  at  a  time 
of  much  difficulty,  he  brought  to  bear  on  the  affairs  of  the 
Academy  will  long  be  remembered. 

This  brief  description  of  Dr.  Stokes  must  now  be  brought  to  a 
close.     It  would  be  wholly  incomplete  without  some  attempt  to 


XXXV111  MEMOIK. 

portray  the  personal  character  and  mode  of  life  of  the  man. 
There  is  a  passage  in  his  Memoir  of  Petrie,  in  which  he  de- 
scribes Petrie's  house  as  the  place  "where  were  assembled  men 
of  letters,  artists,  poets,  archaeologists,  all  lovers  of  Ireland,  and 
true  workers  for  her,  whose  hearts  were  kindled  and  purified  by 
the  perfect  strains  of  simple  music."  This  in  truth  equally 
represented  the  conditions  of  his  own  home.  There  was  a 
charm  about  him  which  attracted  persons  of  intelligence  and 
accomplishment  of  every  kind,  and  his  genial  and  humorous 
disposition  made  gatherings  of  friends  fascinating  to  every  one 
admitted  to  them.  He  would  preside  at  the  games  of  children. 
He  exercised  the  most  gentle  influence  over  refractory  students. 
He  never  tormented  them  with  elaborate  exhortations.  His 
hard  working  days,  constantly  ending  in  these  little  gatherings, 
often  had  begun  between  four  and  five,  when  he  rose  to  write 
lectures  or  other  literary  work  until  eight,  and  after  a  rapid 
breakfast  proceed  to  his  hospital.  He  once  said,  "My  father 
left  me  but  one  legacy,  the  blessed  gift  of  rising  early."  It  might 
be  supposed  from  this  picture  that  his  life  was  one  of  those  rare 
ones  in  which  all  seems  sunshine,  lighting  a  smooth  and  flowery 
way.  It  was  far  otherwise.  This  is  not  the  place  to  lift  the 
veil  from  family  care.  Probably  no  professional  man  had  more 
genuine  education  through  suffering  and  necessary  toil  than 
had  he.  His  marriage  was  in  every  way  a  blessirig  to  him. 
He  was  comforted  by  many  and  happy  children  ;  some  greatly 
distinguished.  Law,  Scholarship,  Surgery,  Archaeology,  all  bear 
record  to  their  valued  work.  But  large  family  circles  usually 
mean  as  multiform  pleasures,  so  also  abundant  sorrow.  One  of 
the  circumstances  which  to  all  who  knew  him  well,  either  by 
personal  experience  or  by  hearsay,  was  the  most  notable,  was 
the  manner  in  which  he  spent  such  periods  of  change  and  rest  as 
from  time  to  time  he  was  able  to  obtain.  The  splendid  work  by 
Lord  Dunraven,  completed  and  edited  by  his  daughter,  was  in 
great  measure  prepared  during  excursions  which  he  made.  And 
indeed  in  many  parts  of  Ireland  there  are  scenes  so  lovely,  and 


MEMOIR.  XXxix 

antiquities  so  singular,  as  to  have  necessarily  exercised  a  great 
charm  over  this  imaginative  nature.  Witness  the  Fort  of  Dun 
Angus,  hanging  over  the  western  cliffs  of  lonely  Arran,  dashed  by 
the  heavy  splash  of  the  long  unbroken  Atlantic  swell,  and 
surrounded  by  the  huts  of  a  people  so  primitive,  so  picturesque, 
so  beautiful ;  or  the  dark  and  mystic  vaults  of  New  Grange,  on 
the  banks  of  the  Boyne,  with  the  strange  and  uninterpreted 
hieroglyphics  on  great  subterranean  stones ;  or  the  huge 
sculptured  crosses,  the  chapels,  the  burial  grounds,  the  towers 
of  Kells  or  Clonmacnois ;  or  the  wild  monastery  majestically 
perched  on  the  storm-stricken  Skelligs.  All  these  were 
calculated  to  evolve  just  that  admixture  of  historical, 
archaeological,  and  artistic  delight  which  were  combined 
in  him.  An  account  is  given  in  a  manuscript  to  which  I 
have  had  access  of  one  of  these  scenes  ;  it  was  not  indeed  in 
Ireland,  but  in  a  place  as  romantic  and  as  interesting  as  the 
most  romantic  and  the  most  interesting  of  the  island,  at  once 
a  cradle  and  centre  of  Christianity,  indissolubly  connected  with 
the  religious  history  of  all  the  British  Isles.  He  describes  a 
scene  in  Iona  too  graphically  to  be  here  omitted:  "We  had 
gone  to  Port-na-Curraich  to  explore  the  landing-place  of  St. 
Columba,  and  having  seen  the  mound  where  it  is  said  his  boat 
lies  buried,  we  climbed  the  heights  over  the  bay.  The  summit 
of  the  hill  forms  a  low  wide  basin,  carpeted  with  soft  green- 
sward, whose  rim  rises  around  like  the  side  of  an  amphitheatre 
or  circus.  Presently  we  saw  the  form  of  a  girl  with  a  milk-pail 
on  her  head,  standing  clear  against  the  crimson  evening  sky  on 
the  verge  of  the  opposite  hill,  then  another  appeared,  and  then 
another,  till  all  the  circle  round  was  crowded  by  these  maidens 
with  their  milk-cans.  Presently  the  cattle  grazing  in  the  fields 
around  came  moving  slowly  forward  in  long  processions  and  entered 
the  circle.  Then  the  girls  began  to  call  each  cow  by  its  name,  and 
the  patient  animal  answered  to  the  call,  and  each  moved  quietly 
up  and  stood  by  her  mistress's  side  to  be  milked.  When  this 
was  finished  an  extraordinary  scene  ensued.      A  flight  of  calves 


Xl  MEMOIR. 

was  let  loose  from  the  neighbouring  farmsteads,  who  wildly 
rushing  over  the  circular  ridge,  plunged  into  the  midst  of  the 
amphitheatre,  the  calves  running  here  and  there  in  search  of 
their  mothers  and  the  cows  in  search  of  their  calves,  all  bellowino- 
and  roaring,  while  the  milk-maids  stood  in  merry  groups  on  the 
heights  laughing  at  this  scene  of  indescribable  din  and  confusion. 
In  a  few  minutes  peace  was  restored,  and  the  girls  sat  down  in 
groups  to  laugh  and  sing.  Nothing  could  exceed  the  pastoral 
beauty  and  variety  of  this  scene — the  happy  laughing  faces  of 
the  girls,  the  picturesque  groups  standing  out  against  the  mellow 
saffron-coloured  sky  and  quiet  sea  beyond." 

But  a  narrative    that   might  be    drawn    in    much  detail   of 
physician,  philosopher,  and    friend,    must    come   to   an    end. 
His  life  had  been  happy  with  its  full  admixture  of  suffering  and 
trial.      In  1870  the  estimable  person,  who  had  shared  his  every 
feeling,  and  doubled  his  every  joy,  was  taken  from  him.     From 
this  blow  he  never  wholly  recovered.     In  1876  he  was  forced  by 
ill-health   to   withdraw  from   the    Medical   Council ;    from   the 
Meath   Hospital  ;    from    the   Presidency   of    the    Eoyal   Irish 
Academy ;    those  posts  of  usefulness   and   honour  which   had 
been  either  the  delight  of  his  working  days,  or  the  pride  of 
his  manhood,  or  the  honour  of  his  later  years.     The  College 
of  Physicians  had  placed  in  its  noble  hall  a  life-sized  statue 
in   his    honour.      He    retired   to    his    Cottage   at   Carigbraig, 
whence  through  many  a  summer  long  he  had,  with  his  Dublin 
friends  and  the  best  intellects  of  Ireland,  so  often  watched  the 
setting  sun  behind  the  lovely  hills  of  Wicklow  that  stretched  out 
beyond  the  famous  Bay  of  Dublin.     There  with  the  children 
that  were  left  to  him,  and  at  times  with  a  younger  generation 
still,  he  would  sit  on  the  old  sward  uttering  from  time  to  time, 
though  with  failing  powers,  many  of  the  bright,  or  humorous, 
or  holy  thoughts  with  which  those  who  knew  him  in  earlier 
days  were  so  familiar.     And  there,  it  is  related,  that  of  these 
grandchildren  one  delighted  to  play,  as  the  veteran  Petrie  used 
to  play  on  the  same  spot,  the  melodies  of  simple  Irish  peasant 


MEMOIR.  Xli 

ditties  which  the  artist  friend  had  in  former  years  collected  ; 
and  there  too  up  to  the  very  last,  when  the  old  man  was  drawn 
out  to  his  summer  seat,  the  flights  of  birds  which  he  had 
encouraged  and  trained  would,  as  in  other  years,  come  in  troops 
to  seek  at  his  hands  their  accustomed  food.  And  so  on  January 
6th,  1878,  he  yielded  peacefully  his  gentle  spirit  to  Him  who 
gave  it.  He  was  borne  to  a  grave  in  a  churchyard  with  a  ruined 
church,  overhanging  the  much-loved  Bay,  by  a  stalwart  band 
of  true-hearted  Irish  students — the  grave  in  wThich  he  had 
himself,  some  years  before,  laid  the  remains  of  the  devoted 
partner  of  his  lovely  life. 

Henry  W.  Acland. 


NOTE    TO   PAGE   XXIII, 


ARTICLES  IN  "DUBLIN  JOURNAL  OF  MEDICAL  SCIENCE," 

BY  DR.  STOKES. 

May,  1832— January,  1872. 

Clinical  Observations  on  the  Exhibition  of  Opium  in  Large  Doses,  in  certain  cases  of 

Disease,  i.  125. 
Contributions  to  Thoracic  Pathology,  ii.  51. 

Ditto  ditto  ditto     iii.  50. 

Eesearches  on  the  Diagnosis  of  Pericarditis,  iv.  29. 
Researches  on  the  Diagnosis  and  Pathology  of  Aneurism,  v.  400. 
Eesearches  on  Laennec's  Vesicular  Emphysema,  with  Observations  on  Paralysis  of 

the  Intercostal  Muscles  and  Diaphragm,  considered  as  new  source  of  Diagnosis, 

ix.  27. 
Researches  on  the  State  of  the  Heart,  and  the  Use  of  Wine  in  Typhous  Fever,  xv.  1. 
Researches  on  the  Pathology  and  Diagnosis  of  Cancers  of  the  Lung  and  Mediastinum, 

xxi.  206. 
Observations  on  the  Case  of  the  late  Abraham  Colles,  M.D.,  i.  303. 
Observations  on  some  Cases  of  Permanently  Slow  Pulse,  ii.  73. 
On  the  Mortality  of  Medical  Practitioners  from  Fever  in  Ireland  (and  J.  W.  Cusack, 

M.D.),  iv.  134. 
On  the  Mortality  of  Medical  Practitioners  in  Ireland,  2nd  Article  (and  J.  W.  Cusack, 

M.D.),  v.  111. 
Clinical  Researches  on  the  Gangrene  of  the  Lung,  ix.  1. 
On  the  Prevention  of  Pitting  of  the  Face  in  Confluent  Small-pox,  xxix.  111. 
On  some  Requirements  in  Clinical  Teaching  in  Dublin,  li.  38. 
Some  Notes  on  the  Treatment  of  Small-pox,  liii.  9. 


PAPERS  READ  TO  SOCIETIES  BY  DR.  STOKES,  REPORTED 
IN  "  DUBLIN  JOURNAL  OF  MEDICAL  SCIENCE." 

August,  1835— February,  1874. 

On  the  Diagnosis  of  some  Diseases  of  the  Thorax,  viii.  196. 

Softening  of  the  Heart  with  Thinning  of  its  Parietes,  xxi.  133. 

Bright's  Disease  of  the  Kidney,  xxi.  144. 

Acute  Induration  of  the  Lung,  xxi.  151. 

Cirrhosis  of  the  Lung,  xxi.  293. 

Gangrene  of  the  Lung,  xxi.  317. 

Aneurism  of   the  Abdominal  Aorta,   opening  into  the   Parenchyma  of   the  Lungs, 

xxiii.  166. 
Vegetation  on  the  Semilunar  Valves,  causing  Patency,  xxiv.  279. 
Atrophy  of  the  Heart  in  Phthisis,  xxiv.  283. 

Granular  Kidney — Diabetes — Pneumonia — Hydrothorax,  xxiv.  295. 
Observations  on  Dr.  Bigger's  Communication  at  the  last  Meeting  (Contraction  of  Left 

Auriculo-ventricular  Opening),  xxv.  526. 


NOTE    TO    PAGE    XXIII.  xliii 

Fatty  Degeneration  of  the  Heart,  i.  491. 

Hypertrophy  with  Dilatation  of  the  Left  Ventricle,  in  an  Anaemic  Subject,  i.  493. 

Aneurism  of  the  Arch  of  the  Aorta,  Compressing  the  (Esophagus,  and  perforating  its 

Parietes,  i.  498. 
Jaundice — Fungous  Growth  round  the  Orifice  of  the  Ductus  Choledochus ;  Dilatation 

of  the  Hepatic  Ducts  in  the  Liver,  ii.  505. 
Aneurism  of  the  Abdominal  Aorta,  involving  the  Coeliac  Axis,  bursting  by  a  large 

rent  into  the  Peritoneum  ;  gradual  Separation  of  the  Serous  Coat  from  the  Liver 

and  Stomach  by  Aneurism  ;  absence  of  Caries  of  Vertebrae,  ii.  519. 
Hydrocephalus,  ii.  526. 

Encephaloid  Tumours  in  the  Abdomen,  x.  202. 
Psoas  Abscess  bursting  into  the  Cavity  of  the  Peritoneum,  x.  471. 
Endocarditis  :  Disease  of  the  Mitral  Valve,  xi.  198. 
Aneurism  of  the  Thoracic  Aorta,  xi.  201. 

Partial  Displacement  of  the  Sternal  End  of  each  Clavicle,  xiii.  459. 
Aneurism  of  the  Abdominal  Aorta,  xv.  480. 
Diphtheria,  xxxv.  175. 
Cancer  of  the  Liver,  xxxviii.  201. 
Pelvic  Abscess,  xxxviii.  440. 
Stricture  of  the  Pylorus,  xxxviii.  448. 
Cancer  of  the  Gall  Bladder,  xxxix.  218. 
Keport  on  Three  Cases  which  occurred  in  Meath  Hospital  under  the  care  of  Drs. 

Stokes  and  Hudson,  xliv.  193. 
Disease  of  the  Aortic  Valves,  xliv.  423. 
Cancer  of  the  Liver,  xliv.  428. 

Chronic  Ulcer  of  Stomach,  opening  the  Coronary  Artery,  xlv.  201. 
Cancer  of  the  Thyroid  Gland  and  adjoining  Lymphatics,  xlvi.  220, 
Pulmonary  Phthisis,  with  Emphysema,  xlvii.  216. 
Ulcer  of  the  Stomach,  xlvii.  220. 
Heart  in  Typhoid  Fever,  1.  197. 

Phlebitis  of  the  Cerebral  Sinuses — Disease  of  the  Tympanum,  1.  212. 
Cancer  of  the  Stomach  and  Mesentery,  1.  220. 
Varicose  Aneurism,  Hi.  249. 

Cancerous  Tumours  of  the  Abdomen  and  Thorax,  liv.  67. 
Chronic  Inflammation  of  the  Spinal  Chord  and  its  Membranes.    Dis  of  the  Spleen, 

lvi.  62. 
Enteric  Fever,  lvii.  483. 
Enteric  Fever ;  Intestinal  Haemorrhage,  lviii.  97. 


SHOKT  REPORT  ON  A   CASE  BY  DR.  STOKES  IN  "DUBLIN  JOURNAL 

OF  MEDICAL  SCIENCE." 
Observations  on  the  Existence  of  a  Proper  Fibrous  Tunic  of  the  Lung,  vi.  471. 


EDITOE'S  PEEPACE.    (Dk.  Hudson,) 


The  objects  and  scope  of  this  work  are  fully  set  forth  in  the 
Author's  preface;  and  in  the  preparation  of  this  edition  I  have 
kept  within  the  same  lines,  and  have  not  attempted  to  mo- 
dernize it  by  the  introduction  of  new  pathological  doctrines  or 
researches. 

The  plan  I  have  adopted  is  to  give  the  original  text — carefully 
revised — with  a  very  few  omissions  or  corrections,  and  with  no 
interpolation,  save  in  those  instances  in  which  Dr.  Stokes  had 
either  rewritten  portions  of  the  work  with  a  view  to  a  future 
re-issue,  or  had  embodied  his  riper  experience  in  published 
essays. 

In  the  first  instance  the  chapters  on  Pneumonia  and  Pleuritis 
have  been  enlarged  by  passages  from  his  own  note  books ;  in  the 
second,  the  chapters  on  Cancer  and  on  Gangrene  of  the  Lung  have 
been  enlarged  by  the  addition  of  portions  of  two  essays  on  these 
subjects,  published  in  the  first  and  second  series  of  the  Dublin 
Medical  Journal. 

In  dealing  thus  with  the  text,  and  in  adding  a  few  notes  of  a 
practical  nature,  chiefly  drawn  from  contemporary  contributions 
to  the  Pathological  Society  of  Dublin,  I  have  endeavoured  to 
realize  the  views  expressed  by  a  distinguished  member  of  the 
Council  of  the  New  Sydenham  Society,*  that  "by  editing  this 
work  with  reference  to  the  original  papers  of  Stokes  himself, 
and  perhaps  of  his  contemporaries  who  were  working  along  with 
him  in  the  Dublin  hospitals  and  journals,  it  might  be  made  a 
representative  book  as  regards  a  most  important  period  in  the 
history  of  auscultation." 

ALFRED  HUDSON. 

*  (Dr.  W.  T.  Gairdner,  in  a  letter  to  the  Editor.) 


PREFACE. 


It  is  now  more  than  two  years  since  this  work  was  commenced, 
and  more  than  a  year  since  the  three  first  sections  were  printed. 
This  delay  was  unavoidable,  and  proceeded  from  causes  which 
need  not  be  specified  here;  and  I  mention  it  in  order  to  explain 
many  imperfections,  and  seemingly  wilful  omissions. 

In  the  composition  of  the  work,  I  have  kept  two  great  objects 
steadily  in  view.  Of  these,  the  first  is  the  close  connexion  of 
the  study  of  physical  signs  with  that  of  symptoms,  so  as  to 
illustrate  their  mutual  bearing  on  diagnosis,  and  remove  that  un- 
just opprobrium  thrown  on  the  advocates  of  auscultation,  that 
they  neglect  the  study  of  symptoms.  In  the  next  place,  I  have 
endeavoured  to  simplify  the  subject  as  much  as  possible.  A 
sufficient  experience  has  convinced  me,  that  any  man  of  ordinary 
education  may  acquire  the  power  of  distinguishing  thoracic 
diseases  in  a  degree  sufficient  for  all  practical  purposes,  without 
troubling  himself  with  those  excessive  refinements  in  the  diagnosis 
from  acoustic  signs,  on  which  some  have  improperly  prided 
themselves.  I  have  endeavoured  to  adapt  this  work  to  the  wants 
of  the  practical  man,  always  assuming  that  he  is  familiar  with  the 
groundworks  of  the  subject,  with  the  characters  and  causes  of 
physical  signs,  as  originally  taught  by  Laennec,  and  more 
recently  investigated  in  the  works  of  Forbes,  Williams,  and  Clark. 
Hence,  I  have  not  entered  at  any  length  into  the  characters  of 
physical  signs,  but  rather  into  the  art  of  reasoning  justly  upon 
them ;  for  it  is  in  this  that  most  observers  fail.  It  cannot  be 
too  often  repeated,  that  physical  signs  only  reveal  mechanical 
conditions,  which  may  proceed  from  the  most  different  causes ; 
and  that  the  latter  are  to  be  determined  by  a  process  of  reasoning 


PREFACE.  Xlvii 

on  their  connexion  and  succession,  on  their  relation  to  time, 
and  their  association  with  symptoms  :  it  is  in  this  that  the 
medical  mind  is  seen.  Without  this  power,  I  have  no  hesitation 
in  saying,  that  it  would  be  safer  to  wholly  neglect  the  physical 
signs,  and  to  trust  in  practice  to  symptoms  alone. 

When  thus  considered,  every  addition  to  our  knowledge  of 
physical  signs  must  be  gladly  received.  I  trust  I  may,  without 
vanity,  allude  to  the  subjects  of  dilatation  of  the  air  cells  ;  the 
early  stages  of  pneumonia,  and  phthisis ;  cancer  of  the  lung ; 
and  the  signs  of  the  accumulative  diseases — in  evidence,  that  I 
have  felt  the  value  of  physical  diagnosis,  and  that  in  this  still 
wide  and  open  field,  the  labours  of  many  years  have  not  been 
unrewarded. 

I  have  only  spoken  of  pathological  anatomy  so  far  as  was 
necessary  to  illustrate  diagnosis ;  for  on  this  latter  subject  there 
is  now  such  a  mass  of  facts,  that  were  I  to  have  attempted  full 
pathological  descriptions,  the  work  would  have  been  swelled  far 
beyond  a  convenient  size. 

The  purely  hoBmorrhagic  and  spasmodic  diseases  of  the  lung- 
are  not  described  in  this  work.  I  could  add  nothing  to  what  is 
already  known  with  respect  to  pulmonary  apoplexy,  asthma,  and 
hooping-cough,  and  have  determined,  for  the  present,  to  omit 
their  consideration.  These  are  diseases  which  still  require 
much  original  investigation. 

In  discussing  treatment,  I  have  endeavoured  more  to  point 
out  principles,  than  enter  at  any  length  into  the  details  of 
practice.  It  would  be  impossible  to  anticipate  all  the 
combinations  of  symptoms  which  may  arise.  If  we  can  get  a 
general  principle,  we  must  trust  to  our  tact  and  experience,  to 
modify  its  application  according  to  circumstances.  As  far  as 
was  possible,  I  have  shewn  the  utility  of  physical  signs  in 
practice ;  for  it  is  in  the  curable  diseases  that  their  great  value 
is  seen.  Indeed,  in  a  large  proportion  of  such  cases,  the  first 
effect  of  treatment  is  to  render  disease  latent,  and  to  cause  an 
absolute  necessity  for  the  study  of  physical  signs. 


xlviii  PREFACE. 

I  have  not  entered  into  any  description  of  the  different 
modifications  of  the  stethoscope  which  have  been  from  time  to 
time  proposed.  All  that  is  necessary  for  a  good  instrument,  is 
that  it  shall  consist  of  but  one  piece,  be  constructed  of  cedar  or 
some  light  wood,  have  its  bell  small,  and  with  rounded  edges, 
and  the  ear-piece  sufficiently  concave.  On  the  subject  of 
mediate  percussion,  I  can  only  say,  that  the  finger,  with  its  back 
turned  to  the  chest,  seems  the  best  pleximeter ;  and  that  I  have 
not  found  the  instrument  of  M.  Piorry,  or  his  mode  of 
investigation,  to  possess  the  advantages  which  he  has  described. 
I  am  far,  however,  from  undervaluing  M.  Piorry' s  labours  in  the 
field  of  diagnosis. 

Finally,  in  availing  myself  of  the  labours  of  others,  I  have 
always  endeavoured  to  acknowledge  the  sources  of  my  information. 
If  in  any  instance  this  has  not  been  done,  the  authors  may  rest 
assured  that  the  omission  was  unintentional,  and  that  I  shall 
thankfully  receive  the  notification  of  the  error,  and  take  the 
first  opportunity  of  correcting  it. 

W.  S. 


Dublin,  April  4,  1837. 


CONTENTS. 


PAGE 

Introduction  by  Dr.  Acland v 

Memoir  of  Dr.  Stokes  by  Dr.  Acland vy 

Editor's  Preface.    Dr.  Hudson xlv 

Preface,    Dr.  Stokes xlvi 


SECTION  I. 

GENERAL  PRINCIPLES  OF  THE  DIAGNOSIS  OF  THORACIC 

DISEASE 1 

Connexion  of  Symptoms  and  Physical  Signs 1 

Physical  and  Vital  Conditions  of  the  Thorax 3 

Similarity  of  Symptoms 11 

Mutual  Dependence  of  Signs  and  Symptoms 12 

Sources  of  Physical  Diagnosis 12 

Insufficiency  of  Signs  alone 13 

Division  of  the  Acoustic  Signs  into  the  Active  and  Passive.        .        .  17 

Principle  of  Percussion .        .        .17 

Active  Auscultatory  Signs 20 

Elucidation  of  the  great  principle  of  comparison 21 

Combination  of  Signs 27 

Signs  considered  with  relation  to  Time 28 

Successive  Changes 30 

Relation  to  Symptoms 32 

Combination  of  Diseases 3t> 


SECTION  II. 

DISEASES  OF  THE  MUCOUS  MEMBRANE     ...  41 

Bronchitis  ...  .41 

Importance  of  the  Disease 41 

Infantile  Bronchitis 42 

Acute  Primary  Bronchitis 48 

Symptoms  of 48 

Successive  Changes 50 

d 


CONTENTS. 

PAGE 

Chronic  Primary  Bronchitis 51 

Expectoration  in 51 

Plastic  Bronchitis 56 

Researches  of  Reynaud 57 

Physical  Signs 60 

Results  of  Percussion 60 

Signs  from  Touch 63 

Active  Auscultatory  Signs 64 

Passive  Signs 65 

Acute  Secondary  Bronchitis 72 

Bronchitis  of  Typhus 72 

Physical  Signs 74 

Bronchitis  in  the  Exanthemata 76 

Chronic  Secondary  Bronchitis 79 

Gouty  Bronchitis 80 

Syphilitic  do 81 

Sympathetic  Cough 85 

Diagnosis  of 88 

Bronchitis  from  Worms 89 

Treatment  of  Bronchitis 93 

Treatment  of  the  Disease  in  the  Infant.        .......  93 

Do.                    in  the  Adult 95 

Bloodletting 96 

Antimonial  Treatment 98 

Treatment  of  the  Second  Stage "              •  •      •  100 

Do.       of  Apyrexial  Bronchitis 107 

Stimulants  and  Emetics 109 

Treatment  of  Secondary  Bronchitis 112 

Emetics  in  the  Suffocative  Catarrh 114 

Organic  Changes  in  the  Tubes  and  Air  Cells  considered  in  re- 
lation to  Bronchitis 117 

Structure  of  the  Lung 117 

Narrowing  and  Obliteration  of  the  Tubes 119 

Researches  of  Reynaud 

Obliteration  by  Adhesion  and  Deposition 121 

Cases  Illustrative  ...                124 

Dilatation  of  the  Tubes 129 

Varieties  of    ...                         129 

Cases  of  Dilatation 130 

Effect  of  Paralysis  of  the  Circular  Fibres 131 

Researches  of  Purkinje,  Valentin,  and  Sharpey 132 

Complications  and  Diagnosis 136 

Physical  Signs 142 

Recapitulation 147 

Ulceration  of  the  Bronchial  Tubes      ...              ...  149 

Varieties  of  Bronchial  Fistulae       .                150 


CONTENTS.  li 

PAGE 

Dilatation  op  the  Air-Cells.    Emphysema  or  Laennec     .       .       .150 

Causes  and  Symptoms 151 

Physical  Signs 2.55 

Effect  of  the  Yielding  of  the  Chest 160 

State  of  the  Intercostals  and  Diaphragm 161 

Mediastinal  Displacement 164 

Signs  from  Bronchitis 166 

Treatment  of  Dilatation  of  the  Cells 169 

Recapitulation 173 

Atrophy  of  the  Lung 175 

Connexion  with  Impermeability 176 


SECTioNan. 

DISEASES  OF  THE  LARYNX  AND  TRACHEA     .        .  180 

Acute  Diseases 180 

Primary  and  Secondary  Croup 181 

Physical  Signs  of  Croup 187 

Treatment 189 

Tracheotomy 192 

Laryngitis  in  the  Adult 196 

Secondary  Croup 196 

(Edematous  Laryngitis 198 

Other  Forms  of  Laryngitis 200 

Diagnosis  of  Laryngitis 201 

Treatment  of  Acute  Laryngitis  in  the  Adult 203 

Chronic  Diseases  of  the  Larynx  and  Trachea       ....  205 

Enumeration  and  Observations  on 206 

Physical  Signs  of  Chronic  Laryngitis 214 

Theory  of  M.  Beau 217 

Examination  of  the  Lung  in  Chronic  Laryngitis 218 

Treatment  of  Chronic  Laryngitis 222 

Diseases  of  the  Uvula 223 

Specific  Irritations  of  the  Larynx 225 

Spasmodic  Affection 225 

In  the  Child 226 

In  the  Adult 227 

Foreign  Bodies  in  the  Larynx,  Trachea,  and  Bronchial  Tubes    .  230 

Entrance  of  the  Foreign  Body 231 

Lodgment  in  the  Bronchus 231 

Effect  of  Complete  or  Imperfect  Obstruction 235 

Diagnosis,  Principles  of 236 

Cases  of  the  production  of  Pulmonary  Disease 244 

Stethoscopic  Diagnosis 245 

Recapitulation 252 

d2 


lii 


CONTENTS. 

PAGE 

Tumours  External  to  and  Compressing  the  Windpipe      .       .  256 

Enumeration  and  Classification     .        .        .        .                 .        .        .  256 

Symptoms  and  Diagnosis 259 

Dislocation  of  the  Clavicle 259 

Diseased  Bronchial  Glands -    ,         .         .  26 1 

Enlargement  of  the  Thymus 262 


SECTION  IV. 

PNEUMONIA 267 

Acute  Primary  Pneumonia 268 

Division  of  the  Disease  into  Five  Stages 270 

Pneumonic  Abscess 271 

Seat  and  resolution 276 

General  History 278 

Physical  Signs 282 

Pulsation  of  the  Lung 292 

Pneumo-thorax 293 

Atrophy  of  the  Lung 295 

Recapitulation 301 

Typhoid  Pneumonia 303 

Varieties  of 303 

Treatment  of  Pneumonia ,  320 

Bloodletting 321 

Antimony  in  Large  Doses 323 

Mercurial  Treatment 323 

Treatment  of  Typhoid  Pneumonia 329 

Chronic  Pneumonia 332 

Different  forms  of 332 


SECTION  V. 

GANGRENE  OF  THE  LUNG 349 

Causes  of 349 

Cases  Illustrative  of 349 


SECTION  VI. 

PERFORATING  ABSCESS  OF  THE  LUNG  .        .        .  378 

Different  Causes  of 378 

Principles  of  Diagnosis  and  Illustrative  Cases 379 

Perforation  of  the  Diaphragm  and  Lung .  379 


CONTENTS.  liii 

SECTION  VII. 

PAGE 

CANCER  OF  THE  LUNG          ....  385 

Division  according  to  the  Mechanical  Conditions  of  the  Cancerous  Matter  385 

Difficulty  of  Diagnosis 380 

Formation  of  a  Compressing  Tumour 390 

Pulsation  of  Cancerous  Tumours 391 

Rarity  of  Signs  of  Ulceration 394 

Recapitulation 396 

SECTION  VIII. 

TUBERCLE  OF  THE  LUNG 422 

Combination  and  Enumeration  of  Signs 423 

Signs  of  Bronchia]  Irritation 423 

Parenchymatous  Irritation 425 

Irritation  of  the  Serous  Membrane 429 

Solidification 430 

Ulceration 434 

Atrophy 440 

from  Measurement  in  the  earlier  Stages 440 

from  the  State  of  the  Circulating  System       .        .        .        .  441 

Varieties  of  Phthisis 443 

Acute  Non-Suppurative  Tubercle 443 

Principles  of  Diagnosis 444 

Acute  Suppurative  Phthisis 445 

Principles  of  Diagnosis 446 

Chronic  Progressive  Tubercle 447 

Symptoms  and  Signs 447 

Chronic  Ulceration  succeeding  to  Pneumonia 451 

Principles  of  Diagnosis 451 

Tubercle  consequent  on  Chronic  Bronchitis 452 

Principles  of  Diagnosis 452 

Tubercle  consequent  on  the  Cure  op  an  Empyema.       .       .       .  453 

Principles  of  Diagnosis 453 

Complication  with  Pneumothorax  and  Fistula       ....  455 

Complication  with  Laryngeal  Disease 455 

Principles  of  Diagnosis 455 

Chronic  Latent  Forms 456 

Examination  of  a  Phthisical  Patient 457 

Recapitulation 4o9 


liv  CONTENTS. 

PAGE 

Treatment  op  Phthisis 462 

Connexion  of  Tubercle  with  Irritation .  463 

Circumstances  favourable  to  cure 465 

Treatment  of  the  Bronchitic  form 466 

of  the  Tracheal  variety 468 

of  the  Hsemoptysical  variety 468 

Use  of  Mercury  in  Incipient  Phthisis 470 

Treatment  after  Excavation 474 

Palliative  Treatment 475 

Appendix ' 477 


SECTION   IX. 

DISEASES  OF  THE  PLEURA      ....  479 

The  Pleura  a  Fibro-serous  Membrane 479 

Extensibility  of  the  Mediastinum 481 

Diseases  of  Accumulation 481 

Paralysis  of  the  Intercostals  and  Diaphragm 484 

Dry  Pleuritis 486 

Principles  of  Diagnosis 486 

Causes  of  the  Friction  Sounds 420 

Pleuritis  with  Liquid  Effusion 490 

Acute  Inflammation 491 

Diaphragmatic  Pleurisy 494 

Complications 495 

Chronic  Pleurisy  with  Effusion 496 

Symptoms  of  Empyema 497 

Physical  Signs 500 

Loss  of  Sonoriety 501 

Signs  of  Respiration  503 

Phenomena  of  Voice 505 

Signs  of  Excentric  Displacement 506 

Displacement  of  the  Heart 507 

of  the  Mediastinum 509 

of  the  Intercostals 509 

of  the  Diaphragm 512 

Phenomena  of  Absorption 531 

Influence  on  the  Heart 514 

New  form  of  Dexiocardia 516 

Contraction  of  the  Chest 518 

Differential  Diagnosis 546 

Phthisis 547 

Hepatization 548 

Enlargement  of  Liver 548 

Typhoid  Pleuritis 549 

Analogy  to  Typhoid  Pneumonia 549 


CONTENTS.  lv 

PAGE 

Treatment  of  Pleuritis 550 

Bloodletting 551 

Mercury 552 

Diuretics 558 

Iodine 554 

Operation  for  Empyema 555 

Mode  of  Performing 557 

Passive  Effusions 558 

Ulcerations  of  the  Pleura 559 

Division  of  Cases 559 

Empyema  and  Pneumothorax 560 

Perforation  in  Phthisis 577 

in  Gangrene  of  the  Lung 581 

Pneumothorax  by  External  Fistula 583 

Recapitulation 591 


THE 

DIAGNOSIS   AND  TREATMENT 


OF 


DISEASES  OF  THE  CHEST. 


SECTION  I. 

GENEKAL    PRINCIPLES    OF    THE    DIAGNOSIS  OF  THORACIC  DISEASE. 

It  cannot  be  doubted,  that  the  labours  of  modern  pathologists 
in  the  localization  of  disease,  overrated  though  they,  perhaps, 
have  been  by  the  disciples  of  certain  schools  of  medicine,  have 
yet  done  much  to  remove  that  great  reproach  of  the  art — its 
uncertainty.  The  discoveries  of  the  different  and  numerous 
seats  of  morbid  action,  led,  directly,  to  the  study  of  the  symp- 
toms of  these  lesions,  and  of  those  physical  phenomena,  which 
resulted  from,  or  accompanied  them ;  and  thus  has  the  science 
of  diagnosis  been  placed  on  a  sure  basis,  that  time  with  its 
mutations  of  opinion  can  never  shake. 

In  the  recognition  of  the  seat  and  nature  of  disease,  it  is 
obvious  that  a  great  number  of  circumstances  must  be  taken  into 
consideration  besides  the  actual  signs  and  symptoms  of  the 
affection.  Age,  sex,  habit,  exciting  cause,  and  duration  of 
symptoms,  all  form  links  in  the  chain  of  evidence  on  which 
we  ground  our  opinion  :  but,  it  would  appear,  that  it  is  in  the 
study  of  what  are  termed  the  signs  and  symptoms  of  disease  that 
we  have  made  the  greatest  advances  in  modern  times. 

By  morbid  signs  we  mean  phenomena,  recognizable  to  the 
senses,  but  particularly  to  those  of  sight,  touch,  and  hearing, 
which  are  evidences  of  physical  alterations  in  the  conditions  and 

B 


22  GENEEAL    PRINCIPLES    OF    THE 

relations  of  parts.  These  alterations  may  be  enumerated,  as 
changes  in  colour,  shape,  and  volume,  changes  in  resistance, 
peculiarities  of  feel,  and  lastly,  the  production  of  particular 
sounds  under  certain  circumstances,  perceptible  either  with  or 
without  the  assistance  of  mediate  auscultation,  and  either  wholly 
new  or  characteristically  altered.  To  the  diagnosis  founded  on 
the  observation  of  these  phenomena  we  give  the  name  of  physical 
diagnosis,  inasmuch  as  by  it,  that  is  to  say,  by  the  observation  of 
physical  signs,  we  recognize  certain  physical  alterations  of  parts, 
which  may  be  studied  without  reference  to  those  functional 
lesions  which  have  preceded,  accompany,  or  follow  them.  Thus, 
the  feeling  of  fluctuation  reveals  the  existence  of  a  fluid,  but  tells 
us  nothing  of  its  cause.  The  sound  of  fluctuation  shows  the 
co-existence  of  fluid  and  air,  which  may  arise  from  different 
diseases.  The  signs  of  gurgling  and  cavernous  respiration  in  the 
lung  point  out  a  cavity  communicating  with  the  bronchial  tubes 
and  containing  some  fluid,  but  the  cavities  which  produce  these 
phenomena  may  be  of  various  kinds — gangrenous,  phthisical, 
pneumonic,  &c.  Dulness  of  sound  of  the  chest  points  out  an 
obliteration  or  displacement  of  the  air  cells,  and  the  substitution 
of  a  solid  or  liquid  for  air,  a  condition  which  may  arise  from 
various  causes.  The  sensation  of  friction  only  points  out  a 
roughened  condition  of  serous  membranes,  but  reveals  nothing  as 
to  its  cause.  The  deviations  of  shape  and  volume  of  the  great 
cavities  indicate  some  anormal  state,  but  when  we  seek  for 
their  causes  we  must  have  reference  to  other  sources  of 
information.  These  illustrations  of  physical  signs  might  be 
extended,  but  enough  has  been  said  to  explain  the  true  significa- 
tion of  the  term. 

We  may  consider  symptoms  as  different  from  signs  in  this, 
that  while  the  signs  belonging  to  sight,  touch,  and  hearing 
are  founded  on  physical  conditions  of  the  organs  themselves, 
symptoms  result  from  changes  in  the  functions  of  the  suffering 
organs,  and  in  the  modifications  produced  by  disease  in  their  vital 
relations  with  other  parts.  And  hence  Ave  consider  symptoms  in 
a  threefold  manner : 

1st.  Changes  in  the  functions  of  the  part  itself. 

2nd.  Changes  in  the  phenomena  of  organic  life  in  various 
parts  of  the  system. 

3rd.  Changes  in  the  phenomena  of  animal  life. 


DIAGNOSIS    OF    THORACIC    DISEASE.  3 

Thus,  in  examining  the  symptoms  of  a  disease  of  a  particular 
organ,  we  investigate  the  state  of  its  own  functions.  We  then 
examine  the  changes  caused  by  disease  in  all  the  phenomena  of 
organic  life,  such  as  digestion,  respiration,  circulation,  absorption, 
nutrition,  exhalation,  secretion,  and  animal  heat.  From  these 
we  advance  to  the  phenomena  of  the  life  of  relation,  and 
examine  the  changes  produced  in  the  muscular  power  or  func- 
tion, the  organs  of  sense,  the  moral  affections,  and  intellectual 
manifestations. 

In  a  case  of  acute  inflammation  of  the  lung,  we  observe,  in 
the  first  place,  lesions  of  its  own  function,  painful  and  hurried 
respiration,  imperfect  arterialization  of  blood,  cough,  and  expec- 
toration ;  these  are  what  may  be  called  local  symptoms,  but  we 
may  have  others  referrible  to  the  disturbance  of  organic  life  in 
parts  distinct  from  the  lung ;  thus  we  observe  excitement  of  the 
heart,  fever,  and  various  derangements  of  the  digestive  and 
urinary  systems :  further,  in  certain  cases  there  may  be  signs 
of  a  lesion  of  the  phenomena  of  the  life  of  relation,  as  for  instance, 
prostration  of  strength,  and  other  signs  of  derangement  of  the 
cerebro- spinal  system. 

It  must  be  obvious,  that  in  the  detection  of  the  nature  and 
seat  of  any  disease,  the  more  we  can  combine  the  observation  of 
physical  signs  with  functional  symptoms  the  greater  will  be  the 
accuracy  of  our  diagnosis.  Now,  if  we  compare  together  the 
diseases  of  the  three  great  splanchnic  cavities,  we  find  that  those 
in  which  this  desirable  combination  is  most  attainable  are,  first, 
those  of  the  chest ;  next,  the  abdomen  ;  and  lastly,  the  affections 
of  the  brain  and  spinal  marrow.  Accordingly,  if  we  compare  the 
diseases  of  these  cavities  or  systems  with  respect  to  the  perfection 
of  diagnosis,  we  find  the  order  to  be,  first,  the  respiratory ;  next, 
the  abdominal ;  and  last,  the  cerebro-spinal,  or  that  in  which 
this  combination  is  least  applicable. 

As  the  principal  object  of  this  work  is  to  elucidate  the  diag- 
nosis of  the  diseases  of  the  thoracic  viscera,  we  shall  enter  on 
this  subject  by  remarking,  that  the  contents  of  the  chest  in  the 
healthy  and  diseased  state  are  most  favourably  circumstanced  for 
the  multiplication  and  distinctness  of  physical  signs.  And  it  is 
obvious,  that  the  great  improvement  by  which  the  present  time  is 
distinguished  in  the  diagnosis,  and  consequently  the  treatment, 
of  thoracic  disease,  is  traceable  to  this  circumstance. 

b  2 


4  GENERAL    PRINCIPLES    OF    THE 

In  confirmation  of  the  former  proposition,  let  us  consider, 

First. — That  of  the  different  cavities  of  the  body,  the  chest  is 
that  in  which  the  existence  of  air  in  quantity  is  a  natural  con- 
dition. It  is  wanting  in  the  cranium,  and  when  occurring  in  the 
abdominal  cavity  may  be  generally  considered  as  a  morbid  pro- 
duction or  an  excretion.  But  the  chest  is  the  receptacle  of  air 
for  the  body.  Now  it  is  easy  to  show,  that  other  things  being 
equal,  the  sound  on  percussion  is  directly  as  the  quantity  of  air 
within  the  chest :  and  the  applicability  of  this  to  diagnosis  is  at 
once  seen,  when  we  consider  that  the  effect  of  every  organic 
change  of  the  lung  is  to  diminish  or  to  increase  the  whole  quantity 
of  air  within  the  thorax,  and,  of  course,  to  cause  a  corresponding 
increase  or  diminution  of  the  natural  sound. 

Secondly. — We  must  recollect  the  remarkable  separation  of 
the  viscera  on  either  side  of  the  chest.  In  fact,  of  all  the  organs, 
which  in  the  life  of  the  embryo,  and  by  the  law  of  excentric 
development,  are  formed  primitively  double  on  the  mesian  line, 
there  is  none  that  preserves  its  duplicity  more  completely  than 
the  lung.  The  brain,  it  is  true,  is  separated  into  hemispheres, 
and  the  liver  into  a  right  and  left  lobe  ;  but  the  union  of  opposite 
portions  of  either  organ  is  much  more  complete  than  what  is 
found  to  exist  in  the  lung,  and  the  latter  also,  with  the  exception 
of  the  testicle,  is  the  only  organ  of  the  body  whose  original 
symmetrical  halves  are  covered  by  separate  serous  membranes. 
The  importance  of  all  this  to  physical  diagnosis  is  immense, 
for  it  is  on  this  circumstance  of  separation  that  its  true  principle, 
comparison,  mainly  depends. 

If  this  great  separation  of  the  lungs  did  not  exist — if  in 
place  of  their  being  merely  connected  by  their  vessels  and  air 
tubes  at  the  root,  they  were  fused  by  continuity  of  their  pa- 
renchyma, and  covered  by  the  one  serous  membrane,  as  the 
liver  or  brain,  then  the  diagnosis  of  the  exact  seat  of  disease, 
which  we  will  see  is  of  the  greatest  practical  importance,  could 
not  be  attained :  and  it  would  be  indeed  difficult  to  discover  an 
empyema,  a  partial  pneumonia,  or  an  incipient  phthisis.  Fur- 
ther, the  division  of  the  lung  into  lobes,  although  these  portions 
be  not  wholly  separated,  is  yet  advantageous  in  the  same  point 
of  view,  as  these  divisions  act  more  or  less  in  circumscribing 
diseased  action,  and  of  course  increase  the  applicabilit}-  of  the 
principle  of  comparison. 


DIAGNOSIS    OF    THORACIC    DISEASE.  5 

Thirdly. — The  thoracic  viscera  differ  widely  from  those  of 
the  cranium  or  abdomen  in  the  constant,  uniform,  and  extensive 
motions  which  their  functions  require.  These,  whether  of  the 
lungs  or  heart,  whether  active  or  automatic,  are  perceptible  by 
physical  signs,  and  thus  we  have  a  standard  by  which  many  de- 
partures from  the  healthy  condition  may  be  easily  estimated.  It 
may  be  said  indeed,  that  this  circumstance  of  motion  is  not  pecu- 
liar to  the  lung  or  heart.  But  while  we  admit  the  existence  of 
the  motions  of  the  brain,  we  must  remember  that  they  are  slight, 
and  in  the  adult  totally  concealed  by  the  bony  cranium,  while 
those  originating  in  the  viscera  of  the  abdomen  are  irregular 
and  often  imperceptible.  Now,  on  the  existence  of  these  mo- 
tions depends  much  of  the  physical  diagnosis.  If  we  look  to 
the  lungs  merely,  we  find  that  the  act  of  respiration  causes  phe- 
nomena appreciable  by  the  ear,  eye,  and  touch.  The  murmur 
produced  during  inspiration  and  expiration,  and  the  alternate 
contractions  and  expansions  of  the  chest,  evident  both  to 
sight  and  feeling,  all  furnish  most  important  physical  signs  in 
cases  of  disease.  Thus,  in  Laennec's  emphysema,  when  the 
disease  has  been  carried  to  a  high  degree,  we  find  that  on  ac- 
count of  the  great  volume  of  the  lung  the  murmur  produced  is 
feeble,  and  the  expansion  and  contraction  of  the  chest  trifling, 
as  compared  with  the  effort  of  the  respiratory  muscles.  These 
circumstances  may  often  suffice  for  the  recognition  of  the  disease. 
Again,  in  certain  cases  of  empyema,  we  can  easily  recognize 
the  absence  of  motion  on  one  side  and  the  corresponding  in- 
crease of  expansion  on  the  other.  Many  more  examples  might 
be  given. 

Further,  the  regular  motions  of  the  heart,  productive  as  they 
are  of  peculiar  impulses  and  sounds,  are  not  only  directly  avail- 
able for  the  detection  of  cardiac  and  aortic  diseases,  but  also  for 
those  of  the  lung,  as  will  be  abundantly  shown  in  the  progress 
of  this  work. 

Fourthly. — The  thoracic  cavity  is  the  only  one  in  the  dis- 
eases of  which  the  phenomena  of  the  voice  can  be  made 
available  for  diagnosis.  It  is  true,  that  of  the  various  phy- 
sical signs  these  are  perhaps  of  the  lowest  value  and  most 
liable  to  mislead,  but  when  combined  with  other  circum- 
stances, they  become  of  important  assistance  in  the  detection 
of  pulmonary  disease.     There  is  one  case  of  disease  of  the  cir- 


O  GENERAL    PRINCIPLES    OF    THE 

culating  system  in  wliicli  we  may  avail  ourselves  of  the  signs 
drawn  from  this  source.* 

Fifthly. — Great  assistance  is  derived  in  the  detection  of 
pulmonary  and  cardiac  disease,  from  the  peculiar  modifications 
of  shape  which  the  chest  undergoes  from  a  number  of  causes. 
If  we  look  to  the  affections  of  the  head  and  spinal  cavity,  we 
find,  that  with  the  exception  of  some  few  cases  of  congenital 
dropsy,  arrest  of  development,  or  chronic  effusion,  the  more 
frequent  diseases  of  this  class  do  not  produce  any  perceptible 
alteration  or  change  of  shape  in  the  bony  cases  of  the  cerebro- 
spinal mass.  In  the  abdomen,  on  the  other  hand,  from  the 
very  yielding  nature  of  its  parietes,  changes  of  volume  and 
shape  are  common ;  but  it  will  be  found,  that  these  seldom  are 
available  for  the  detection  of  the  nature  of  their  cause,  a  cir- 
cumstance as  well  attributable  to  the  great  yielding  of  the 
parietes,  as  to  the  fact  of  the  viscera  being  contained  in  a 
single  cavity.  The  chest,  however,  presents  bony,  elastic,  and 
fleshy  parietes,  and  its  principal  viscera  occupy  three  distinct 
cavities. 

Although  it  cannot  be  maintained,  that  the  alterations  of 
shape  and  volume  of  the  chest  will  always  suffice  to  point  out 
the  nature  of  their  causes,  yet  we  must  admit,  that  with  respect 
to  the  diseases  of  its  interior,  the  modifications  of  its  exterior 
are  more  numerous  and  of  greater  diagnostic  value  in  the  chest 
than  in  either  of  the  other  two  cavities.  Let  us  consider  the 
extraordinary  convexity  of  the  whole  chest,  the  arching  of  the 
sternum,  and  the  appearance  of  the  shoulders  in  a  case  of  dila- 
tation of  the  air  cells ;  the  loss  of  symmetry  in  the  sides,  and 
the  peculiar  smooth  appearance  produced  by  the  pressure  of 
the  fluid  on  the  intercostal  spaces,  in  the  case  of  empyema ;  the 
contraction  of  the  side  and  the  depression  of  the  shoulder  while 
the  spine  remains  unbent,  in  the  same  case,  where  absorption  of 
the  fluid  has  taken  place  ;  and  the  sunken  and  flattened  appear- 
ance of  the  antero-superior  regions  in  advanced  phthisis.  All 
these  are  instances  of  peculiar  modifications  of  shape  of  the  ex- 
terior walls  of  the  cavity,  coinciding  with  physical  changes  in 
the  subjacent  viscera.  It  is  true,  that  taken  alone  they  could 
not  lead  to  a  positive  diagnosis,  but  when  combined  with  other 
signs  and  symptoms  their  value  is  highly  important,  and  this, 

*  See  Aneurism  of  the  Aorta. 


DIAGNOSIS    OF    THORACIC    DISEASE.  7 

with  their  number,  should  make  us  admit,  that  as  a  means  of 
diagnosis,  the  modifications  of  external  form  produced  by  dis- 
ease are  more  valuable  and  much  more  frequently  applicable  in 
thoracic  than  in  the  cerebro-spinal  or  abdominal  affections. 

Sixthly. — The  thoracic  viscera,  at  least  as  far  as  the  lungs 
are  concerned,  differ  most  remarkably  from  the  cranial  and 
the  abdominal,  in  the  facilities  furnished  by  their  structure  and 
function,  for  the  detection  of  disease,  by  the  direct  recognition 
of  the  products  of  that  disease.  The  conditions  on  which  these 
facilities  are  found  to  depend  are  various,  but  the  principal  are 
separation,  mobility,  elasticity,  and  their  direct  and  universal 
permeability  to  air  by  means  of  the  bronchial  ramifications.  Of 
these  the  last  is  the  most  important. 

Thus,  if  we  look  to  the  brain  with  respect  to  the  discovery 
of  effusion  in  a  case  of  arachnitis,  we  find  that  there  is  no  direct 
physical  sign  of  such  a  lesion,  and  its  presence  can  only  be 
guessed  at  by  the  existence  of  certain  symptoms,  which  modern 
researches  have  shown  to  be  extremely  fallacious.*  We  have 
no  physical  means  of  ascertaining  its  presence  or  absence.  But 
how  different  is  the  case  with  the  lung,  in  which,  by  the  assist- 
ance of  percussion,  by  the  observation  of  changes  of  position,  by 
the  characters  of  respiration  and  of  the  voice,  and  by  the  obser- 
vation of  the  displacements  of  the  lung  itself,  the  heart,  and  the 
abdominal  viscera,  the  detection  of  a  fluid  in  the  serous  cavity 
becomes  as  easy  as  it  is  certain.  Again,  let  us  compare  the 
facility  of  diagnosis  of  an  abscess  of  the  cerebral  with  that  of  the 
pulmonary  substance  ;  here  also,  the  existence  of  the  first  lesion 
can  only  be  determined  by  the  study  of  functional  alterations ; 
there  is  no  physical  sign,  and  we  must  farther  admit,  that  even 
after  the  researches  of  a  Lallemand,  a  Serres,  a  Foville,  or  an 
Abercrombie,  that  he  who  would  make  the  positive  diagnosis  of 
such  a  lesion,  must  have  a  confidence  not  justified  by  the  present 
state  of  the  science. 

But  if  in  a  case  of  pneumonia,  after  the  recognition  of  the 
ordinary  symptoms  and  signs  of  the  disease,  we  discover  the 
phenomena  of  cavernous  respiration,  gurgling,  and  pectorilo- 
quism  in  the  affected  portion  of  the  lung,  we  know  that  there 
must  be  a  cavity  of  some  kind,  and  of  its  nature  our  previous 
observations    leave    scarcely    a    doubt.      Here,    the    facility    of 

*  See  Andral,  Clinique  Medicale,  Maladies  de  l'Encephale. 


8  GENERAL    PRINCIPLES    OF    THE 

diagnosis  would  not  exist,  if,  like  the  brain,  the  lung  had  been 
a  closed  organ  ;  but  its  permeability  to  air,  and  the  regular  and 
forcible  entrance  and  expulsion  of  this  fluid  into  and  from  its 
cavities,  are  the  conditions  which,  by  enabling  us  to  discover 
new  secretions,  and  organic  changes,  easily  reveal  the  lesion. 

The  same  train  of  reasoning  applies  to  the  diseases  of  the 
parenchymatous  organs  of  the  abdomen  :  the  liver,  spleen, 
kidneys,  pancreas,  and  mesenteric  glands.  Here,  for  the  same 
reasons,  neither  auscultation  nor  percussion  can  apply,  unless  in 
a  case  of  mere  enlargement,  when  the  latter  mode  of  investiga- 
tion can  be  sometimes  employed.  Abscess  of  any  of  these  organs 
cannot  be  accompanied  by  signs  similar  to  those  of  abscess  of 
the  lung,  nor  are  there  any  physical  means  which  assist  in  detect- 
ing the  earlier  stages  of  inflammation.  Nothing  is  so  easy  as  to 
detect  the  suppuration  of  pulmonary  tubercles  ;  but  in  the  case 
of  the  abdominal  organs,  even  supposing  that  tubercles  were 
recognized,  who  could  pronounce  upon  their  actual  state  ? 

Further,  in  comparing  the  diseases  of  the  gastro-intestinal 
with  those  of  the  pulmonary  mucous  membrane,  with  respect  to 
the  facility  of  diagnosis,  we  are  at  once  struck  with  the  difference 
in  favour  of  the  latter.  There  is  no  physical  sign  proper  to  a 
gastro-enteritis,  and  its  detection  must  depend  altogether  upon 
vital  phenomena  ;  but  in  the  case  of  bronchitis  we  have,  in 
addition  to  the  functional  lesion,  a  group  of  signs  resulting  from 
the  physical  changes  of  the  part,  which  often  enable  us  to  detect 
the  slightest  shade  of  mucous  irritation,  and  to  pronounce  on  the 
exact  locality,  extent,  and  stage  of  the  disease. 

Lastly. — If  we  consider  the  chest  as  to  the  mechanical  nature 
of  its  walls,  and  the  mobility  of  its  contained  viscera,  we  see, 
that  in  its  diseases,  a  fruitful  source  of  physical  signs  is  contained 
in  the  various  and  remarkable  displacements,  not  only  of  these 
viscera,  but  of  those  contained  in  the  cavity  of  the  abdomen,  a 
source  of  diagnosis  not  applicable  to  the  diseases  of  the  brain, 
and  scarcely  to  those  of  the  digestive  system. 

Thus,  a  moderate  effusion  into  the  pleura  will  displace  the 
lung  from  below  upwards,  acting  but  little  on  the  side,  on 
account  of  its  greater  resistance.  When  more  extensive  it 
presses  the  lung  against  the  mediastinum,  and  in  consequence 
of  this  septum  yielding  more  than  the  bony  wall,  it  is  pushed 
beyond  the  mesian  line,  of  course  carrying  with  it  the  heart 


DIAGNOSIS    OF    THORACIC    DISEASE.  9 

either  to  the  right  or  left  side,  as  the  case  may  be.  Now  all 
these  displacements  of  the  lung,  mediastinum,  and  heart,  are 
easily  appreciable  by  physical  signs. 

But  we  observe  displacements  of  the  abdominal  viscera  conse- 
quent on  thoracic  disease,  a  circumstance  explicable  by  consider- 
ing the  nature  of  the  floor  of  the  thorax ;  that  it  is  not,  as  the 
rest  of  its  parietes,  bony  or  cartilaginous,  but  formed  principally 
by  muscle  and  some  tendinous  expansion.  Under  circumstances 
of  great  accumulation  of  fluid,  or  of  hypertrophy  of  the  lung, 
this  muscular  wall  yields  to  pressure,  its  convex  surface  becomes 
flattened  or  even  concave,  the  viscera  of  the  abdomen,  on  the 
side  corresponding  to  the  affected  lung,  are  pushed  down  before 
it,  and  from  their  displacement  a  new  and  most  important 
source  of  diagnosis  is  obtained.  It  is  true  that  the  reverse 
may  happen,  and  the  thoracic  viscera  shall  be  displaced  by 
abdominal  disease  ;  thus,  an  enlarged  liver  or  spleen,  an  abdo- 
minal aneurism,  or  an  accumulation  of  air  or  fluid  in  the  belly, 
by  pressing  on  the  concave  side  of  the  diaphragm,  may  displace 
the  lung  or  heart,  but  it  is  obvious,  that  when  we  consider  the 
difference  between  the  abdominal  and  thoracic  walls,  and  the 
yielding  nature  of  the  latter,  such  can  only  occur  in  very  exten- 
sive disease.  It  is  plain,  too,  that  the  natural  action  of  the 
diaphragm  will  tend  to  diminish  these  effects,  while  in  the 
former  case  it  could  have  no  such  influence ;  and  it  will  be 
proved  in  the  following  pages,  that  an  amount  of  pressure  on  the 
concave  side  of  the  diaphragm,  carried  even  so  far  as  to  displace 
the  superjacent  viscera,  does  not  deprive  it  of  its  contractile  power. 

If  we  take  a  general  view  of  the  cranial,  thoracic,  and  abdo- 
minal cavities,  it  would  appear  that  in  none  of  them  is  the 
diagnosis  of  disease,  from  symptoms  alone,  so  difficult  as  in  the 
chest.  But  further  investigation  will  prove  to  us,  that  there  is 
no  cavity  in  the  diseases  of  which,  when  we  combine  the  study 
of  symptoms,  properly  so  called,  with  that  of  physical  signs, 
the  determination  of  the  nature,  extent,  and  modifications  of 
disease  is  so  easy  and  certain.  In  fact,  the  diagnosis  of  thoracic 
diseases  is  founded  on  the  combination  of  signs  and  symptoms, 
and  we  shall  find,  that  of  all  the  cavities  the  chest  is  that  in 
which  the  physical  signs  are  most  numerous  and  of  most  exten- 
sive application. 

The  nature  of  thoracic  disease  may  be  occasionally  determined 


10  GENERAL    PRINCIPLES    OF    THE 

by  the  consideration  of  signs  or  the  observation  of  symptoms ; 
but  it  is  obvious  that  the  more  we  combine  the  two  the  more 
exact  will  our  diagnosis  be.  In  diseases  of  the  thoracic  viscera 
there  is  a  greater  necessity  for  mechanical  diagnosis  than  in 
those  of  the  brain  or  abdomen,  for  the  general  resemblance  of 
the  symptoms  of  the  different  thoracic  diseases  is  much  more 
striking  than  that  of  the  cranial  or  abdominal  affections. 

In  the  case  of  the  brain  we  can  often  distinguish  between 
arachnitis  and  deep-seated  local  inflammation.  In  that  of  the 
abdomen  it  is  not  difficult  to  distinguish  between  a  mucous  and 
a  serous  inflammation,  nay,  we  are  even  able  to  distinguish 
between  the  disease  of  the  different  portions  of  the  mucous 
expansion,  as  between  gastritis,  duodenitis,  ileitis,  and  inflam- 
mation of  the  large  intestine.  But  in  the  case  of  the  thorax, 
this  accuracy  from  symptoms  alone  is  too  often  inaccessible. 
Pain,  dyspnoea,  acceleration  of  breathing,  cough,  and  expectora- 
tion, are  the  prominent  characteristics  of  a  great  number  of 
essentially  different  diseases. 

It  has  been  asserted,  that  by  studying  the  varieties  in  the 
nature,  mode  of  occurrence,  succession,  and  modification  of  these 
symptoms,  we  can,  independently  of  the  information  derivable 
from  physical  signs,  arrive  at  an  accurate  diagnosis  of  thoracic 
disease.  This  is  the  common  assertion  of  those  few  who  are 
still  opposed  to  the  use  of  mechanical  diagnosis.  It  is  not  to  be 
denied,  that  in  many  instances  the  physician  without  the  aid  of 
the  stethoscope  or  percussion  may  arrive  at  a  sufficiently  accurate 
diagnosis,  and,  that  before  these  modes  of  ascertaining  chest 
disease  were  introduced,  the  nature  of  many  cases  was  cor- 
rectly determined  ;  but  I  feel  no  hesitation  in  saying,  that  for 
the  attainment  of  such  accuracy,  the  combination  of  careful 
observation,  uncommon  tact,  and  long  experience,  is  absolutely 
necessary.  In  other  words,  that  there  must  be  qualifications 
which  it  is  next  to  impossible  any  young  practitioner  can  pos- 
sess. And,  after  all,  however  painfully  and  slowly  this  power 
of  diagnosis  has  been  acquired,  it  is  still  imperfect,  an  assertion 
well  borne  out  by  the  comparison  of  the  state  of  our  know- 
ledge previous  and  subsequent  to  the  discoveries  of  Laennec. 
The  prominent  symptoms  of  chest  affections  which  have  been 
enumerated,  may  occur  in  the  same  order  and  the  same  manner 
in  many  essentially  different  diseases;  in  bronchitis,  pneumonia, 


DIAGNOSIS    OF    THORACIC    DISEASE.  11 

tuberculization  of  the  lung,  and  pleuritis.  Every  one  who  has 
studied  chest  affections  must  have  seen  examples  of  all  these 
cases,  accompanied  by  symptoms  exhibiting  a  resemblance  which 
would  puzzle  the  most  profound  and  accurate  symptomatologist. 
Now,  supposing  that  the  character  and  succession  of  the  symptoms 
were  the  same,  and  the  diseases  of  equal  frequency,  and  that  we 
were  to  fix  upon  any  one  disease  as  the  cause  of  these  symptoms, 
there  would  be  three  chances  to  one  against  our  coming  to  an 
accurate  conclusion. 

I  am  quite  aware  that  many  persons  will  object  to  this,  and 
maintain,  that  although  these  symptoms  occur  in  the  above- 
mentioned  diseases,  and  even  in  the  same  order,  yet  that  their 
nature  is  different.  In  the  characters  of  expectoration,  for 
instance,  sufficient  data  for  ascertaining  the  nature  of  its  cause 
may  exist ;  thus,  in  advanced  phthisis  it  is  purulent ;  in  bron- 
chitis, mucous  ;  in  pneumonia,  bloody,  and  so  on.  All  this, 
though  true  to  a  certain  degree,  is  yet,  when  generally  applied, 
far  behind  the  actual  state  of  medicine,  which  has  proved,  that 
we  may  have  in  each  of  these  principal  diseases  every  variety  of 
expectoration,  or  no  expectoration  at  all ;  and  we  may  extend  the 
same  kind  of  observation  to  the  cough,  dyspnoea,  acceleration  of 
breathing,  and  pain. 

It  may  be  said,  that  besides  those  mentioned  there  are  other 
symptoms  capable  of  assisting  in  diagnosis  ;  as,  for  instance, 
the  mode  of  decubitus,  or  the  occurrence  or  non-occurrence  of 
hectic.  But  both  of  these  are  equally  fallacious.  A  patient 
with  the  most  enormous  empyema  shall  lie  on  the  healthy  side, 
and  hectic  is  often  absent,  though  the  lung  be  full  of  suppurating 
cavities,  or  well  marked  without  a  tubercle  in  the  lung.  And, 
with  respect  to  the  occurrence  of  fever  in  general,  it  is  notorious 
that  every  disease  of  the  lung  may  be  apyrexial,  or  occur  with 
all  varieties  of  fever. 

Lastly,  the  advocates  of  physical  examination  may  well  appeal 
to  the  frequency  of  the  latent  affections  of  the  lung,  as  showing 
the  necessity  of  this  mode  of  investigation.  The  lung  may  be 
hepatized  without  cough,  dyspnoea,  acceleration  of  breathing, 
pain,  expectoration,  or  fever.  But  this  change  cannot  occur 
without  the  existence  of  physical  signs  sufficient  for  its  detection, 
and  nearly  the  same  remark  is  applicable  to  many  other  in- 
stances of  pulmonary  lesion. 


12  GENERAL    PRINCIPLES    OF    THE 

It  is  plain  that  the  study  of  symptoms  alone  cannot  lead  to 
accurate  distinction  of  chest  disease  ;  the  same  remark  is  appli- 
cable to  that  of  physical  signs  unconnected  with  symptoms. 
Symptoms  are  insufficient  without  signs,  and  signs  insufficient 
without  a  careful  comparison  of  these  with  the  symptoms. 
There  is  no  such  thing  as  a  perfectly  pathognomonic  symptom 
or  sign  of  any  thoracic  disease.  We  must  combine  the  lights 
drawn  from  the  careful  study  of  symptoms,  both  past  and  pre- 
sent, with  the  observation  of  physical  signs,  for  by  this  mode 
alone,  can  we  hope  to  arrive  at  an  accurate  result.  Great  injury 
has  been  done  to  the  cause  of  physical  diagnosis  by  some  in- 
experienced men,  who,  departing  from  the  principles  of  its 
illustrious  founder,  have  neglected  too  much  the  study  of  symp- 
toms.    To  this  subject  I  shall  hereafter  recur. 

Let  us  now  enumerate  the  sources  of  physical  diagnosis. 

1st.  Signs  purely  acoustic,  including  the  results  of  percussion 
and  of  auscultation,  mediate  and  immediate.  It  may  be  observed 
here,  that  of  all  the  signs  these  are  of  the  most  universal  appli- 
cation, there  being  no  disease  of  the  lung  or  heart  in  which  they 
do  not  occur. 

2nd.  Signs  derived  from  the  alterations  of  shape  and  volume 
of  the  thorax.  This  source  of  diagnosis  is  capable  of  application 
to  many,  though  by  no  means  to  all  the  diseases  of  the  lungs, 
heart,  and  great  vessels.  Changes  of  shape  and  volume  imply 
either  the  existence  of  acute  diseases,  in  which  the  products  of 
the  disease  have  rapidly  accumulated,  or,  which  is  the  more 
frequent  case,  of  diseases  which  have  a  great  degree  of  chronicity. 
Under  the  first  head  we  may  reckon  rapid  liquid  effusions  into 
the  pleura  or  pericardium,  the  result  of  inflammation  ;  and  recent 
pneumothorax  from  fistula.  Under  the  second,  we  have  chronic 
liquid  and  aeriform  effusions ;  hypertrophy  and  atrophy  of  the 
lung,  both  the  result  of  chronic  disease  ;  and  aneurismal  or  other 
organic  tumours. 

3rd.  Signs  referrible  to  the  sense  of  touch :  these  we  find  to 
occur  in  a  considerable  number  of  thoracic  diseases,  as,  for 
instance,  in  bronchitis  with  effusion,  in  dry  pleurisy  and  peri- 
carditis, in  various  diseases  of  the  heart  and  great  vessels,  in 
abscesses  of  the  lung  communicating  with  the  bronchial  tubes, 
and  in  certain  cases  of  liquid  effusions  into  the  serous  cavities, 
and  in  hepatization  of  the  lung. 


DIAGNOSIS   OF    THORACIC    DISEASE  13 

4th.  Signs  derived  from  the  inspection  of  the  motions  of  the 
thorax  during  respiration:  these  occur  in  cases  of  local  or 
general  impermeability  of  one  lung,  and  in  cases  where  the 
motions  of  respiration  are  otherwise  impeded  or  altered. 

5th.  Signs  derived  from  the  inspection  of  the  thorax  with 
reference  to  the  action  of  the  heart  and  great  vessels. 

6th.  Signs  derived  from  the  existence  of  an  external  collateral 
circulation,  as  indicative  of  the  existence  of  obstruction  of  the 
great  internal  venous  trunks,  such  as  the  cava  and  innominata. 

7th.  Signs  derived  from  the  observation  of  the  displacement 
of  the  thoracic  or  abdominal  viscera;  of  these,  some  may  be 
appreciable  by  the  senses  of  sight  and  touch  merely,  while  others 
must  be  ascertained  principally  by  that  of  hearing.  The  dis- 
placement of  the  heart  (perceptible  to  the  eye  and  touch)  and 
the  protrusion  of  the  liver  into  the  abdominal  cavity  are  ex- 
amples of  the  first  division  ;  while  the  displacements  and  com- 
pression of  the  lung  from  liquid  or  aeriform  effusions  into  the 
serous  sacs  furnish  examples  of  the  second. 

Now  it  is  never  to  be  forgotten,  that  although  in  these  various 
classes  we  have  a  vast  number  of  well-marked  and  essentially 
differing  physical  phenomena,  there  is  not  one  of  them  which, 
taken  singly,  can  be  considered  as  a  pathognomonic  sign.  Nay, 
we  might  go  farther  and  declare,  that  no  possible  combination  of 
them  can  be  considered  absolutely  pathognomonic.  By  some  of 
them,  taken  singly,  or  by  various  possible  combinations,  we 
may,  indeed,  ascertain  the  existence  of  certain  mechanical  con- 
ditions of  the  intra-thoracic  viscera,  as,  for  instance,  permeability 
or  impermeability,  increase  or  diminution  of  the  quantity  of 
air,  the  existence  of  cavities  of  various  sizes  and  with  various 
communications,  the  roughened  state  of  a  serous  membrane,  or 
the  displacement  of  particular  organs ;  but  if  we  seek  to  deter- 
mine by  physical  signs  alone  the  cause  of  all  or  any  of  these 
phenomena,  we  shall  find  it  to  be  difficult  or  impossible.  It  is 
only,  as  we  have  said  before,  by  the  connexion  of  the  accurately 
ascertained  physical  signs  Avith  the  previous  history  and  actual 
symptoms  of  the  case  that  a  correct  diagnosis  can  be  ever 
arrived  at. 

In  order  to  establish  the  proposition  that  no  physical  sign, 
taken  singly,  can  be  considered  as  pathognomic,  let  us  take  a 
brief  review  of  these  different  signs,  commencing  with  those  least 


14  GENERAL    PRINCIPLES    OF    THE 

frequently  applicable,  and  proceeding  to  those  of  most  common 
occurrence. 

1st.  Existence  of  an  external  collateral  venous  circulation. 

n 

This  appearance,  which  has  been  described  by  Reynaud,  is 
indicative  of  a  great  amount  of  obstruction  to  the  internal  venous 
circulation.  But  of  the  nature  of  that  obstruction  it  alone  can 
tell  nothing.  It  may  proceed  from  the  pressure  of  a  tumour, 
aneurismal  or  otherwise,  or  from  disease  on  the  internal  surface 
of  the  venous  trunk  itself.  This  was  observed  to  occur  in  the 
vena  portse  and  inferior  cava  in  a  patient  whose  case  is  described 
by  the  same  author,  and  in  whom  the  superficial  veins  of  the 
abdomen  took  on  a  supplementary  action. 

In  obstructions  at  the  right  side  of  the  heart,  the  dilatations 
of  the  jugular  veins,  so  long  noticed,  seems  to  be  the  commence- 
ment of  the  same  morbid  appearance,  and  Dr.  Graves  has  shown 
that  a  varicose  state  of  the  superficial  thoracic  veins  may  occur 
from  cancerous  degeneration  of  the  lung  itself. 

If,  for  the  sake  of  argument,  we  assume  that  these  different 
causes  for  the  appearance  in  question  were  of  equal  frequency, 
and  that  from  it  alone  we  determined  on  the  existence  of  any 
one  of  them,  there  would  be  four  chances  to  one  against  our 
making  a  correct  diagnosis. 

'2nd.  Signs  derived  from  the  displacement  of  the  thoracic  or 

abdominal  viscera. 

Of  these,  those  that  are  most  frequently  recognized  are  the 
displacements  of  the  heart  and  liver;  the  first  is  commonly 
observed  in  cases  of  empyema,  the  displacement  to  the  right  of 
the  mesian  line  occurring  in  empyema  of  the  left  side,  while  that 
in  the  opposite  direction  indicates  accumulation  in  the  right 
pleura.  Now,  although  displacement  of  the  heart  to  the  right 
side  of  the  sternum  constitutes  one  of  the  best  indications  of 
empyema  of  the  left  pleura,  yet  taken  alone  it  is  anything  but 
unequivocal.  A  tumour  or  an  hypertrophy  of  the  left  lung  may 
produce  a  pulsation  to  the  right  of  the  sternum  ;  the  same 
may  be  caused  by  an  hypertrophy  and  dilatation  of  the  right 
cavities  of  the  heart.  And  Dr.  Graves  and  I  have  shown  that 
an  aneurism  of  the  aorta  may  push  the  heart  to  the  right  side. 


DIAGNOSIS    OF    THORACIC    DISEASE.  15 

I  have  also  published  the  particulars  of  an  extraordinary  case  of 
dislocation  of  the  heart  from  external  violence,  in  which  the 
organ  was  driven  far  to  the  right  of  the  mesian  line,  and  in 
which  no  sign  of  empyema  of  the  left  pleura  had  ever  occurred. 
When  I  come  to  treat  of  the  affections  of  the  heart  I  shall  eive 
the  particulars  of  this  case.  Lastly,  well  attested  examples  of 
congenital  displacement  of  the  viscera  have  been  recorded,  in 
which  the  heart  was  placed  at  the  right  of  the  mesian  line.  On 
the  other  hand,  displacement  of  the  heart  towards  the  left 
axillary  region  is  a  circumstance  which,  from  its  nature,  is 
commonly  overlooked,  and  which  may  occur  from  other  causes. 
I  may  also  remark,  that  the  previous  contraction  of  either  side 
from  a  former  attack  of  pleurisy  should  be  added  to  the  possible 
uncertainties  of  this  source  of  diagnosis,  for  in  such  cases  the 
heart  seldom  resumes  its  normal  situation  with  respect  to  the 
healthy  side. 

As  the  displacement  of  the  heart,  considered  alone,  and  with- 
out reference  to  any  acoustic  observation,  is  reducible,  as  a  sign, 
to  the  mere  feeling  or  seeing  its  pulsations  in  an  anormal  situa- 
tion ;  so,  the  displacement  of  the  liver  is  reducible  to  the  ob- 
servation of  a  tumour  in  the  right  hypochondrium.  Now,  even 
supposing  that  the  case  was  one  of  displacement  of  the  liver,  it 
will  be  shewn  that  this  might  arise  from  other  causes  than 
empyema,  to  which  it  is  commonly  attributed :  intra-thoracic 
tumours  may  produce  it.  I  have  observed  it  from  Laennec's 
emphysema  ;  it  may  occur  from  aneurism  of  the  abdominal  aorta, 
or  from  that  of  the  hepatic  artery  ;  and  I  need  scarcely  remark,  that 
we  may  have  hepatic  tumours,  independent  of  any  disease  of  the 
pleura,  and  conversely,  pleural  effusion  without  this  sign.  These 
observations  are  sufficient  to  shew,  that  displacements  of  the 
heart  or  liver  cannot  alone  be  looked  upon  as  certain  diagnostics 
of  the  lesion  which  has  produced  them. 

3rd.  Signs  derived  from  the  inspection  of  the  motions  of  the 
thorax  during  respiration. 

I  shall  not  occupy  the  time  of  my  readers  with  any  com- 
mentary upon  this  class  of  signs.  The  respiratory  movements 
are  so  infinitely  various  in  the  different  diseases  of  the  chest, 
that  we  are  not  warranted  in  founding  any  certain  diagnosis 
upon  the  observation  of  them  alone. 


16  GENERAL    PRINCIPLES    OF    THE 

4th.  Signs  referrible  to  the  sense  of  touch. 

This  class  presents  to  us  several  signs,  which,  as  far  as  they 
go,  lead  to  a  greater  degree  of  certainty  than  those  in  the  pre- 
ceding one.  Yet,  like  the  other  physical  signs,  they  only  reveal 
to  us,  and  that  not  constantly,  mechanical  conditions,  without 
leading  to  the  diagnosis  of  the  nature  of  disease,  or  the  patholo- 
gical state  of  the  viscera.  Thus,  the  bronchial  vibration  may 
occur  from  any  liquid  effusion  into  the  tubes,  and  with  various 
states  of  the  lungs.  The  feeling  of  gurgling  may  proceed  from 
a  tuberculous,  pneumonic,  or  gangrenous  abscess,  or  from  a 
dilated  tube  containing  muco-puriform  matter.  The  cause  of 
the  sensation  of  friction  has  not  been  sufficiently  investigated, 
but  we  know  that  the  rubbing  feel  may  arise  in  various  states  of 
the  serous  membranes ;  while  that  of  non-expansion  of  parts  of 
the  lung,  will  obviously  be  produced  by  many  different  causes. 
The  cases  in  which  the  sense  of  touch  leads  us  to  most  certainty 
in  diagnosis  are  those  of  the  diseases  of  the  heart  and  great 
vessels  ;  yet  every  practical  man  knows,  that  the  most  violent 
impulses  occur  without  organic  disease  of  the  circulating  system, 
while,  on  the  other  hand,  extensive  hypertrophy  of  the  heart 
may  exist  with  a  natural  impulse,  and  an  aneurism  of  the  aorta 
give  no  morbid  pulsation. 

5th.  Signs  derived  from  alteration  in  the  shape  and  volume  of 

the  thorax. 

In  this  class  of  signs  we  meet  with  some  of  considerable  value  ; 
thus,  the  convexity  of  the  chest  in  Laennec's  emphysema,  when 
carried  to  a  great  degree,  is  an  appearance  almost  peculiar  to  the 
disease ;  and  which,  combined  with  the  elevated  shoulders  and 
the  hypertrophied  state  of  the  muscles  in  the  neck,  will  scarcely 
mislead.  But  of  the  various  partial  dilatations  and  contractions, 
there  is  no  one  at  all  pathognomonic :  many  of  them  may  be 
congenital,  or  the  result  of  former,  and  of  various  diseases. 
Thus,  dilatation  of  either  side  may  arise  from  emphysema, 
pneumothorax,  pleural  effusions  of  various  kinds,  effusions  into 
the  pericardium,  enlargements  of  the  liver,  or  aneurisms  of  the 
aorta.  An  apparent  dilatation  too,  may  exist,  in  consequence 
of  the  contraction  of  the  opposite  side :  and  contraction  itself 
may  arise  from  a  variety  of  morbid  causes,  or  be  a  congenital 
conformation. 


DIAGNOSIS    OF    THORACIC    DISEASE.  17 

6th.  Signs  referrible  to  acoustics. 

These  have  been  hitherto  divided  into  those  obtained  by 
percussion,  and  by  mediate  or  immediate  auscultation  ,•  a  divi- 
sion which  seems  to  be  unnecessary,  as  both  classes  of  signs 
being  appreciable  by  the  ear  alone,  should  be  ranged  under  the 
general  head  of  auscultatory  phenomena.  Under  this  head, 
therefore,  we  shall  treat  of  Percussion,  and  Auscultation,  whe- 
ther Mediate  or  Immediate.  Previous,  however,  to  our  entering 
on  an  investigation  of  their  value  as  diagnostic  means,  we  shall 
briefly  describe  the  principles  of  these  modes  of  diagnosis. 
It  is  plain,  that  we  have  acoustic  phenomena  referrible  to  a 
passive  and  an  active  state  of  the  lung ;  in  other  words,  to 
conditions,  on  the  one  hand  independent  of  motion  or  life, 
and  on  the  other,  inseparable  from  them.  The  passive  phe- 
nomena, or  those  of  percussion,  which  relate  merely  to  the 
quantity  of  air  within  the  thorax,  may  be  as  well  observed  in 
the  dead  as  in  the  living  body;  while  the  active,  or  those  of 
respiration,  the  voice,  or  the  phenomena  of  the  heart  and 
arteries,  imply  motion  and  life.  Hence,  Ave  may  divide  the 
phenomena  of  auscultation  into  those  of  the  passive  and  active 
conditions. 


PASSIVE    AUSCULTATORY   PHENOMENA. 

The  great  object  of  percussion  is  to  determine  the  diminution 
or  increase  of  the  quantity  of  air  within  the  thorax,  or  in  certain 
portions  of  that  cavity.  It  has  been  already  observed  that  of  the 
different  cavities  in  the  body,  the  chest  is  that  in  which  the 
existence  of  air  in  quantity  is  a  natural  condition  ;  and  it  need 
scarcely  be  repeated,  that  in  the  normal  state  of  the  cerebro- 
spinal cavities,  air,  in  a  free  state,  is  always  wanting.  We 
know,  also,  that  when  it  occurs  in  any  part  of  the  abdomen,  it  is 
either  the  product  of  disease,  of  the  fermentation  of  the  ingesta, 
or  of  a  secretion  from  the  mucous  surface,  by  no  means  constant 
in  its  occurrence  or  quantity;  but  the  chest  is  the  great  re- 
ceptacle for  air,  and  from  the  first  moments  of  extra-uterine  life, 
contains  a  vast  quantity  of  it.  Upon  this  peculiarity  does  the 
employment  of  percussion  depend,  because,  cceteris  paribus,  the 

c 


18  GENERAL    PRINCIPLES    OF    THE 

sound  on  percussion  is  directly  as  the  quantity  of  air  contained 
within  the  thorax. 

Now,  the  result  of  almost  every  organic  disease  of  the  lung  or 
heart  is  to  diminish  or  increase  the  capacity  of  the  thorax  for 
air,  and  consequently  to  diminish  or  increase  the  sound  on  per- 
cussion ;  hearing  this  in  mind,  we  find  that  the  greater  number 
of  thoracic  affections  tend  to  diminish  the  quantity  of  contained 
air,  and  consequently  are  accompanied  by  a  proportional  decrease 
of  sound,  while  the  smaller  (very  few  in  number)  have  the 
opposite  effect  and  results.  If  we  consider  that  the  general 
result  of  most  of  the  organic  diseases  is  to  cause  impermeability 
of  the  lung,  produced  either  by  deposition  within,  or  pressure 
without  the  organ,  we  shall  see  that  the  principle  above  stated 
holds  good :  thus,  in  pneumonia,  congestion,  oedema,  pulmonary 
apoplexy,  tubercle,  cancer,  and  hydatid  of  the  lung,  portions  of 
the  lung,  more  or  less  extensive,  which  had  previously  contained 
air,  are  now  filled  by  a  fluid  or  solid  substance.  Even  in 
bronchitis,  we  can  have  no  doubt,  that  the  sound  on  percussion 
is  diminished  in  proportion  to  the  turgescence  of  the  mucous 
membrane,  a  fact  observed  by  Avenbrugger  in  the  exanthematous 
diseases.  It  is  true,  that  the  diminution  of  sound  is  generally 
so  slight  as  to  escape  detection ;  yet  that  it  exists  even  in  the 
first  stages  cannot  be  doubted ;  and  when  secretion  takes  place 
to  any  degree  into  the  bronchial  tubes,  the  diminution  of  the 
quantity  of  air  can  be  generally  detected  by  percussion. 

The  same  result  is  observed  in  all  those  cases  of  disease  of 
the  pleura  or  pericardium,  in  which  a  liquid  effusion  occurs. 
In  these  cases,  as  in  the  former,  we  see  a  similar  effect,  though 
from  a  different  cause  :  namely,  the  obliteration  of  air  cells,  the 
diminution  of  the  quantity  of  air,  and  the  occupation  of  its 
situation  with  reference  to  the  thorax,  by  a  medium  giving  a 
dull  sound  on  percussion.  The  same  remarks  are  applicable  to 
enlargements  of  the  heart,  aneurisms  of  the  aorta,  and  organic 
tumours  exterior  to  the  lung. 

Of  those  diseases,  in  which  an  increase  of  the  quantity  of  air, 
and  consequently  an  increase  of  the  sound  on  percussion,  are 
results,  we  have  but  two :  namely,  dilatation  of  the  air  cells,  and 
pneumothorax.  It  seems  possible  also,  that  an  extremely 
anaemic  state  of  the  body,  by  diminishing  the  amount  of  the 
circulating  fluid,  may  produce  a  morbidly  clear  sound  on  percus- 


DIAGNOSIS    OF    THORACIC    DISEASE.  19 

sion,  and  that  in  this  way,  we  may  explain  the  extraordinary 
clearness  observed  in  many  phthisical  patients,  even  though  the 
lung  contains  considerable  quantities  of  scattered  tubercle. 

I  shall  now  briefly  recapitulate  the  principal  thoracic  affections, 
with  reference  to  the  result  of  percussion. 

First. — Diseases  causing  a  diminution  in  the  sound  on 

percussion. 

The  different  forms  and  stages  of  pneumonia,  serous  and  san- 
guineous congestions,  pulmonary  apoplexy. 

Tubercle,  cancer,  melanosis,  hydatids. 

Bronchitis  in  its  first  and  second  stages. 

All  liquid  effusions  into  the  pleura  and  pericardium. 

Active  and  passive  enlargements  of  the  heart. 

Aneurisms  of  the  aorta  or  innominata. 

Organic  tumours  of  the  mediastinum,  pleurae,  pericardium,  or 
heart. 

Secondly. — Diseases  causing  an  increase  of  the  sound  on 
percussion,  either  partial  or  general. 

Dilatation  of  the  air  cells. 

Hypertrophy  of  the  lung. 

Pneumothorax,  with  or  without  fistula. 

Pneumopericardium. 

Now,  the  great  point,  as  connected  with  the  applicability  of 
percussion  to  diagnosis  is,  that  these  diminutions  or  augmenta- 
tions of  the  quantity  of  air  being  almost  always  partial,  give 
consequently,  partial  phenomena.  A  circumstance  admitting  of 
the  application  of  comparison,  which,  as  we  have  said  before,  is 
so  important  in  physical  diagnosis. 

For  example,  in  the  case  of  solidification  of  one  lung,  although, 
for  the  sake  of  argument,  we  may  suppose  that  the  quantity  of 
air  within  the  thorax  is  diminished  by  one-half ;  yet,  it  does  not 
follow,  that  the  sound  on  percussion  of  the  whole  thorax  is  pro- 
portionally lessened.  For  the  healthy  side  retains  its  natural 
sound,  or  at  all  events  gives  a  sound  so  little  diminished,  as  by 
no  means  to  interfere  with  the  comparison  of  the  healthy  with 
the  diseased  lung.  Again,  in  a  case  of  incipient  phthisis,  the 
upper  lobe  of  the  lung  is  tubercular ;  yet,  this  diminution  of  the 


20  GENERAL    PRINCIPLES    OF    THE 

quantity  of  air  does  not  affect  the  sound  of  the  lower  portions ; 
and  hence,  a  comparison  between  them  can  he  established,  and 
the  disease  he  thus  detected.  Further,  in  a  case  of  pneumo- 
thorax, or  of  partial  dilatation  of  the  air  cells,  the  increase  of 
sound  is  only  partially  observed,  the  healthy  portions  giving  less 
resonance  on  percussion ;  so  that  here  also,  comparison  can  be 
established.  I  am  aware,  that,  reasoning  upon  strictly  physical 
principles,  we  should  expect  some  diminution  or  increase  of  sound 
in  the  healthy  portions ;  yet,  if  this  does  occur,  the  alteration  is 
so  slight  as  not  to  interfere  with  the  facility  of  diagnosis,  unless 
in  extreme  cases  of  disease.  It  is  plain,  that  if  such  alteration 
occur,  it  will  interfere  more  with  the  comparison  of  the  parts  of 
the  affected  lung  among  one  another,  than  to  that  of  the  diseased 
with  the  health}'  lung. 


ACTIVE    AUSCULTATORY    PHENOMENA. 

The  principle  of  diagnosis,  founded  on  these  signs,  is  ex- 
tremely simple.  I  may  give  the  following  explanation  of  this 
principle. 

The  manner  in  which  the  stethoscope  assists  us  in  detecting 
the  state  of  the  thoracic  viscera  can  be  explained  in  a  very  few 
words.  The  air,  as  it  passes  through  the  lungs  in  the  acts  of 
inspiration  and  expiration  ;  the  sound  of  the  voice  in  different 
parts  of  the  chest ;  and  the  impulse  and  sound  of  the  heart  at 
each  pulsation,  have  all  certain  characters  in  the  state  of  health. 
They  present  phenomena,  which  are  to  be  considered  as  standards 
of  comparison.  Now,  every  disease  of  the  lungs  and  heart  alters 
or  modifies  these  characters,  according  as  the  case  may  be ;  and 
it  is  by  the  knowledge  of  the  morbid  phenomena  or  deviations 
from  the  natural  state,  that  we  may  judge  of  the  state  of  the 
thoracic  viscera. 

I  need  scarcely  remark,  that  I  do  not  maintain,  that  health 
implies  an  identity  of  phenomena  in  every  individual ;  the  signs 
in  a  child  differ  from  those  in  the  adult,  those  of  the  female 
from  those  of  the  male ;  and  there  are  other  cases  of  natural 
modification,  but  still,  taking  these  circumstances  into  con- 
sideration, the  active  auscultatory  phenomena  of  health  have  a 
sufficiently  constant  character  to  deserve  the  name  of  standard* 
of  comparison,  and  to  be  used  as  such. 


DIAGNOSIS    OF    THORACIC   DISEASE.  21 

The  active  auscultatory  phenomena  may  be  classed  as  follows  : 
I.   Sounds  of  respiration  : — 
Tracheal. 
Vesicular. 
II.  Sounds  of  cough. 

III.  Sounds  of  voice. 

IV.  Sounds  of  the  heart  and  great  vessels. 

Now,  the  effect  of  disease  is  two-fold  :  it  modifies  these 
phenomena,  and  it  gives  rise  to  new  and  non-analogous  signs ; 
so  that  we  have  active  auscultatory  phenomena  of  health, — 
next,  modifications  of  these,  produced  by  disease  ;  and,  lastly, 
entirely  new  active  auscultatory  signs,  whose  existence  is  solely 
the  result  of  a  diseased  state  :  as  for  instance,  the  different 
rules ;  the  metallic  phenomena ;  the  rubbing  sounds  of  the 
serous  membranes  ;  and  the  various  murmurs  of  the  heart  and 
great  vessels,  &c. 

Having  now  given  a  short  sketch  of  the  sources  of  physical 
diagnosis,  I  shall  announce  the  great  principles  that  govern  their 
application  to  the  detection  of  disease ;  these  may  be  stated  as 
follows  : — 

First. — That  the  value  of  most  of  the  preceding  signs,  or 
of  their  combinations,  in  the  determination  of  the  seat,  nature, 
or  extent  of  disease,  is  to  be  estimated  more  by  comparison  with 
the  phenomena  of  other  portions  of  the  chest,  than  by  their  mere 
existence  in  a  particular  situation. 

Second, — That  the  greater  the  number  of  physical  signs  which 
can  be  combined  in  any  particular  case,  the  more  accurate  will 
our  conclusions  be.  But  of  these  combinations,  the  most  im- 
portant and  indispensable  is  that  of  the  passive  and  active  aus- 
cultatory phenomena. 

Third. — That  the  existing  physical  signs  are  to  be  considered 
in  relation  to  the  period  of  duration  of  the  disease,  and  the 
rapidity  or  slowness  of  their  own  changes. 

Fourth. — That  in  all  cases,  the  value  of  physical  signs  must 
be  tested  by  the  existing  symptoms  and  previous  history ;  while 
on  the  other  hand,  the  observation  of  these  physical  signs,  enables 
us  to  correct  the  conclusions  to  which  we  would  be  led  by  the 
unaided  study  of  symptoms. 

I  shall  first  proceed  to  the  elucidation  of  the  principle  of 
Comparison.     This  principle,  which  may  be  said  to  be  the  basis 


22  GENEKAL    PRINCIPLES    OF    THE 

of  physical  diagnosis,  has  not  been  sufficiently  insisted  on,  either 
in  the  work  of  Laennec,  or  of  any  of  the  succeeding  writers  on 
auscultation.  Indeed,  Dr.  Williams  is  the  onry  author  who 
alludes  to  the  subject.*  But  even  this  author  does  not  suffi- 
ciently insist  on  its  paramount  importance,  and  refers  to  i-t 
principally  as  connected  with  the  use  of  percussion.  "A  person 
commencing  the  practice  of  percussion,  will  be  guided  more 
safely  by  the  comparative  than  by  the  absolute  sounds  of  different 
parts  of  the  chest ;  and  although  he  should  lose  no  opportunity 
of  acquainting  himself  with  the  sounds,  both  of  percussion  and 
auscultation,  in  healthy  subjects,  he  should  in  case  of  disease, 
more  particularly  at  first,  direct  his  attention  to  irregularities  or 
want  of  correspondence  of  the  two  sides  in  the  same  subject. 
In  instituting  this  comparison,  he  should  be  careful,  likewise,  to 
practise  percussion  on  corresponding  parts  of  the  two  sides,  and 
with  such  an  attention  to  the  manner  in  which  his  fingers  fall, 
and,  if  he  uses  the  digital  pleximeter,  the  manner  in  which  this 
is  placed,  that  any  difference  of  sound  may  not  arise  from  these 
fortuitous  circumstances." 

But  the  principle  of  comparison  must  be  applied  to  all  the 
means  of  physical  diagnosis,  and  must  never  be  lost  sight  of, 
either  by  the  tyro  or  the  most  practised  investigator  of  disease ; 
for,  as  will  be  shewn,  it  is  the  only  mode  of  avoiding  error. 

We  have  already  seen  how  beautifully  the  anatomical  structure 
of  the  thorax  favours  the  application  of  this  principle  ;  the  organs 
in  this  cavity  being  more  remarkably  and  completely  separated 
than  those  of  the  cranium  or  abdomen.  From  this  circumstance 
two  important  consequences  are  derived  :  first,  the  facility  of 
comparison  of  the  different  portions,  and  next,  the  circumscription 
of  disease. 

Let  us  now  take  some  examples  of  the  value  of  comparison. 
Feebleness  of  respiration  occurs  in  many  diseases  of  the  lung. 
Now,  suppose  we  are  called  to  examine  a  patient  with  symptoms 
of  incipient  phthisis,  we  may  find  the  vesicular  murmur  under 
the  clavicle  exceedingly  feeble,  a  character  of  common  occurrence 
in  cases  of  tubercular  disease  ;  yet,  if  from  this  alone  we  were  to 
conclude,  that  the  case  was  really  phthisis,  we  might  be  altogether 
wrong,  for  many  persons  have  a  naturally  feeble  respiration  over 

*  Rational  Exposition  of  the  Physical  Signs  of  the  Diseases  of  the  Lungs  and 
Pleura. 


DIAGNOSIS    OF    THORACIC    DISEASE.  23 

the  whole  chest.  In  such  a  case,  the  sign  of  feebleness  of 
respiration  under  the  clavicle  might  be  of  no  value,  for  it  would 
be  only  the  natural  character  of  the  respiratory  murmur.  But 
suppose  that,  in  another  case,  we  found  the  same  feebleness  of 
respiration  in  the  same  place,  and  not  content  with  this  super- 
ficial examination,  we  explored  the  opposite  side,  and  found  the 
respiration  there  unusually  loud,  then,  indeed,  the  feebleness 
of  respiration  would  become  a  sign  of  positive  value ;  because, 
under  such  circumstances,  experience  tells  us,  that  in  most 
cases,  it  is  actually  produced  by  tubercular  development. 
Thus,  in  this  instance,  the  sign  derives  its  whole  value  from 
comparison. 

Let  us  now  take  the  opposite  case :  there  is  a  character  of 
respiration,  termed  puerile,  from  its  resemblance  to  that  of 
children,  and  which  commonly  occurs  in  cases  where  some 
other  portion  of  the  lung  has  been  disorganized.  But  the  mere 
circumstance  of  hearing  puerile  respiration  in  one  portion  of  the 
lung,  is  by  no  means  a  conclusive  proof  of  the  existence  of 
disease  in  some  other  part,  for,  in  certain  cases,  the  respiration 
is  universally  puerile,  independent  of  any  disease  ;  it  is  only  the 
co-existence  of  puerility  in  one  portion  and  feebleness  in  another, 
that  gives  any  value  to  the  sign  ;  in  other  words,  it  is  by  the  test 
of  comparison  that  its  value  must  be  estimated. 

The  same  observations  apply  to  the  phenomena  of  the  voice. 
An  increased  resonance  of  the  voice  is  a  common  sign  of  solidity 
of  the  lung,  but  one  of  no  value,  except  by  comparison,  for  many 
persons  present  a  natural  bronchophony  over  a  large  portion  of 
both  lungs.  But,  where  the  resonance  is  loud  and  distinct  in 
one  lung,  and  either  wanting  or  much  less  intense  in  the  corres- 
ponding portion  of  the  opposite  one ;  it  then  becomes  a  sign 
of  decided  value.  I  might  also  extend  this  to  the  sign  of 
pectoriloquism,  about  which,  such  a  quantity  of  error  is  extant. 
Some  persons  are  naturally  pectoriloquous  in  the  upper 
portions  of  the  lungs  ;  and  it  is  plain  that,  in  such  cases,  the 
discovery  of  the  phenomenon  under  the  clavicle,  or  over  the 
shoulder  of  one  side,  might  lead  to  great  error  unless  tested  by 
comparison. 

The  following  is  an  important  and  common  illustration  of  the 
value  of  comparison.  A  patient  presents  the  symptoms  of  cough, 
muco-purulent  expectoration,    accelerated  breathing  and  pulse, 


24  GENERAL    PRINCIPLES    OF    THE 

emaciation,  and  hectic.  Under  these  circumstances,  we  detect  a 
mucous  rattle  in  the  subclavicular  region ;  a  sign  which,  when 
properly  estimated  and  corrected,  may  lead  to  an  almost  positive 
diagnosis  of  phthisis,  with  softening  of  the  tubercles.  Now  if, 
in  a  patient  labouring  under  the  above  symptoms,  we  were  to 
conclude  from  the  mere  existence  of  this  sign  in  this  situation, 
that  the  case  was  really  phthisis,  we  might  fall  into  error,  for  a 
comparative  examination  of  the  different  portions  of  the  chest 
might  shew,  that  the  rale  was  universal ;  a  discovery,  which 
would  greatly  diminish  its  value  as  a  sign  of  phthisis,  and  leave 
a  probability  that  the  case  was  one  of  bronchitis,  with  copious 
effusion  into  the  smaller  tubes.  In  such  a  case,  the  value  of 
comparison  is  obvious. 

On  the  other  hand,  the  existence  of  rale,  either  under  one  or 
both  clavicles,  while  the  inferior  portions  remained  free,  would, 
when  occurring  with  the  symptoms  described,  be  a  most  important 
diagnostic  sign  of  phthisis. 

Comparison  must  be  used  in  determining  the  value  of  the 
modifications  of  the  original  active  phenomena,  as  well  as  of  that 
of  the  new  or  non-analogous  signs.  A  good  example  of  this  is 
seen  in  the  detection  of  foreign  bodies  in  the  bronchial  tubes,  for 
it  is  principally  by  the  comparison  of  the  respiratory  sounds  in 
both  lungs,  that  the  diagnosis  of  a  foreign  body  can  be  arrived 
at  :  to  this  subject  I  shall  return  hereafter.  I  may  also 
observe,  that  in  certain  cases  of  aneurism  of  the  aorta  or  in- 
nominata,  it  is  by  a  comparison  of  the  respiratory  murmur  in 
either  lung,  that  the  existence  of  the  tumour  at  an  early  period 
can  be  detected. 

We  get  a  good  idea  of  the  value  of  comparison,  by  reflecting 
that  the  cases  in  which  diagnosis  is  most  difficult,  are  those  in 
which  the  phenomena  are  the  same  over  the  entire  chest.  There 
are  two  cases  of  phthisis  in  which  physical  diagnosis  is  extremely 
difficult;  the  one  an  acute,  the  other,  a  chronic  case  ;  yet,  in  both 
of  which,  the  tubercle  is  equally  and  universally  developed  in 
both  lungs,  and  consequently,  similar  phenomena  being  given  by 
all  parts  of  the  chest,  the  diagnosis  by  comparison  founded  on 
the  localization  of  disease,  becomes  inapplicable.  The  same 
remarks  apply  to  the  case  of  double  empyema,  in  which  we  lose 
the  advantages  that  the  comparison  of  the  differences  between 
the  physical  phenomena  of  either  side  gives  us  in  single  pleurisy; 


DIAGNOSIS    OF    THORACIC    DISEASE.  25 

and  also  to  that  of  double  and  equal  dilatation  of  the  air  cells, 
the  detection  of  which  must  depend  on  the  direct  signs,  and 
history  of  the  case. 

One  of  the  most  striking  instances  of  the  difficulties  which 
arise  when  the  application  of  comparison  is  fallacious,  is  that  of 
the  development  of  tubercle  in  a  patient,  whose  chest  has  been 
deformed  from  previous  disease.  Patients  who  have  recovered 
from  empyema  with  a  contracted  side,  are  liable  to  tubercular 
development,  and  the  stethoscopist  may  be  called  to  determine 
the  question,  as  to  whether  tubercle  exist  or  not.  I  have  been 
more  than  once  in  this  situation,  and  believe  that  a  more  difficult 
case  for  diagnosis  can  hardly  be  met  with.  The  symptoms  will 
seldom  afford  any  assistance,  as  they  may  proceed  either  from 
incipient  phthisis,  or  be  those  commonly  present  during  the 
convalescence  from  empyema.  And  in  consequence  of  the  previous 
disease  of  one  pleura,  and  the  contraction  of  the  chest,  we  are 
deprived  of  the  advantages  of  comparison  of  the  phenomena  of 
both  lungs,  by  the  stethoscope  and  percussion.  Thus,,  if  we  find 
the  side  originally  affected  to  be  duller  than  the  other  on  per- 
cussion, this  may  be  explained  either  by  the  diminished  volume 
of  the  lung,  or  by  the  development  of  tubercles.  The  same 
difficulty  exists  in  the  observation  of  respiration,  and  the  phe- 
nomena of  the  voice.  But  if  the  opposite  lung  be  the  seat  of 
tuberculous  disease,  we  may  detect  the  affection  in  its  early 
periods  ;  yet,  in  a  remarkable  case  that  I  lately  saw,  and  in 
which,  after  a  comparatively  rapid  recovery  from  empyema  of  the 
left  side,  tuberculous  disease  set  in  ;  all  the  stethoscopic  signs 
indicated  disease  in  the  left  lung,  and  not  in  the  right ;  and  yet, 
on  dissection,  the  right  lung  was  found  full  of  miliary  and 
granular  tubercles,  while  the  left  contained  scarcely  any.  Of 
this,  the  preceding  considerations  afford  an  easy  explanation. 
The  left  lung  was  dull  on  percussion,  from  its  diminished  volume; 
for  the  same  reason,  its  vesicular  murmur  was  feeble,  while  in 
the  right,  the  disease  had  not  become  sufficiently  extensive  to 
cause  a  greater  dulness,  or  even  an  equality  of  sound.  It  is  plain, 
that  under  these  circumstances,  a  greater  amount  of  disease  in 
the  right  lung  would  be  required  to  lead  to  its  detection,  than  in 
a  case  where  the  opposite  lung  had  not  been  previously  affected 
by  empyema. 

Independent   of  the  importance   of  the    principle  of   compa- 


26  GENERAL    PRINCIPLES    OF    THE 

rison,  its  practice  in  all  cases  is  of  the  greatest  utility,  by  lead- 
ing to  the  discovery  of  lesions  which  would  otherwise  escape  us. 
I  remember  being  called  to  see  a  patient,  who  had  received  an 
injury  of  the  side,  and  who  was  labouring  under  fever,  cough, 
expectoration,  and  dyspnoea.  His  attendants  had  examined  him 
repeatedly  with  the  stethoscope,  and  discovered  nothing  but 
bronchitis.  I  had  him  stripped,  and  found  the  phenomena  of 
empyema  and  pneumothorax  in  the  lower  part  of  the  right 
lung ;  his  attendants  had  examined  the  upper  part  of  the  chest 
carefully,  but  had  neglected  the  lower,  and  thus  the  true  nature 
of  the  disease  had  escaped  them. 

With  respect  to  the  heart,  it  is  evident,  that  the  diagnosis 
by  comparison  of  signs  with  one  another,  is  not  so  applicable  as 
in  the  lungs.  We  are  forced,  in  many  cases,  to  depend  upon  the 
characters  of  isolated  phenomena  ;  and  hence,  the  difficulty  which 
attends  the  detection  of  diseases  of  the  heart  may  be  in  part  ex- 
plained. If  we  consider  the  heart  as  a  single  organ,  it  is  plain, 
that  we  have  no  standard  for  comparison,  and  the  same  obser- 
vation applies,  if  we  take  it  as  a  double  organ  ;  for  the  arterial 
and  pulmonary  hearts  have  original  differences,  whether  ana- 
tomically or  physiologically  considered. 

Yet,  comparison  is  not  wholly  inapplicable  in  cases  of  dis- 
eases of  the  heart.  By  it,  we  may  often  determine  the  seat  of 
disease,  if  not  its  nature  ;  we  also  find  it  applicable  in  the 
diagnosis  of  certain  cases  of  aneurism  of  the  great  vessels. 

In  the  progress  of  this  work,  I  shall  shew  many  other  ex- 
amples of  the  importance  of  comparison.  We  now  proceed  to 
consider  the  next  principle  of  physical  diagnosis ;  namely,  the 
combination  of  signs,  and  in  particular,  those  drawn  from  per- 
cussion and  the  stethoscope. 

For  example :  a  patient  is  affected  with  stridulous  breath- 
ing, and  by  percussion  we  discover  that  one  clavicle  is  decidedly 
dull.  This  proves,  that  there  is  in  that  situation  a  diminution 
of  the  normal  quantity  of  air  ;  a  condition  generally  produced 
by  either  pulmonary  solidity,  or  by  displacement  of  the  lung 
from  an  aneurismal  tumour.  Here,  to  determine  the  important 
question,  as  to  whether  the  case  be  disease  of  the  lung  or 
aneurism,  the  employment  of  the  stethoscope  becomes  abso- 
lutely necessary.  We  must  correct  the  passive  by  the  active 
signs. 


DIAGNOSIS    OF    THORACIC    DISEASE.  27 

Again,  suppose  that  we  detect  feeble  respiration  in  ap- 
portion of  the  lung,  we  have  a  character  which  may  be  produced 
by  essentially  opposite  states  of  the  pulmonary  tissue,  in  other 
words,  by  an  increased  or  a  diminished  quantity  of  air.  Percus- 
sion must  be  used  to  correct  the  stethoscopic  observation.  The 
active  signs  are  to  be  corrected  by  the  passive. 

A  patient  has  presented,  for  some  time,  decided  dulness  of 
the  upper  portion  of  one  lung,  and  we  find,  subsequently,  that 
this  portion  regains  its  sound.  Now,  this  circumstance  may  be 
produced  either  by  the  formation  of  a  cavity,  or  by  the  return  of 
the  lung  to  its  healthy  state.  Here  the  observation  of  the  active 
signs  is  necessary  to  determine  the  value  of  the  passive. 

A  patient  has  presented  the  sign  of  friction,  or  the  rub- 
bing sound  produced  by  the  inflamed  state  of  the  serous  mem- 
brane ;  and  after  a  time,  this  active  phenomenon  is  observed  to 
disappear,  which  may  result  either  from  the  cure  of  the  disease, 
or  the  separation  of  the  layers  of  the  pleura  or  pericardium, 
by  a  liquid  effusion.  To  determine  the  point,  we  must  have 
recourse  to  the  observation  of  the  passive  phenomena.  If  it 
be  the  former  case,  percussion  will  give  a  clear,  if  the  latter,  a 
dull  sound. 

In  the  case  of  a  foreign  body  in  the  trachea,  or  the  pressure  of 
an  aneurismal  tumour  on  one  bronchus,  we  may  observe  either 
complete  absence  or  great  diminution  of  the  respiratory  murmur 
in  either  lung.  This  modification  of  the  active  auscultatoiy 
phenomena,  for  its  value  in  the  diagnosis  of  aneurism,  depends 
entirely  on  the  result  of  percussion,  as  we  shall  see  hereafter. 

It  is  only  by  the  combination  of  these  two  classes  of  signs,  that 
we  are  able  to  arrive  at  the  diagnosis  of  a  rare,  but  most  impor- 
tant disease,  namely,  acute  general  development  of  tubercle, 
with  bronchial  irritation.  In  many  of  these  cases,  stethoscopic 
observation  can  only  detect  intense  bronchitis ;  and,  without  the 
aid  of  percussion,  no  other  diagnosis  could  be  arrived  at.  Now, 
acute  bronchitis  may  exist  with  apparent  clearness  of  sound ;  but 
if,  in  such  a  case,  we  observe  an  increasing  and  decided  dulness 
of  the  chest,  the  diagnosis  of  a  general  development  of  tubercle 
may  be  often  safely  arrived  at. 

Many  more  instances,  illustrative  of  the  necessity  of  this  and 
other  combinations,  will  be  given  in  the  course  of  the  work.  I 
may,  however,  add  one  more  common  example.     A  patient  has 


28  GENERAL    PRINCIPLES   OF    THE 

been  attacked  with  symptoms  of  inflammation  of  the  lung,  and 
at  an  advanced  period  we  find  the  affected  side  completely  dull 
on  percussion.  This  may  arise  either  from  a  pleural  effusion  or 
a  solidification  of  the  lung,  and  the  observation  of  the  active 
phenomena  will  be  necessary  to  determine  the  question. 

Thus,  the  passive  and  active  auscultatory  signs  mutually 
correct  each  other  ;  yet,  even  their  combination  with  all  other 
classes  of  signs  will  be  insufficient,  if  the  history  and  symptoms 
of  the  case  be  not  accurately  considered  and  compared  with 
them.  In  other  words,  it  is  not  enough  to  compare  one  set  of 
signs  with  another,  but  all  the  signs,  whether  acoustic  or  not, 
with  the  history  and  symptoms. 

Let  us  next  consider  the  physical  signs  in  reference  to  the 
duration  of  the  disease,  and  the  rapidity  or  slowness  of  their 
own  changes.* 

A  patient,  previously  healthy,  is  attacked  with  inflammatory 
symptoms  and  pain  in  the  side.  Now,  if  in  the  course  of  twenty- 
four  hours  we  find  the  affected  side  dull  on  percussion,  a  strong 
probability  exists  that  the  case  is  one  of  effusion  into  the  pleura, 
rather  than  of  hepatization  of  the  lung.  Let  us,  on  the  other 
hand,  suppose  that  the  symptoms  have  continued  for  a  week  or 
ten  days,  and  that  at  the  end  of  that  time  we  find  the  sound 
clear  on  percussion,  then,  at  all  events,  we  may  conclude,  that 
the  case  is  not  pleurisy  with  effusion,  or  hepatization  of  the  lung. 
It  may  be  dry  pleuritis,  pleurodyne,  or  bronchitis. 

We  discover  the  signs  of  a  cavity  in  any  portion  of  the  chest. 
Now,  the  determination  of  the  nature  of  that  cavity  will  depend 
much  on  the  history  of  the  patient.  If  he  has  been  in  good 
health,  and  free  from  pulmonary  symptoms  up  to  within  a  week 
or  fortnight  of  the  time  when  we  have  first  examined  him,  the 
great  probability  is,  that  the  cavity  is  not  tuberculous.     It  may 

*  The  consideration  of  time  in  reference  to  the  existence  of  morbid  phenomena  is  a 
subject  of  the  greatest  importance.  We  cannot  in  local,  as  in  some  of  the  essential 
diseases,  shew  any  rule  as  to  the  duration  of  phenomena,  or  their  period  of  develop- 
ment, considered  with  reference  to  certain  stages  of  the  disease;  in  pleurisy,  for 
example,  we  cannot  say  when  the  effusion  will  appear,  when  the  secreting  process 
will  stop,  and  when  the  absorption  will  commence ;  while  in  variola  the  progress  of 
the  disease  is  generally  so  certain,  and  the  relation  of  its  different  stages  to  regular 
periods  of  time  so  generally  constant,  that  the  rule  is  easily  applicable.  And  even 
though  we  had  such  a  rule  in  the  acute  diseases,  we  could  never  hope  for  it  in  the 
chronic  affections.  Yet  the  study  of  time  in  relation  to  morbid  phenomena  gives 
approximative  results  of  great  value  in  Diagnosis. — MS.  Note  Book. 


DIAGNOSIS    OF    THORACIC    DISEASE.  29 

be  a  pneumonic  or  a  gangrenous  abscess.  On  the  other  hand, 
if  the  case  has  been  chronic,  in  the  ordinary  acceptation  of  the 
word,  the  chances  are,  that  the  cavity  is  tuberculous. 

Let  us  suppose  that  we  discover  an  extensive  gurgling  over 
the  upper  portion  of  one  side,  and  that  the  question  arises  as 
to  whether  this  is  caused  by  an  anfractuous  phthisical  cavity,  or 
by  dilated  tubes.  Here,  along  with  other  sources,  the  period  of 
the  continuance  of  the  symptoms  is  a  most  important  element 
in  settling  the  question.  If  the  patient  has  had  similar  symp- 
toms for  five,  ten,  or  fifteen  years,  the  chances  are  that  the 
case  is  one  of  dilated  tubes,  but  if  his  symptoms  have  continued 
only  for  three  or  six  months,  then  it  would  be  almost  certain 
that  the  signs  proceeded  from  a  multilocular  phthisical  abscess. 

It  would  be  easy  to  shew  that  many  other  diagnoses  are 
founded  on  the  connexion  of  the  actually  existing  physical  signs 
with  reference  to  the  period  of  continuance  of  symptoms.  I  may 
enumerate  a  few  of  these. 

Foreign  bodies  in  the  trachea. 

Acute  general  development  of  tubercle. 

Laennec's  emphysema  of  the  lung. 

Certain  cases  of  empyema  and  pneumothorax. 

Hydrothorax. 

Nervous  palpitation  of  the  heart,  as  distinguished  from  organic 
disease. 

Pericarditis  with  effusion. 

Rupture  of  an  hepatic  abscess  into  the  lung. 

Sympathetic  cough.  This  example,  perhaps,  requires  some 
explanation.  We  may  find  in  a  case,  where  violent  cough  has 
existed,  either  that  there  is  no  physical  sign  of  disease,  active  or 
passive,  or  that  if  there  be,  the  signs  are  insufficient  to  account 
for  the  symptoms.  Now,  these  circumstances  may  arise  either 
from  incipient  organic  disease,  or  from  mere  functional  lesion. 
If  the  symptoms  have  continued  for  a  considerable  length  of 
time,  the  great  probabilities  are  that  the  case  is  one  of  original 
or  symptomatic  neurosis  of  the  lung. 

The  above  instances  are  sufficient  to  shew  the  application  of 
the  principle  of  combination  of  the  history  of  the  case,  quoad  the 
period  of  duration  of  symptoms,  with  the  actually  existing 
physical  signs.  But  we  must  go  farther,  and  consider  these 
signs  with  reference  to  the  rapidity  and  slowness  of  their  own 


30  GENERAL   PRINCIPLES    OF    THE 

changes.  Perhaps  the  most  interesting  source  of  physical  diag- 
nosis is  drawn  from  considering  the  signs,  with  reference  to 
their  permanence  for  certain  periods,  and  the  mode  and  order  of 
their  successive  manifestations.  One  of  the  best  examples  of 
this  is  seen  in  the  case  of  dilated  tubes.  It  may  be  often 
difficult  to  pronounce  whether  the  signs  of  an  excavation  proceed 
from  a  phthisical  cavity  or  from  dilated  tubes.  Now,  as  a 
general  rule,  it  may  be  stated,  that  the  extension  of  the  cavity  is 
much  more  rapid  in  the  former  than  in  the  latter  case ;  and 
from  this  we  derive  the  following  rule  :  that  if,  in  any  instance, 
we  can  recognize  a  rapid  extension  of  a  cavity,  the  case  is  not 
one  of  dilated  tubes.  If,  in  the  course  of  a  fortnight,  or  a 
month,  the  stethoscope  indicates  a  decided  increase  in  the  size 
of  the  excavation,  we  recognize  an  ulcerative  extension,  rather 
than  that  almost  imperceptibly  slow  process  by  which  the 
bronchial  tubes  become  dilated,  so  as  to  simulate  abscess  of  the 
lung. 

Again,  we  may  experience  difficulty  in  determining  whether 
a  patient  labours  under  enlargement  and  valvular  disease  of  the 
heart,  or  an  aneurism  of  the  ascending  aorta.  I  have  seen 
several  of  such  cases,  in  which  I  at  first  suspected  an  aneurism ; 
as  much,  if  not  more,  from  the  history  and  symptoms  as  from 
the  signs  ;  but  in  which  my  suspicions  were  converted  into  cer- 
tainty from  observing  that  the  extension  of  the  signs  of  dulness, 
pulsation,  and  the  accompanying  murmurs  occurred  much  too 
rapidly  to  permit  the  supposition,  that  they  proceeded  from  a 
further  enlargement  of  the  heart  itself. 

In  the  case  of  a  foreign  body  lodging  in  the  right  bronchus, 
we  have  another  excellent  example  of  this  source  of  diagnosis : 
the  sudden  suspensions  and  re-appearances  of  the  respiratory 
murmur  in  the  affected  lung,  while  the  sound  on  percussion 
remains  clear,  point  out  sudden  alternations  of  the  conditions  of 
permeability  and  impermeability  in  the  corresponding  bronchus. 
And  it  is  scarcely  necessary  to  observe  that  these  are  circum- 
stances only  explicable  on  the  supposition  of  a  moveable  foreign 
body  existing  in  the  tube.  Indeed,  in  the  mode  of  succession 
of  the  various  signs  in  the  different  thoracic  diseases,  we  have  a 
source  of  diagnosis  of  such  importance,  that  it  seems  not  im- 
possible but  that  future  investigation  will  show  that  it  is  in 
this  department  we  are  to  seek  for  the  perfection  of  physical 


DIAGNOSIS    OF    THORACIC    DISEASE.  31 

diagnosis.  For  in  many  instances  we  find  that  in  different 
diseases  the  characters  of  the  signs  are  identical,  hut  their  modes 
of  succession  are  constantly  and  characteristically  different. 

For  example,  cedema  of  the  lung  presents  a  crepitating  rale, 
often  undistinguishable  from  that  of  pneumonia,  as  far  as  its 
physical  characters  are  concerned ;  but  successive  observations 
may  determine  the  point.  In  cedema  the  dropsy  of  the  lung 
causes  no  further  organic  change,  and  the  crepitus  consequently 
persists,  with  little  or  no  change,  for  a  length  of  time,  the 
sound  on  percussion  remaining  the  same.  On  the  other  hand, 
there  exists  in  pneumonia  a  cause  which  produces  successive 
and  important  modifications  in  the  structure  of  the  lung ;  and 
accordingly,  we  find  corresponding  changes  in  the  physical 
signs.  The  crepitating  rale  by  degrees  masks  the  vesicular 
murmur,  and  as  the  congestion  advances  gradually  disappears, 
until  impermeability  of  the  cells  and  finer  tubes  is  produced. 
We  have  then  dulness  of  sound  and  bronchial  respiration.  But 
the  changes  do  not  stop  here,  for  the  lung  may  pass  into 
suppuration,  or  return  to  health ;  in  either  of  which  cases 
important  changes  in  physical  signs  take  place. 

In  these  successive  changes,  then,  is  founded  the  physical 
diagnosis  between  pneumonia  and  cedema.  I  may  here  remark, 
as  illustrative  of  the  importance  of  studying  the  mode  of  suc- 
cession of  signs,  that  although  there  is  no  single  sign  in  pneu- 
monia which  is  pathognomonic,  the  possibility  existing  of  every 
one  of  them  arising  from  other  causes  ;  yet  we  know  of  no  other 
disease  which  presents,  in  its  progress  or  resolution,  the  same 
mode  of  succession  of  phenomena.  I  have  already  stated  that 
no  possible  combination  of  signs  can  be  considered  as  absolutely 
pathognomonic.  The  observations  just  now  made  are  by  no 
means  contradictory  of  this,  as  they  apply  not  to  any  existing 
combination,  but  to  the  successive  developments  of  physical 
phenomena. 

I  might  adduce  many  other  instances  of  this  mode  of  inves- 
tigation, but  enough  has  been  stated  to  explain  the  principle. 
The  preceding  observations  strongly  illustrate  one  of  the  most 
important  principles  connected  with  the  science  of  thoracic 
disease,  namely,  that  it  is  not  enough  to  be  able  to  recognize, 
nicely  distinguish  and  remember  signs,  but  that  we  must  know 
how  to   reason  upon   them.     Here  we  see  the  fusion  of  the 


32  GENERAL    PRINCIPLES    OF    THE 

mechanical  and  the  pathological  parts  of  the  science,  learn  their 
mutual  dependence,  and  find  why  it  is  that  the  mere  auscultator, 
or  the  mere  symptomatologist,  can  never  excel  in  the  diagnosis 
of  diseases  of  the  chest. 

I  shall  now,  in  conclusion,  briefly  allude  to  the  absolute 
necessity  of  studying  the  symptoms  in  relation  to  the  physical 
signs. 

It  is  true  that  the  mere  observation  of  certain  physical  signs 
may,  under  particular  circumstances,  lead  us  to  conclusions 
probably  correct,  but  the  object  of  medicine  is  certainty.  The 
existence  of  gurgling  and  cavernous  respiration  under  the  clavicle, 
tells  of  a  cavity  communicating  with  the  bronchial  tubes,  and 
containing  air  and  liquid ;  in  other  words,  of  an  anormal 
physical  change ;  so  far  we  have  certainty.  From  the  relative 
frequency  of  its  causes,  we  might  say,  that  the  cavity  was  pro- 
bably phthisical,  but  the  possibility  would  exist  of  its  being  a 
dilated  tube,  a  pneumonic  or  a  gangrenous  abscess. 

Again,  the  occurrence  of  metallic  tinkling  and  amphoric 
resonance  points  out  the  presence  of  a  vast  cavity  communicating 
with  the  bronchial  tubes,  and  containing  air  and  liquid ;  and  in 
like  manner,  from  the  comparative  frequency  of  its  cause,  we 
might  conclude  that  the  case  was  probably  an  example  of 
empyema,  pneumothorax  and  fistula  ;  but  on  the  other  hand, 
these  phenomena  may  occur  from  an  essentially  different  patho- 
logical condition  of  the  lung ;  nay,  further,  we  shall  find  that 
some  of  the  metallic  phenomena  may  arise  from  sources  alto- 
gether external  to  the  thorax. 

Let  us  take  a  few  more  examples,  illustrative  of  the  insuffi- 
ciency of  mere  physical  diagnosis.  It  is  commonly  held  by 
those  who  are  but  partially  acquainted  with  auscultation,  that 
the  crepitating  rale  is  a  sign  of  pneumonia  ;  that  it  is  so  is  true, 
but  in  some  of  its  forms,  it  may  occur  in  other  affections.  Let 
us  suppose  that  we  are  called  to  a  patient  whom  we  have  never 
before  seen,  and  with  the  history  of  whose  case,  or  his  present 
symptoms,  we  are  ignorant,  and  that  on  applying  the  stethoscope 
to  the  postero- inferior  portion  of  the  right  lung,  we  discover  a 
crepitating  rale,  we  have  then  a  phenomenon  which  may  be  pro- 
duced by  many  essentially  different  causes ;  and  were  we  to 
make  the  diagnosis  of  pneumonia,  our  opinion  would  rank 
nothing  better  than  a  mere  guess.     Among  its  various  causes, 


DIAGNOSIS    OF    THORACIC    DISEASE.  33 

the  phenomenon  might  be  produced  by  the  following  :  acute 
pneumonia  in  the  first,  the  suppurative,  or  the  resolutive  stage  ; 
chronic  pneumonia,  congestion,  oedema,  mucous  catarrh,  tuber- 
cle, hepatic  abscess  opening  into  the  lung,  pulmonary  apo- 
plexy. Now,  supposing  that  these  were  all  the  possible  causes 
of  the  phenomenon,  and  that  their  occurrence  was  of  equal 
frequency,  and  that  without  an  accurate  investigation  into  the 
history  and  symptoms  of  the  case,  we  concluded  that  its  cause 
was  an  acute  pneumonia  in  the  first  stage,  there  would  be  nine 
chances  to  one  against  our  guessing  right.  But  if  this  crepi- 
tating rale  was  observed  in  a  patient,  who  had  been  but  twenty- 
four  or  forty-eight  hours  ill,  and  had  previously  no  symptoms 
of  pulmonary  disease  ;  if  he  had  inflammatory  fever,  pain  of  the 
side,  cough,  acceleration  of  breathing,  and  viscid  expectoration, 
we  might  safely  conclude  that  its  cause  was  an  acute  pneumonia 
in  the  early  stage.  Again,  if  it  occurred  in  a  patient  who 
had  been  attacked  some  days  before  with  the  constitutional 
symptoms  of  pneumonia,  which  had  subsided  after  judicious 
treatment,  and  in  whom  there  had  been  pain  of  the  side  which 
had  disappeared  ;  bloody  and  viscid  expectoration,  which  had 
been  succeeded  by  a  clear  or  concocted  mucus  ;  dulness  of  sound 
and  bronchial  respiration,  which  had  subsided  or  was  diminish- 
ing; we  might  safely  conclude,  that  the  rale  was  an  example 
of  Laennec's  crepitus  of  resolution.  Lastly,  if  it  occurred  in  a 
patient  in  the  advanced  stages  of  pneumonia,  in  whom  the 
powers  of  life  were  sinking,  who  had  the  prune  juice  sputa, 
or  was  expectorating  a  yellow  purulent  matter,  and  in  whom 
the  affected  portion  of  the  chest  sounded  absolutely  dull  and 
with  distinct  bronchial  respiration,  we  might  safely  declare  that 
the  lung  was  in  the  third  or  suppurative  stage.  It  is  true,  that 
differences  in  the  character  of  the  sign  in  these  different  stages 
may  exist,  and  be  appreciable,  but  my  experience  leads  me  to 
the  firm  belief,  that  in  testing  the  value  of  any  sign,  we  are  to 
look  more  to  the  history  of  the  case,  and  the  accompanying 
physical  and  vital  phenomena  than  to  its  absolute  character. 
Here,  I  am  anxious  not  to  be  understood  as  depreciating  the 
importance  of  studying  the  actual  characters  of  physical  signs. 
On  the  contrary,  I  am  convinced,  that  the  more  the  ear  is  accus- 
tomed to  appreciate  minute  differences  of  sound,  the  greater 
will  be  our  accuracy  in  detecting  the  nature  of  disease.     But 

D 


34  GENERAL    PRINCIPLES    OF    THE 

while  I  do  not  deny  the  possibility  of  training  the  sense  of 
hearing  to  such  a  pitch  of  accuracy,  as  that  from  the  character 
of  sounds  we  may,  in  certain  cases,  infer  the  vital  cause  of 
phenomena,  I  yet  feel,  that  this  perfection  is  not  easily  attainable, 
and  at  best,  can  be  enjoyed  only  by  the  few.  And  it  must  never 
be  forgotten,  that  disease  occurs  under  infinitely  numerous  modi- 
fications, so  that  the  result  being  the  same,  the  physical  pheno- 
mena may  not  be  absolutely  similar. 

Again,  we  meet,  under  the  same  circumstances,  a  patient 
with  feebleness  of  respiration,  and  dull  sound  on  percussion  in 
the  same  situation ;  this  may  depend  on  inflammatory,  tuber- 
cular, or  cancerous  solidification  of  the  lung,  pulmonary  apo- 
plexy, empyema,  hydrothorax,  contraction  of  the  chest  from 
a  former  attack  of  pleuritis,  enlargement  of  the  liver,  pushing 
up  the  diaphragm,  ascites,  and  aneurism  of  the  aorta.  Here 
the  same  observations,  as  in  the  former  case,  evidently  apply. 

The  same  train  of  argument  is  applicable  to  most  of  the  other 
classes  of  physical  signs,  as  will  be  abundantly  shewn  when 
I  come  to  speak  of  the  diseases  in  particular. 

It  has  been  objected  to  the  advocates  for  the  stethoscope,  that 
they  discard  the  consideration  of  symptoms,  and  that  throwing 
overboard  all  the  knowledge  we  possessed  previously  to  the 
introduction  of  auscultation,  they  pretend  to  ascertain  the  exist- 
ence of  all  diseases  of  the  chest  by  the  sole  observation  of  phy- 
sical signs.  There  is  only  one  answer  to  be  made  to  this 
objection,  namely,  that  it  is  wholly  groundless  ;  indeed,  those 
who  make  it  only  betray  their  ignorance  of  the  subject.  Laennec 
never  taught  that  auscultation  could  supersede  the  mode  of 
examination  by  symptoms :  on  the  contrary,  he  devotes  a  con- 
siderable portion  of  his  work  to  their  history  and  analysis, 
and  in  many  places,  especially  insists  on  the  necessity  of  their 
careful  study.  He  gives  instances  where  the  physical  signs 
having  been  accurately  observed,  the  history  and  symptoms  of 
the  case  were  alone  to  determine  the  nature  of  the  disease  : 
thus  in  describing  a  case  of  dilatation  of  the  bronchial  tubes, 
he  states  that  the  physical  signs  allowed  of  two  suppositions  ; 
either  that  of  an  extensive  dilatation  of  the  bronchial  tubes,  or 
of  a  multilocular  phthisical  excavation; — "I  determined  how- 
ever on  the  first  diagnosis,"  says  Laennec,  "from  the  general 
state  of  the  patient  and  the  history  of  the  disease."     Andral, 


DIAGNOSIS    OF    THORACIC    DISEASE.  35 

who  is  the  second  writer  on  auscultation,  devotes  a  large  portion 
of  his  work  to  the  examination  of  symptoms ;  so  do  Louis, 
Bertin,  Forhes,  Duncan,  Elliotson,  Hope,  Williams,  and  all 
other  writers  of  any  authority  on  the  suhject. 

It  is  true  that  combinations  of  physical  phenomena  may 
sometimes  arise,  which  would  lead  to  a  great  degree  of  proba- 
bility, indeed,  almost  a  certainty  in  diagnosis.  A  patient  with 
a  dilated  side,  giving  morbid  clearness  on  percussion,  with  the 
sound  of  fluctuation  on  succussion,  and  in  whom  also  the  stetho- 
scope detected  the  metallic  tinkling,  &c,  might  be  said,  with 
almost  positive  certainty,  to  labour  under  empyema,  pneumotho- 
rax, and  pulmonary  fistula  :  but  such  cases,  or  those  analogous  to 
them,  are  comparatively  rare  ;  and  even  in  the  case  in  question, 
the  cause  of  the  fistula  would  be  undetermined.  In  the  cases 
we  are  every  day  called  to  treat,  the  value  of  pliysical  signs 
must  be  tested  by  the  history  and  symptoms,  and  these  in  their 
turn  must  be  corrected  by  the  physical  signs.  Whoever  neglects 
either  source  of  information  will  fall  into  the  most  fatal  errors. 
We  must  have  recourse  to  the  assistance  of  each  and  every  one  of 
these  means  ;  and  even  still,  with  all  this  combined  knowledge, 
we  shall  meet  with  cases,  the  real  nature  of  which  is  involved 
in  the  greatest  obscurity.  Indeed,  when  we  reflect  on  the 
infinite  complications  of  disease,  modified  by  circumstances 
infinitely  numerous,  it  would  be  strange  if  such  did  not  arise, 
and  there  can  be  no  doubt,  that  if  our  means  of  diagnosis  were 
extended  one  hundred  fold  beyond  their  present  state,  the 
same  circumstances  would  still  occur.  Physical  signs  form  an 
addition,  constitute  an  assistance  to  diagnosis,  but  nothing  more  : 
yet  of  their  value  every  impartial  mind  must  be  convinced,  who 
compares  the  state  of  our  knowledge  previous  and  subsequent 
to  their  disco  very.  It  is  on  the  discovery,  explanation,  and 
connexion  of  these  signs  with  organic  changes,  and  with  the 
symptoms  and  history  of  the  case,  that  Laennec's  imperishable 
fame  is  founded.  Time  has  shown  that  his  principles  of  diag- 
nosis were  not  the  bagatelle  of  a  day,  or  the  brain-lorn  fancy 
of  an  enthusiast,  the  use  of  which,  like  the  universal  medicine, 
was  to  be  soon  forgotten,  or  remembered  only  to  be  ridiculed. 
It  has  shown  that  the  introduction  of  auscultation,  and  its  sub- 
sidiary physical  signs,  has  been  one  of  the  greatest  boons  ever 
conferred   by  the   genius  of  man  on  the  world.     A  new  era  in 

d2 


36  GENERAL    PRINCIPLES    OF    THE 

medicine  has  been  marked  by  a  new  science,  depending  on  the 
immutable  laws  of  physical  phenomena,  and,  like  other  dis- 
coveries, founded  on  such  a  basis,  simple  in  its  application  and 
easily  understood.  A  gift  of  science  to  a  favoured  son  :  not  as 
was  formerly  supposed,  a  means  of  merely  forming  a  useless 
diagnosis  in  incurable  disease,  but  one  by  which  the  ear  is  con- 
verted into  the  eye ;  the  hidden  recesses  of  visceral  disease 
opened  to  the  view ;  a  new  guide  in  the  treatment,  and  a  new 
help  in  the  early  detection,  prevention,  and  cure,  of  the  most 
widely  spread  diseases  which  afflict  mankind. 

In  conclusion,  I  would  refer  to  one  of  the  most  essential 
points  as  bearing  on  the  diagnosis  of  chest  disease,  namely,  the 
co-existence  of  morbid  action  in  the  different  tissues  or  struc- 
tures of  the  lung.  In  a  practical  point  of  view  the  lung  may  be 
considered  as  consisting  of  three  different  parts  or  tissues.  We 
have  in  the  first  place  an  extensive  mucous  expansion,  forming 
the  internal  or  lining  membrane  of  the  lung,  and  which  may  be 
described  as  commencing  at  the  rima  glottidis  and  terminating 
in  the  air  cells.  We  have  next,  these  air  cells,  and  their  con- 
necting cellular  tissue,  forming,  with  their  blood  vessels,  what  is 
called  the  parenchyma  of  the  lung  ;  and  lastly,  we  have  its 
external  serous  covering,  the  pleura. 

From  this  division  authors  have  arranged  pulmonary  affec- 
tions into  those  of  the  mucous  membrane,  those  which  involve 
the  air  cells  and  intervesicular  cellular  tissue,  and  lastly,  those 
affecting  the  serous  covering.  Under  the  first  they  class  the 
different  varieties  of  laryngeal,  tracheal,  and  bronchial  disease ; 
under  the  second,  such  affections  as  pneumonia,  tubercle,  pul- 
monary apoplexy,  &c,  &c,  and  under  the  third,  we  have  the 
different  forms  of  pleuritic  inflammations,  and  the  various 
effusions  into  the  cavity  of  the  pleura. 

This  division,  though  convenient  in  the  writing  of  systems, 
and  to  a  certain  degree  applicable  in  the  practice  of  medicine, 
is  found  to  fail  when  we  accurately  consider  the  symptoms 
and  pathology  of  thoracic  disease.  In  many  cases,  indeed,  do 
Ave  find  it  impossible  to  draw  the, line  of  distinction  between  the 
affections  of  these  different  elements,  for  not  unfrequently  the 
diseased  action  extends  more  or  less  to  them  all.  We  have 
bronchitis  combined  with  pneumonia,  pneumonia  complicated 
with  pleuritis,   and  very  frequently  the  three  lesions  co-exist ; 


DIAGNOSIS    OF    THOKACIC    DISEASE.  37 

an  observation  which  applies  both  to  the  acute  and  the  chronic 
diseases  of  the  lung.  In  the  treatment  of  pulmonary  affections 
it  is  of  the  utmost  importance  to  bear  this  principle  always  in 
view. 

For  example,  in  almost  every  instance  of  acute  pneumonia 
•  there  is  bronchitis  also,  a  circumstance  never  to  be  forgotten  in 
the  treatment  and  progress  of  the  case.  For  in  many  instances, 
after  the  relief  of  the  pneumonia,  properly  so  called,  we  have  to 
contend  with  an  extensive  and  severe  bronchial  inflammation, 
which  if  unrelieved,  may  cause  the  death  of  the  patient.  And 
the  importance  of  this  is  further  shewn,  if  we  recollect  that  the 
mode  of  treatment  of  the  two  cases  is  not  the  same,  and 
the  source  of  danger  and  the  effects  on  the  economy  totally 
different. 

But  the  complication  with  bronchitis  is  not  the  only  one  to 
which  such  a  case  is  subject,  for  disease  of  the  pleura  is  per- 
haps as  frequent,  from  whence  the  term  pleuro-pneumonia,  one 
applicable  to  the  great  majority  of  cases.  It  is  true  that  the 
pleuritic  inflammation  is  generally  of  the  dry  kind,  and  hence  of 
less  importance  ;  but  the  reverse  may  occur,  and  a  purulent 
effusion,  or  a  serous  collection,  form  in  the  cavities  of  the 
pleura ;  so  that  in  certain  cases  the  practitioner,  ignorant  of 
these  facts,  might  suppose  that  he  was  contending  with  hepa- 
tization of  the  lung,  when  in  truth  his  patient  was  labouring 
under  empyema  or  hydrothorax. 

Again,  let  us  consider  the  ordinary  case  of  tubercular  con- 
sumption. Were  we  to  confine  our  ideas  of  this  affection  to  the 
mere  growth  and  suppuration  of  tubercles,  we  would  have  indeed 
a  most  limited  and  erroneous  view  of  the  disease.  For  in  this 
affection  we  have  not  only  tubercle  in  every  stage  and  form,  but 
also  the  extension  of  disease  to  all  the  tissues  of  the  lung. 
Many  varieties  of  pneumonia  may  occur,  and  the  disease  in  the 
abstract  is  a  common  complication,  producing  the  most  im- 
portant modifications  in  the  symptoms  and  progress  of  the  case. 
If  we  consider  the  mucous  membrane  we  shall  find  the  same 
remarks  to  apply  ;  many  cases  appear  to  commence  by  bronchitis, 
and  in  their  progress  the  state  of  the  mucous  membrane  comes 
to  be  of  the  utmost  importance.  Every  form  of  disease  may, 
and  commonly  does  occur,  and  bronchial  secretion  is  frequently 
the  chief  source  of  the  wasting  expectoration. 


38  GENERAL    PRINCIPLES    OF    THE 

If  we  now  examine  the  serous  membrane  we  find  evidence  of 
extensive  disease.  In  the  great  majority  of  cases,  adhesions — 
sometimes  so  complete  as  to  obliterate  the  whole  sac — thicken- 
ings, effusions,  or  even  ulceration  with  a  fistulous  communication 
passing  inwards,  are  common  occurrences.  This  frequent  com- 
plication of  pleuritis  in  consumption,  as  we  shall  find  hereafter, 
may  be  considered  as  a  great  good ;  for  in  many  cases  it  may  be 
looked  on  as  one  of  the  processes  of  nature  towards  bringing 
about  a  cure. 

It  may  be  laid  down  as  a  general  principle,  that  in  many 
acute,  and  in  almost  all  chronic  affections  of  the  lung,  we  find 
these  three  tissues  more  or  less  engaged.  In  one  case  the 
disease  predominates  in  the  bronchial  mucous  membrane,  in 
another,  in  the  parenchyma,  in  a  third,  in  the  pleura ;  yet  still 
the  principle  will  be  found  very  generally  true,  and  its  practical 
application  is  sufficiently  obvious.  But  as  in  the  present  state 
of  our  pathological  knowledge,  we  must  admit  that  cases  are  to 
be  met  with,  in  which  disease  seems  to  be  confined  to  a  single 
tissue,  and  further,  that  even  in  the  complicated  cases,  disease 
may  be  traced  as  commencing  in  one  tissue  and  then  extending 
to  another,  it  becomes  convenient  to  study  the  affections  sepa- 
rately ;  and  experience  shews  that  the  principles  of  treatment 
should  vary  according  to  the  isolation  or  predominance  of  irrita- 
tion in  any  of  these  three  essential  elements. 

Now  the  knowledge  of  these  facts  is  of  the  utmost  im- 
portance to  the  student  of  physical  diagnosis,  and  will  remove 
many  difficulties  which  must  otherwise  occur  in  the  course  of  his 
investigations.  Thus,  in  a  case  of  bronchitis,  he  will  be  pre- 
pared to  meet  with  dulness  of  sound  on  percussion,  resulting 
from  an  accompanying  congestion  of  the  vesicular  structure,  or 
the  sound  of  frottement  from  the  deposition  of  lymph  on  the 
pleura,  or  even  oegophony  from  a  slight  liquid  effusion.  Nor 
will  he  be  surprised  or  puzzled,  if,  in  a  similar  case,  the  signs  of 
a  pneumonia  or  a  hydrothorax  should  supervene.  In  a  case  of 
partial  pneumonia,  the  existence  of  a  sonorous  or  sonoro-mucous 
rattle  in  the  other  portions  of  the  lung  will  not  embarrass  him. 
He  gives  to  the  first  case  the  denomination  of  bronchitis,  because 
lie  finds  that  irritation  predominates  in  the  mucous  membrane, 
and  although  there  may  be  signs  of  sanguineous  congestion,  or 
even  of  pleurisy,   yet  these    seem   of  comparatively   little   im- 


DIAGNOSIS    OF    THORACIC    DISEASE.  39 

portance,  and  their  treatment  may  often  he  merged  in  that  of 
the  prominent  inflammation.  On  the  other  hand  these  may 
hecome  sources  of  danger,  and  for  this  he  is  prepared.  So  also 
in  the  case  of  pneumonia,  the  extent  and  character  of  its  proper 
signs  enahle  him  to  recognize  the  disease,  even  although  more 
or  less  of  bronchitis  or  pleurisy  may  co-exist.  The  same 
observations  will  apply  to  the  diseases  of  empyema  and  phthisis  ; 
in  the  first  of  which  the  signs  of  bronchitis  so  commonly  occur, 
and  in  the  second,  where  there  is  scarcely  a  physical  sign  of 
pulmonary  disease  that  may  not  arise. 


i  Dr.  Stokes'  account  of  the  passive  acoustic  phenomena  is  open 
to  the  criticism  of  Dr.  Walshe,  who  says,  "English  writers  as 
a  body  have  hitherto  employed  only  two  terms  to  indicate  the 
varying  characters  of  the  thoracic  percussion  sounds :  namely, 
dulness  and  clearness." 

This  writer  and  Skoda  have  each  arranged  these  sounds  under 
four  heads,  their  nomenclature  differing :  thus — Skoda's  division 
is  into 

1.  Full  or  empty. 

2.  Clear  or  dull. 

3.  Tympanitic  or  non-tympanitic. 

4.  High  or  low. 

Dr.  Walshe's  into 

Modified  in  cases  of  disease. 

1.  Amount    of    intensity   of  J   Diminished. 

resonance I    Increased. 

2.  Pitch j  *fwei;ed" 

(.    Kaised. 

i  Hardened  or  otherwise  modified. 
Softened. 
Annulled 
(    Increased. 

4.  Duration "j    Lessened, 

I   or  not  sensibly  changed. 

The  alteration  of  sound  in  morbid  states  he  arranges^  under 
four  types  :  namely,  Type  1.  Tonelessness,  or  dulness.  Type  2. 
Extra  resonance.  '  Type  3.  Hardness.     Type  4.  Muffled  tone. 


40  DIAGNOSIS    OF    THORACIC    DISEASE. 

Dr.  Stokes  makes  no  mention  of  the  important  sign  of  varia- 
tion in  pitch  of  the  percussion  sound  which  Dr.  Walshe  justly 
places  "in  the  first  rank  clinically  considered,"  nor  of  the  feeling 
of  resistance  communicated  to  the  finger  in  degree  differing  in 
different  diseased  conditions.  Of  its  value  as  a  sign  Dr.  Walshe 
remarks,  "  that  douht  often  exists  as  to  the  relative  resonance  on 
the  two  sides  is  unquestionahle  ;  and  in  these  cases  the  condition 
of  the  subjacent  parts  may  frequently  he  settled  by  taking  into 
consideration  the  amount  of  resistance.  To  those  persons  whose 
sense  of  touch  is  more  delicate  than  that  of  hearing,  this  source 
of  diagnosis  is  of  especial  value." 

Skoda  asserts  that  "  this  resistance  is  greatest  when  the  walls 
of  the  chest,  are  rendered  tense,  and  its  intercostal  spaces  dis- 
tended by  pleuritic  effusions."  It  is  even  more  remarkable  in 
tubercular  consolidation  with  thickened  pleura  of  the  apex,  and 
most  of  all  in  medullary  cancer  of  the  lung  and  pleura.*) 

*  See  Dr.  Mayne's  typical  case  of  cancer  of  the  lung,  Trans,  of  Dub.  Path.  Society, 
vol.  iii. ;  also  Guttman's  Handbook  of  Physical  Diagnosis,  p,  116. 


41 


SECTION  II. 


BKONCHITIS. 


This  affection,  in  its  simple  or  more  complicated  forms,  presents 
the  strongest  claims  to  our  attention.  In  fact,  its  study 
furnishes  us  with  a  key  to  thoracic  pathology,  as  in  a  great 
number  of  pulmonary,  and  even  cardiac  diseases,  the  inflam- 
mation of  the  mucous  membrane  of  the  lung  seems  to  be  the 
first  link  in  the  chain  of  morbid  action  ;  a  circumstance  illus- 
trative of  the  proposition  of  Broussais,  that  the  various  external 
morbid  influences  which  affect  the  system  are  first  exercised  on 
one  of  the  surfaces  of  relation,  viz.  :  the  skin,  the  bronchial,  and 
the  gastro-intestinal  mucous  membrane. 

When  we  reflect  on  the  various  forms  of  this  disease,  and  on 
the  number  of  secondary  affections  to  which  it  may  give  rise,  its 
importance  is  obvious ;  and  we  shall  find  that  many  examples  of 
diseases,  which  have  received  a  separate  name,  have  commenced 
by  this  lesion,  or  are  complicated  with  it.  We  frequently  find 
it  a  prominent  feature  in  what  have  been  termed  the  nervous 
affections  of  the  lung  ;  we  know  that  it  may  give  rise  to  dilata- 
tions of  the  air  cells  and  tubes,  and  to  pulmonary  emphysema  ; 
that  it  may  have  been  the  first  lesion  in  many  cases  of  ulceration 
of  the  cartilages  ;  that  there  is  a  close  connexion  between  it  and 
inflammation  of  the  substance  and  the  serous  membrane  of  the 
lung  ;  that  many  cases  of  phthisis  seem  to  commence  by  this 
affection,  and  that  it  may  ultimately  cause  morbus  cordis,  and 
all  the  evil  consequences  resulting  from  obstructed  circulation. 

We  further  find  that  bronchitis  is  present,  and  has  a  most 
important  share  in  almost  all  diseases  of  the  lung,  whether  acute 
or  chronic.  Thus,  in  most  cases  of  pneumonia,  there  is  distinct 
evidence  of  bronchitis  ;  a  complication  which,  according  to  cir- 
cumstances, may  be  of  the  greatest  advantage  or  danger  to  the 
patient.  It  is  a  constant  complication  in  pleuritis,  particularly 
of  the  chronic  form ;  while  in  phthisis,  according  to  the  best 
pathologists,    the  bronchial    mucous    membrane    rarely  escapes 


42  BRONCHITIS. 

disease.     It  occurs  in  Laemiec's  emphysema,  in  many  cases  of 
pulmonary  apoplexy,  in  cancer  of  the  lung,  aud  other  affections. 

Further,  it  is  ascertained  that  bronchitis  is  the  most  common 
result  of  the  sympathetic  irritations  of  the  lung.  It  forms  an 
important  part  of  the  phenomena  of  many  of  the  eruptive 
diseases,  while  in  fever,  taken  in  its  ordinary  acceptation,  it  is 
exceedingly  frequent,  and  too  often  the  direct  cause  of  a  fatal 
termination.  From  my  experience,  I  would  say,  that  many 
patients  would  recover  from  fever  but  for  the  occurrence  of  this 
disease. 

In  classifying  the  different  forms  of  bronchitis,  we  may  take, 
for  the  basis  of  our  division,  the  different  immediate  results  of 
irritation  of  the  mucous  membrane  and  glands.  In  the  first,  or 
most  ordinary  form,  we  have  a  mucous,  and  afterwards,  a  muco- 
purulent secretion  ;  in  the  second,  we  have  a  secretion  bearing 
the  character  of  lymph,  as  in  some  of  the  forms  of  croup  ;  in  the 
third,  the  secretion  is  principally  serous,  as  in  the  different 
forms  of  humid  catarrh  and  asthma  ;  while  in  the  fourth,  there  is 
little  or  no  secretion,  a  disease  which  has  received  the  name  of 
the  dry  catarrh.  It  may  be  remarked,  that  in  certain  cases,  the 
more  copious  and  elaborated  the  secretion,  the  greater  is  the 
relief  produced  ;  thus  a  mucous  expectoration  gives  more  relief 
than  a  watery  ;  a  muco-purulent,  more  than  a  mucous ;  and  a 
purulent,  perhaps,  more  than  any. 

All  ages  are  subject  to  this  disease.  It  may  be  even  con- 
genital ;  and  either  as  a  simple  affection,  or  combined  with  other 
inflammations,  such  as  pneumonia,  pleurisy,  or  gastro-enteritis, 
is  not  uncommon  in  the  earliest  periods  of  extra-uterine  life.  It 
is  stated  by  Billard,  that  in  some  cases  the  disease  is  extremely 
latent,  and  that  although  an  infant  may  no!;  present  either  rale 
or  cough,  yet  that,  on  dissection,  the  liner  bronchial  ramifications 
may  be  found  red,  and  filled  with  thick  mucosities.  But  this 
latency  of  the  disease  is  not  constant,  as  the  affection  has  been 
observed  in  children  of  but  fifteen  days  old,  with  every  symptom 
and  physical  sign  of  the  inflammatory  bronchitis  in  the  adult. 
Under  these  circumstances,  the  disease  may  terminate  by  resolu- 
tion, or  produce  death  by  asphyxia,  and  on  dissection,  the 
pathological  appearances  observed  are  similar  to  those  found  in 
the  adult  subject.  The  affection  may  also  pass  into  the  chronic 
form,   and  thus   continue   for  an  indefinite  period,  without  ap- 


BRONCHITIS.  43 

parent  injury  to  the  general  health,  while  in  other  cases  it  lays 
the  foundation  of  various  pulmonary  diseases. 

As  connected  with  the  subject  of  infantile  bronchitis,  I  may 
here  allude  to  the  researches  of  Dr.  Joerg,  of  Leipsig,  on  a 
condition  of  the  lung,  which  according  to  him,  may  be  induced 
by  a  too  rapid  or  a  too  slow  delivery.  Under  these  circumstances 
a  portion  of  the  lung,  more  or  less  extensive,  remains  uninflated, 
the  consequence  of  which  is  imperfect  respiration,  and  the  pro- 
duction of  various  pulmonary  diseases.  In  a  difficult  delivery, 
he  maintains,  that  the  infant,  from  the  compression  of  the  brain, 
respires  imperfectly,  and  consequently,  but  partially  expands  its 
lungs  ;  while  in  the  too  speedy  delivery,  in  consequence  of  its 
short  duration,  and  the  inferior  degree  of  compression  of  the 
placenta,  he  conceives  that  the  foramen  ovale  is  not  closed,  and 
hence  that  the  necessity  for  respiration  is  diminished. 

"  Under  the  circumstances  above  mentioned,"  says  Dr.  Joerg, 
'•'we  have  often  seen  infants  suddenly  seized  with  illness,  and 
sometimes  die,  in  spite  of  every  exertion  made  to  save  them, 
before  the  real  cause  of  the  attack,  and  the  proper  method  of 
treatment,  were  discovered  ;  and  on  examination  the  followinQ- 
appearances  were  observed,  arising  all  from  the  same  causes, 
though  differing  greatly  among  themselves  in  many  respects. 

"In  every  case  in  which  we  made  a  -post  mortem  exami- 
nation for  several  years  past,  a  portion  only  of  the  lungs,  from 
the  greater  half  to  merely  an  eighth  or  tenth  part,  was  found 
filled  with  air,  and  of  a  red  colour  ;  while  the  remaining  portion 
continued  in  the  same  state  in  which  it  had  been  in  the  foetus, 
and  was  of  a  liver  colour.  When  the  infant  had  died  soon  after 
birth,  the  condensed  portion  was  susceptible  of  inflation ;  but 
where  death  did  not  occur  till  several  weeks  after  that  event,  it 
was  found  carnified  and  incapable  of  being  inflated  ;  sometimes 
the  partition  between  the  healthy  and  diseased  portion  was  in  a 
state  of  inflammation,  and  the  latter  contained  vomica? :  the 
bronchi,  too,  were  often  inflamed  and  filled  with  mucus.  The 
great  contrast  between  the  bright  red  of  the  healthy,  and  the 
liver  brown  of  the  diseased  portions,  struck  the  eye  immediately 
on  opening  the  thorax.  In  most  cases,  the  foramen  ovale  was 
still  open,  and  there  were  very  firm  polypi  in  the  heart  and  large 
vessels.  The  brain  was  frequently  gorged  with  blood,  which  was 
sometimes    even  effused   between    its   membranes   and  over   its 


44  BRONCHITIS. 

surface  :  it  also  occasionally  contained  abscesses  corresponding  to 
others  on  the  cranium,  or  fontanelle,  that  had  been  produced  by 
the  use  of  instruments,  or  by  violent  pressure  against  the  pelvis 
during  delivery.  In  the  rest  of  the  body,  there  was  no  particular 
morbid  phenomenon  constantly  present :  however,  in  the  greater 
number  of  cases,  the  skin,  particularly  on  the  face,  had  a  bluish 
cast ;  while  in  some  it  was  withered  and  emaciated,  and  the 
whole  body,  especially  the  intestines,  pale  and  bloodless. 

"From  these  facts,  and  from  observations  made  of  late  years 
during  the  progress  of  the  disease,  we  are  warranted  in  describ- 
ing its  nature  and  terminations  in  the  following  manner :  The 
solidification,  or  continuation  in  the  foetal  condition  of  a  greater 
or  less  portion  of  the  lungs,  so  that  during  inspiration  their 
substance  cannot  be  penetrated  by  the  air.  The  blood,  being- 
still  more  incapable  of  penetrating,  cannot  be  supplied  with 
oxygen,  and  must  consequently  continue  venous,  and  produce 
obstructions  and  dangerous  congestions ;  while  at  the  same  time, 
from  its  being  unable  to  afford  the  stimulus  requisite  to  the 
system  for  the  continuation  of  its  functions,  an  atonic  senile 
condition  obtains,  attended  with  the  utmost  weakness,  and  com- 
plete atrophy,  and  terminating  in  death  in  hectic  fever.  The 
general  morbid  condition  is,  consequently,  difficulty  of  respira- 
tion and  impeded  circulation,  producing  dangerous  and  even 
fatal  congestions.  Its  terminations  are  :  1st,  recovery ;  2nd, 
secondary  diseases  ;  and  3rd,  death. 

"  I.  Recovery  ensues  when  the  efforts  of  the  infant  to  inspire 
are  assisted  by  proper  treatment,  and  the  subsequent  symptoms 
properly  managed. 

"II.  Secondary  diseases: — (a)  obstruction  of  the  lungs,  inas- 
much as  a  portion  of  them  remains  condensed,  which,  without 
actually  producing  death,  is  very  oppressive  and  dangerous :  (b) 
chronic  cyanosis,  the  foramen  ovale  continuing  open,  and  the 
infant  being  liable  to  constant  suffering. 

"III.  Death: — (a)  from  apoplexy;  in  consequence  of  ob- 
struction and  congestion  :  (b)  from  suffocative  catarrh,  when  the 
feeble  respiration  is  not  able  to  expel  the  mucus  secreted  in  the 
bronchi,  and  the  violent  efforts  at  full  inspiration  produce 
bronchitis,  and  an  over-abundant  secretion  of  mucus,  which  the 
patient  has  not  strength  to  get  rid  of :  (c)  from  fever,  the  result 
of  bronchitis  :   (d)  from  atrophy  ;  the  production  of  animal  heat 


BKONCHITIS.  45 

being  prevented  by  the  deficiency  of  oxygen,  and  the  whole  system 
paralyzed  by  the  want  of  its  requisite  stimulus. 

"  Symptoms. — When  the  infant  comes  into  the  world,  the  head 
is  either  found  greatly  swollen,  (in  which  case  abscesses  often 
form  in  the  part  that  has  suffered  from  pressure,  and  inflammation 
or  violent  congestion  of  the  brain  ensues,)  or  else,  though  quite 
uninjured,  and  the  delivery  having  been  rapid  and  easy,  it  cries  but 
feebly,  breathes  very  short,  and  exerts  the  muscles  of  the  thorax 
greatly;  it  is  presently  attacked  with  a  faintness,  and  if  it  had 
been  capable  of  drinking  previously,  now  loses  that  power,  the 
voice  becomes  hoarse  and  weak,  and  scarcely  audible.  Stertor 
and  convulsions  soon  follow,  the  little  patient  becomes  quite  blue, 
the  eye-balls  turn,  and  the  respiration  remits,  sometimes  for  so 
long  as  five  minutes,  till  the  scene  at  last  closes  with  death. 
Should  the  illness  continue  for  some  days  or  weeks,  a  little  short 
cough,  the  most  certain  sign  of  violent  bronchitis,  comes  on ; 
together  with  total  weakness,  atrophy,  and  hectic  fever ;  and  the 
child,  at  the  very  latest,  four  or  five  weeks  after  birth,  sinks  under 
a  violent  attack  of  cyanosis,  or  bronchitis,  or  from  the  effects  of 
the  fever  and  atrophy." 

There  can  be  no  doubt  that  this  non-expansion  of  the  pulmon- 
ary cells  must  be  a  powerful  exciting  cause  of  congestive  and  of 
inflammatory  diseases  of  the  lung,  as  the  natural  proportions  which 
should  exist  between  the  capacity  of  the  lung  and  the  circulating 
fluid,  are  thus  destroyed ;  just  as  we  observe  in  cases  of  the  ob- 
literation of  one  lung,  that  the  opposite  one  may  become 
ultimately  congested  and  otherwise  diseased.  I  think  it  not 
unlikely  that  the  condition  of  the  lung,  as  described  by  Dr.  Joerg, 
is  a  frequent  one,  and,  though  it  has  never  struck  me  to  connect 
its  existence  with  the  exciting  causes  which  he  has  described,  yet 
I  have  observed  it  in  several  cases.  In  these  instances  one  lobe, 
or  a  certain  portion  of  it,  was  found  in  a  non-crepitating  state,  of 
a  yellowish  colour,  somewhat  translucent  and  flabb}',  and  without 
any  appearance  of  inflammatory  vascularity,  or  effusions  of  lymph 
on  the  pleura.  In  these  cases  the  children  died  immediately 
after  birth. 

Thus  we  see,  that  a  child  may  present  the  symptoms  and  signs 
of  pulmonary  irritation  from  the  first  moment  of  extra-uterine  life, 
a  condition  traceable  to  one  of  two  causes ;  first,  the  existence  of 
an   intra- uterine  bronchitis,   or  pneumonia;    and  secondly,  the 


46  BRONCHITIS. 

non- expansion  of  a  portion  of  the  lung,  as  described  by  Dr.  Joerg. 
In  this  way  Ave  may  have  an  explanation  of  those  cases  in  youth 
and  adult  age,  in  which  we  are  informed  that  the  patient  has  had 
a  cough  from  the  time  he  was  born.  Many  of  such  cases 
terminate  in  dilatation  of  the  air  cells,  and  emphysema  of  the  lung, 
and  its  train  of  miserable  consequences. 

But  the  infant,  after  birth,  is  subject  to  many  varieties  of 
bronchial  inflammation.  One  of  the  simplest  and  mildest  forms 
of  this  disease  occurs  about  the  period  of  the  first  dentition,  and 
it  seems  likely  that  it  is  not  then  a  primary  disease,  but  rather 
the  effect  of  the  general  constitutional  disturbance,  as  we  often 
observe  it  arising  either  along  with,  or  subsequent  to  the  irritation 
of  the  gums,  and  subsiding  after  the  adoption  of  means  calculated 
to  relieve  these  parts. 

Nor  is  bronchitis  a  constant  attendant  on  dentition,  for  irritation 
may  be  localized  in  the  abdomen,  the  head,  or  the  skin,  all  which 
tends  to  show  that  the  bronchial  irritation  is  not  the  first  link  in 
the  chain,  and  that  its  occurrence  is  accidental  and  secondary. 
That  this  doctrine  is  important  in  a  practical  point  of  view,  no 
one  can  doubt ;  yet  whether  it  may  be  shown  that  the  bronchitis 
be  the  cause  or  the  effect  of  the  fever,  the  detection  of  its  existence 
is  of  importance,  and  its  removal  absolutely  necessary. 

There  is  no  difficulty  in  recognizing  this  affection,  even  though 
it  should  exist  in  an  apyrexial  form.  Under  such  circumstances 
the  child  may  be  observed  to  be  irritable,  his  breathing  hurried, 
with  a  slight  wheezing  in  the  throat,  and  acceleration  in  the 
pulse.  In  more  severe  cases  there  is  fever  and  cough,  the  nares 
dilate  during  inspiration,  and  the  act  of  sucking  seems  to  be 
performed  with  difficulty.  If  we  examine  the  mouth,  we  often 
find  it  hot,  and  the  gums  dry  and  swollen,  and  one  or  two  teeth 
may  be  observed  coming  forward.  I  have  more  than  once  found, 
that  such  an  attack  supervened  in  children  who  had  had  copious 
dribbling  for  a  length  of  time  previously,  and  that-  the  arrest 
of  this  secretion  preceded  the  bronchitis  and  constitutional 
disturbance. 

In  some  cases  the  cough  has  a  decidedly  croupy  character, 
although  during  the  intervals  the  breathing,  though  hurried,  is  not 
at  all  stridulous.  This  character  of  cough  is  often  a  source  of 
great  alarm,  and  may  lead  to  an  unnecessary  degree  of  activity  in 
practice.     The  symptoms,  such  as  have  been  described,  continue 


BRONCHITIS.  47 

from  four  to  five  days,  and  often  subside  rapidly  on  the  appearance 
of  a  tooth,  although  they  may  be  liable  to  return  upon  every  new 
irritation  of  the  gums. 

We  shall  now  proceed  to  examine  the  occurrence  of  bronchitis 
in  the  more  advanced  subject,  and  it  must  be  admitted,  that  when 
we  consider  it  in  its  various  forms,  whether  of  an  idiopathic,  a 
secondary,  or  a  symptomatic  affection,  or  as  occurring  compli- 
cated with  many  other  diseases  of  the  chest,  we  cannot  help 
admitting  it  to  be  one  of  the  most  frequent,  and  often  most  fatal 
of  diseases.  In  discussing  this  subject,  I  shall  not  describe  the 
bronchitis  of  the  advanced  child  separately  from  that  of  the  adult, 
inasmuch  as  its  signs,  symptoms,  and  pathology  are  the  same,  but 
having  examined  into  the  nature  and  diagnosis  of  the  idiopathic 
disease,  I  shall  consider  it  in  its  secondary  and  symptomatic  forms. 

We  may  divide  the  cases  of  bronchitis  into  the  examples  of  the 
primary,  secondary,  and  complicated  forms  :  the  primary,  those  in 
which  the  first  morbid  influence  seems  to  be  exercised  on  the 
respiratory  mucous  membrane,  and  in  which  the  fever,  if  it  exists, 
may  be  considered  as  purely  symptomatic  :  in  the  secondary,  on 
the  other  hand,  there  has  been  a  pre-existing  disease  elsewhere, 
which,  in  general  terms,  may  be  stated  to  be  either  the  irritation 
of  another  organ,  which  acts  by  sympathy  on  the  lung,  or  the 
existence  of  that  general  morbid  state  which  has  got  the  name 
of  essential  fever,  and  of  which  one  of  the  most  remarkable 
pathological  characters  is,  the  production  of  secondary  diseases  in 
the  gastro-pulmonary  mucous  membrane,  and  also  in  the  solid 
viscera  themselves.  Thus,  in  a  typhoid  fever  we  may  have  an 
affection  of  the  bronchial  mucous  membrane,  analogous  to  the 
secondary  inflammation  of  the  stomach  and  intestines  :  a  disease 
which,  although  not  the  first  cause  of  symptoms,  exercises  an 
important  part  in  the  progress,  and  is  not  unfrequently  a  cause  of 
the  fatal  termination  of  the  case.  Lastly,  by  the  complicated  form 
we  mean  the  bronchial  inflammation  which  accompanies  other 
diseases  of  the  lung,  such  as  pneumonia,  pleurisy,  pulmonary 
apoplexy,  tubercle,  cancer,  &c. 

This  complication  has  been  already  stated  to  be  exceedingly 
frequent  and  important,  as  yet,  however,  no  certain  relation,  as  to 
nature,  extent,  or  intensity,  has  been  established  between  it  and 
the  parenchymatous  disease  in  different  individuals,  or  even  at 
different  periods  of  the  same  case. 


48  BRONCHITIS. 


ACUTE    PRIMARY   BRONCHITIS. 

This  affection  may  be  met  with  under  various  conditions. 
As  a  mild,  and  often  apyrexial  disease,  in  which  the  irritation 
seems  to  be  consecutive  to  an  affection  of  the  lining  membrane 
of  the  nares  and  throat,  and  so  slight  as  to  scarcely  interfere 
with  the  healthy  functions,  it  is  not  uncommon.  In  this  case, 
secretion  takes  place  at  an  early  period,  and  is  followed  by  relief. 
In  fact,  it  seems  to  be  to  the  respiratory,  what  the  slight  apyrexial 
diarrhoea  is  to  the  digestive  system.  It  is  scarcely  necessary  to 
remark,  that  the  symptoms  of  cough,  dyspnoea,  and  internal 
soreness,  vary  remarkably,  according  to  the  susceptibility  of  the 
individual  affected ;  thus,  in  a  female,  subject  to  hysterical  or 
spasmodic  diseases,  a  slight  catarrh  may  produce  the  tussis 
ferina,  while  in  another  subject,  who  is  predisposed  to  asthma, 
there  may  be  severe  dyspnoea  from  the  same  cause. 

There  is  also  the  greatest  variety  with  respect  to  the  fre- 
quency and  the  character  of  the  cough ;  some  patients  being 
harassed  with  continual  paroxysms,  while  others  enjoy  long 
intervals  of  rest.  In  some  cases  the  exertion  of  the  voice  is 
most  distressing,  its  sound  is  feeble,  and  the  act  of  speaking  is 
followed  by  dyspnoea.  In  other  instances,  on  the  contrary, 
speaking,  unless  when  long  continued,  is  productive  of  but  little 

distress. 

One  of  the  most  curious  symptoms  connected  with  this 
disease,  and  which  is  met  with  in  other  forms  as  well  as  that 
under  consideration,  is  the  tickling  sensation  perceived  in  the 
trachea,  which  commonly  precedes,  and  seems  to  be  the  cause  of 
cou»h,  and  which  is  referred  either  to  the  situation  of  the 
bifurcation  of  the  trachea,  or  that  portion  of  the  windpipe  im- 
mediately above  it.  This  is  often  perceived  on  the  patient's 
lying  down,  but  may  also  occur  when  he  is  in  the  erect  position, 
particularly  in  the  morning,  when  it  will  continue  for  a  con- 
siderable time,  and  cease  only  after  a  free  expectoration.  I  am 
not  aware  that  any  author  has  investigated  this  curious  symptom, 
except  Dr.  Graves,  who  has  alluded  to  it  in  one  of  his  published 
clinical  lectures,  and  has  suggested  it  as  an  interesting  subject 
for  inquiry.  He  observes,  that  the  sensation  of  tickling  or  itching 
seems  to  be  almost  exclusively  confined  to  the  skin,  where  it 
appears  to  be  dependent  on   slight  causes,  apparently  incapable 


BRONCHITIS.  49 

of  producing  that  modification  of  nervous  sensation  termed  pain . 
In  other  cases,  as  the  same  author  remarks,  it  seems  to  be 
■connected  with  the  rise  and  decline  of  inflammatory  action,  and 
it  does  not  appear  to  affect  the  mucous  tissue,  except  in  a  slight 
degree,  and  under  peculiar  circumstances,  and  the  only  liable 
part  of  the  pulmonary  mucous  membrane  seems  to  be  that  of 
the  trachea  already  referred  to. 

In  speaking  of  the  symptom  of  cough,  when  the  patient 
assumes  the  recumbent  position,  Dr.  Graves  suggests  that  this 
may  depend  on  the  fluid  secreted  by  the  mucous  membrane 
passing  over  that  part  of  the  trachea  where  the  tickling  sensation 
is  felt,  the  flow  of  mucus  to  this  part  being  favoured  by  the 
recumbent  position ;  and  I  have  little  doubt,  that  although  the 
symptom  of  cough  coming  on,  on  the  patient's  lying  down, 
may  proceed  from  other  causes  besides  this,  yet  that  the  above 
explanation  is  applicable  in  a  considerable  number  of  cases.  I 
may  observe  here,  that  among  the  known  causes  for  this  symp- 
tom, one  the  most  remarkable  is  the  extreme  elongation  of  the 
uvula,  and  next  to  this  is  the  existence  of  suppurating  cavities, 
which  communicate  freely  with  either  bronchus.  Between  these 
two  cases  we  observe  the  following  remarkable  difference,  namely, 
that  when  the  symptom  proceeds  from  an  elongated  uvula  its 
severity  is  unaffected  by  the  position  of  the  patient  on  either 
side,  while  in  the  case  of  a  suppurating  cavity,  the  cough  is  often 
worse  when  the  patient  lies  on  the  healthy  side,  a  symptom 
easily  understood,  when  we  reflect  that  this  position  is  the  most 
favourable  for  tli3  direct  passage  of  the  purulent  secretion  into 
the  bronchial  tubes  and  trachea. 

From  a  consideration  of  the  symptoms  and  the  stethoscopic 
phenomena  in  this  disease,  it  seems  highly  probable,  that  in  the 
majority  of  cases,  the  smaller  bronchial  ramifications  are  un- 
affected. We  find  that  fever  is  either  absent  or  extremely  slight, 
and  that  unless  with  a  complication  of  decided  spasm  of  the 
lung,  we  have  never  any  perceptible  degree  of  lividity  of  the 
countenance.  Further,  we  almost  never  observe  the  occurrence 
of  dropsical  effusions,  a  circumstance  which,  as  far  as  it  goes, 
points  out  that  no  notable  obstruction  to  the  pulmonary  circulation 
has  occurred.  With  respect  to  the  stethoscopic  phenomena,  we 
shall  describe  them  presently,  and  here  only  observe  that  they 
strengthen  the  above  opinion. 

E 


50  BRONCHITIS. 

But  in  the  more  severe  form  of  the  disease,  we  find  all  the 
foregoing  symptoms  greatly  aggravated  ;  there  may  be  high  fever, 
with  remarkable  exacerbations,  severe  dyspnoea,  and  difficult 
expectoration,  the  mucus  being  sometimes  tinged  with  blood.  It 
is  in  this  affection  that  lividity  of  the  face  is  principally  observed, 
a  proof  of  the  imperfect  arterialization  of  the  blood.*  Cerebral 
and  abdominal  congestions  may  also  occur,  as  has  been  remarked 
by  Laennec,  and  dropsical  swellings  are  a  frequent  result.  The 
disease  may  pass  into  congestion  and  inflammation  of  the 
substance  of  the  lung,  and  in  many  cases  stitches  are  felt  in 
the  sides,  which  there  is  every  reason  to  believe,  proceed  from 
the  occurrence  of  pleuritis,  generally  of  the  dry  form,  but  leaving 
adhesions  more  or  less  extensive  according  to  the  violence  of  the 
disease. 

This  acute  stage  having  continued  for  a  period,  the  duration  of 
which  is  extremely  variable  according  to  circumstances,  the 
second  stage  sets  in,  which  is  characterized  by  a  change  in  the 
nature  of  the  fever ;  the  inflammatory  passing  more  into  the 
hectic  type ;  the  countenance  becoming  pale  and  shrunken,  and 
the  pulse  feeble  and  often  rapid.  The  patient  perspires,  and  a 
sour  smell  may  be  perceived  from  the  surface ;  the  cough 
continues  frequent  though  less  distressing,  and  is  followed  by 
copious  expectoration  of  concocted  mucus  or  muco-purulent  matter, 
and  the  breathing,  though  hurried,  is  generally  less  laborious 
than  in  the  acute  stage.  The  patient  emaciates,  and  to  a  person 
unacquainted  with  the  history  of  the  case,  would  seem  in  an 
advanced  stage  of  suppurative  phthisis.  There  can  be  no  doubt 
that  the  recovery  of  an  individual,  under  these  circumstances, 
has  been  in  many  cases  described  as  an  example  of  the  cure  of 
phthisis,  and  particularly  in  those  cases  where  the  expectoration 
was  copious  and  muco-puriform. 

On  the  subject  of  the  expectoration  in  acute  bronchitis  I  shall 
be  brief.  In  the  earlier  forms  the  secretion  is  scantv,  and 
consisting  of  a  clear  gelatinous  mucus,  combined  with  a  frothy 
serum ;  according  as  the  disease  advances  this  secretion  becomes 
more  opaque,  more  abundant,  and  less  tenacious ;   and  at  that 

*  I  have  long  observed  that  lividity  is  much  more  an  attendant  on  severe  bronchitis 
than  on  pneumonia  with  hepatization,  or  even  pleurisy  with  copious  effusion.  This  I 
do  not  put  forward  as  a  novel  observation,  but  may  remark  that  it  strengthens  the 
opinion,  that  the  aerating  power  resides  more  in  the  bronchial  ramifications  than  in 
the  air  cells. 


BRONCHITIS.  51 

period  when  the  inflammatory  fever  ceases,  and  is  either  succeeded 
by  an  apyrexial  state,  or  by  a  hectic  condition,  we  observe  a 
remarkable  change  in  its  character.  It  becomes  thick  and  has 
considerable  consistence,  or  it  may  pass  into  the  nmco-puriform 
character,  when  we  observe  it  in  masses  of  a  greenish  yellow 
colour,  quite  opaque,  and  though  somewhat  viscid,  yet  flowing 
together. 

But  although  in  its  milder  forms  the  primary  bronchitis  is  a 
common  affection,  yet  the  more  violent  attacks  of  the  disease  are 
far  from  being  frequent,  at  least  in  those  of  mature  age;  for  in 
the  great  majority  of  the  cases  of  acute  bronchitis  which  come 
before  us,  we  see  it  either  as  supervening  on  some  chronic 
affection  of  the  lung,  or  as  a  secondary  disease,  such  as  that 
which  arises  in  the  course  of  the  eruptive  and  continued  fevers. 
Indeed  the  more  violent  primary  bronchitis,  though  common  in 
the  child,  is  a  rare  disease  in  the  adult,  while  with  respect  to 
the  chronic  forms  of  the  affection,  the  reverse  seems  to  be  true,  as 
this  latter  is  common  in  the  adult,  and  comparatively  rare  in  the 
child. 

This  disease  may  terminate  by  resolution,  it  may  pass  into  a 
chronic  and  increasing  flux  from  the  bronchial  membrane,  with 
or  without  hectic,  giving  rise  to  various  alterations  of  the  lung  ; 
it  may  cause  death  by  a  sudden  obstruction  of  a  large  tube ;  it 
may  be  accompanied  by  a  rapid,  or  followed  by  a  slow  develop- 
ment of  tubercle  ;  it  may  pass  into  pneumonia,  or  terminate 
fatally  by  an  excessive  secretion  into  the  bronchial  tubes,  or  by 
hydrothorax. 

CHRONIC    PRIMARY    BRONCHITIS. 

It  is  not  easy  to  draw  the  line  of  distinction  between  this 
affection  and  the  second  stage  of  the  last  variety,  as  we  may 
observe  it  either  as  its  continuation,  with  certain  modifications, 
or  as  an  affection  in  which  there  never  have  been  the  precursory 
inflammatory  symptoms.  We  may  get  a  good  idea  of  the 
ordinary  form  of  this  disease  by  considering  it  as  a  species  of 
gleet  of  the  mucous  membrane,  in  which  the  inflammatory 
irritation,  if  it  exists,  is  in  many  cases  not  so  severe  as  to  act 
sympathetically  on  the  system ;  so  that  patients  under  these 
circumstances,  although  labouring  under  cough  and  expec- 
toration,  may  yet    preserve    a    good  state   of  general  health. — 

e  2 


*' 


2  BRONCHITIS. 

Nutrition  may  go  ou  well ;  there  may  be  no  fever  whatever,  and 
even  but  little  dyspnoea,  unless  upon  considerable  muscular  ex- 
ertion. In  such  cases,  there  is  generally  a  more  or  less  complete 
remission  of  the  symptoms  during  the  summer  season,  but  when 
winter  approaches,  the  cough  and  expectoration  become  more 
troublesome,  again  to  subside  on  the  approach  of  summer. 
Thus  may  these  patients  continue  for  years,  when  the  duration 
of  the  remissions  becomes  less,  their  completeness  diminishes, 
and  a  permanent  irritation  and  flux  are  established.  This  may 
have  various  terminations,  giving  rise  in  one  patient  to  dilatation 
of  the  tubes,  in  another  to  Laennec's  emphysema,  and  in  a  third, 
to  the  complication  of  these  affections  with  phthisis,  morbus 
cordis,  hydrothorax,  or  general  dropsy.  The  sufferings  of  these 
patients  vary  according  to  the  degree  of  nervous  susceptibility  of 
the  lung,  as  we  observe  that  in  some,  asthmatic  symptoms  may 
be  established,  while  in  others,  the  disease  never  assumes  this 
character. 

Where  the  flux  becomes  very  considerable,  there  is  often  a 
great  degree  of  emaciation,  yet  in  such  cases  I  have  remarked, 
that  the  circulating  and  digestive  systems  often  continue  in  a 
singularly  healthy  state,  a  circumstance  which,  as  far  as  it  goes, 
is  of  importance  in  the  diagnosis  between  this  affection  and 
tubercular  phthisis.  I  have  already  stated  that  in  certain  cases 
a  chronic  bronchitis  becomes  complicated  with  tubercular  disease 
of  the  lung,  and  my  experience  leads  me  to  conclude  that  this 
occurrence  is  much  more  frequent  than  has  been  hitherto  sup- 
posed. In  describing  phthisis,  I  shall  return  to  this  subject, 
and  here  only  remark,  that  as  far  as  I  have  seen,  this  result  of 
bronchitis  is  more  common  in  individuals  who  have  passed  the 
meridian  of  life,  and  although  the  transition  from  the  state  of 
mere  bronchitis  into  that  of  the  tubercular  complication  is  com- 
monly slow  and  indistinct,  yet  that  it  is  pointed  out  by  a  general, 
though  gradual  failure  of  the  vital  powers,  by  the  pulse  becoming 
accelerated,  and  by  a  slow,  though  decided,  emaciation  of  the 
patient.  Under  these  circumstances,  a  careful  physical  ex- 
amination will  often  enable  us  to  detect  some  degree  of  solidity 
in  the  upper  portion  of  one  lung,  advancing  slowly,  and  ulti- 
mately, though  almost  always  at  a  remote  period,  being  succeeded 
by  the  signs  of  ulceration  of  the  lung. 

This  most  unfavourable  change  in  the  symptoms  and  signs,  I 


BRONCHITIS.  53 

have  seen  to  supervene  at  so  late  a  period  as  four  years  after  the 
first  invasion  of  the  bronchitis.  The  patients  appeared  to  resist 
the  tubercular  development  for  a  great  length  of  time,  and 
then,  in  some  cases,  without  any  obvious  exciting  cause,  and 
apparently  from  the  constitution  giving  way,  and  in  others,  after 
some  access  of  local  irritation  or  general  disease,  did  this  fatal 
complication  become  slowly  but  decidedly  manifest. 

The  characters  of  the  expectorated  matter  in  bronchitis  are 
so  varied,  that  to  give  any  description  of  them,  which  would  be 
at  the  same  time  clear  and  succinct,  is  indeed  extremely  difficult. 
But  the  subject  is  one  of  great  importance,  for  we  shall  find  it  to 
be  connected  with  many  points  in  the  history,  prognosis,  and 
treatment,  not  only  of  the  disease  in  question,  but  of  most  other 
pulmonary  affections. 

We  are  as  yet  ignorant  of  the  pathological  laws  which  regulate 
the  various  lesions  of  secretion  in  different  diseases,  or  in 
different  individuals  apparently  labouring  under  the  same  disease  ; 
and  of  the  reasons  why  the  bronchial  membrane,  varying  in  its 
products  like  other  tissues,  at  one  time  pours  out  a  serous,  at 
another  a  mucous,  and  at  a  third  a  purulent  fluid,  we  know  nothing. 
But  still,  by  observing  the  actual  condition  of  the  secretion  in 
relation  to  the  symptoms,  and  studying  its  changes  in  connexion 
with  the  history  of  the  case,  we  may,  and  often  do,  arrive  at  most 
important  practical  results. 

The  secretion  from  the  bronchial  mucous  membrane  may  be 
modified  in  quantity  and  in  quality,  and  the  extent  and  number 
of  these  modifications  are  infinitely  numerous.  As  we  cannot 
describe  even  the  principal  modifications  in  connexion  with  any 
certain  condition  of  the  lung,  I  shall  content  myself  with 
enumerating  the  varieties  of  secretion  which  are  most  commonly 
observed,  and  shall  make  a  few  comments  upon  each. 

We  may  divide  the  secretions  from  the  bronchial  mucous 
membrane,  when  in  a  state  of  irritation,  as  follows  : 

First. — Transparent  mucous  secretions. 

Second. — Opaque  mucous,  or  albuminous  secretions. 
a. — Amorphous. 
b. — Moulded  to  the  form  of  the  tubes. 

Third. — Muco-puriform  secretions. 

Fourth . — Puriform  secretions. 

Fifth. — Serous  secretions. 


54  BRONCHITIS. 

Transparent  mucous  Secretions. 

We  meet  with  this  form  of  secretion  most  commonly  in  the 
earlier  stages  of  acute  bronchitis,  when,  however,  we  find  that 
previous  to  its  appearance  there  has  been  either  a  dry  cough, 
or  a  cough  with  expectoration  of  a  serous  fluid.  There  is 
considerable  variety  in  the  quantity  of  this  secretion  formed  in 
different  cases,  as  also  in  its  tenacity,  which  latter  character  has 
been  considered  as  a  measure  of  the  violence  of  the  irritation. 

But  transparent  and  adhesive  mucus  may  be  formed  in  other 
cases  of  bronchitis.  Thus,  in  some  violent  cases,  long  after  the 
expectoration  has  become  muco-puriform,  we  may  observe,  as  it 
were,  a  return  of  the  secretion  to  its  original  form.  It  loses  its 
diffluent  character,  and  its  opacity,  and  its  expulsion  becomes 
difficult.  This  unfavourable  change,  which  is  generally  accom- 
panied by  constitutional  disturbance,  may  subside  in  a  few 
hours,  and  reappear  many  times  in  the  course  of  a  single  case. 
Under  these  circumstances  we  shall  often  observe  a  correspond- 
ing change  in  the  stethoscopic  phenomena,  to  which  I  shall 
presently  allude.  In  cases  too  of  ordinary  chronic  and  apyrexial 
bronchitis,  we  find  that  a  new  attack  of  bronchial  inflammation 
may  altogether  arrest  the  secretion,  or  change  it  from  the  opaque 
and  diffluent  to  the  transparent  and  viscid  character.  On  the 
subsidence  of  the  irritation,  however,  the  former  character  of  the 
secretion  returns. 

From  a  consideration  of  these  facts,  we  cannot  help  in  some 
way  connecting  the  occurrence  of  this  transparent  and  viscid 
secretion  with  a  condition  of  irritation  in  which  the  morbid 
action  is  not  relieved  by  the  secretion.  We  find  that  the  sooner 
the  opaque  sputa  appear,  the  sooner  shall  Ave  observe  the 
convalescence  of  the  patient ;  and  that  in  those  cases  where 
this  salutary  change  is  delayed,  the  sufferings  and  danger  are 
proportionally  increased.  How  commonly  do  we  observe  this  in 
phthisis,  in  which  the  bronchial  irritation  seems  to  continue  in 
its  first  stage  for  an  indefinite  length  of  time,  and  in  which  there 
is  every  indication  of  a  local  but  unrelaxed  irritation  of  the 
lung ;  and  in  the  cases  of  Laennec's  emphysema  we  may  see 
other  instances  of  a  bronchial  disease  which  has  not  been  relieved 
by  the  more  elaborated  secretion,  and  which  consequently  has 
continued  so  as  to  disorganise  the  lung. 


BRONCHITIS.  55 

Opaque  mucous  or  albuminous  Secretions. 

In  the  characters  of  this  class  we  do  not  find  much  variety, 
and  the  circumstances  attendant  on  their  appearance  are,  in 
general,  constant.  In  almost  all  cases  where  these  sputa  are 
met,  there  has  been  a  preceding  stage,  in  which  other  characters 
occurred,  and  in  which  there  was  the  formation  of  the  transparent 
secretion,  occurring  with  or  without  a  symptomatic  fever. 

In  commenting  on  this  kind  of  expectoration  I  shall  first  notice 
the  amorphous  variety,  and  next  that  in  which  the  secreted 
matter  adapts  itself  to  the  form  of  the  bronchial  tubes,  so  as  to 
produce,  as  it  were,  casts  of  the  air  passages. 

In  their  ordinary  form  we  find  these  sputa  to  consist  of  shape- 
less masses  of  a  dull  white  colour,  with  a  slight  yellow  tinge. 
These  masses  may.  be  expectorated  with  scarcely  any  accom- 
panying serous  fluid,  when  they  unite,  more  or  less,  so  as  to 
form  a  semi-fluid,  adhesive  mass.  In  other  cases,  however,  a 
considerable  quantity  of  serous  fluid  is  expelled  along  with  them, 
when  we  observe  them  more  frothy,  and  presenting  the  appearance 
of  rounded  sputa,  floating  in  a  nearly  transparent  fluid,  of  much 
less  tenacity,  and  containing  a  few  albuminous  striae,  not  unlike 
fragments  of  vermicelli. 

Lastly,  there  are  cases  of  chronic  bronchitis,  in  which  we 
observe  the  expectoration  of  a  vast  quantity  of  opaque  albuminous 
matter,  of  a  whitish  colour,  and  without  any  tendency  to  a 
purulent  character.  In  such  cases,  when  the  containing  vessel  is 
inverted,  we  see  its  contents  slowly  evacuated  in  one  elongated 
homogeneous  mass,  on  the  surface  of  which  more  or  less  of  a 
frothy  serum  may  be  observed.  Such  cases  are  generally  of 
extreme  chronicity,  and  present  the  signs  of  chronic  bronchitis, 
with  dilatation  of  the  tubes,  or  even  the  air  cells  of  the  lung. 

We  shall  next  consider  that  form  of  secretion  in  which  the 
secreted  matter  is  moulded  to  the  form  of  the  bronchial  tube,  and 
acquires  a  certain  degree  of  consistence. 

Although  our  knowledge  on  this  subject  is  as  yet  but  limited, 
it  may  be  stated,  that  this  formation  of  inspissated  mucus,  or  of 
a  substance  approaching  to  lymph,  may  be  found  either  as  a  very 
circumscribed  or  a  more  general  lesion.  In  the  first  of  these  a 
plug  is  formed,  which  by  obstructing  one  of  the  larger  tubes,  may 
bring  on  a  violent  dyspnoea,  and  be  even  a  cause  of  death  ;  while 


DO 


G  BRONCHITIS. 


in  the  second,  cylinders  of  this  substance,  corresponding  to  the 
form  of  the  bronchial  tree,  are  found  to  follow  its  ramifications 
most  extensively,  and  to  be  continuous,  as  Reynaud  has  shewn, 
nearly  as  far  as  it  was  possible  to  trace  the  bronchial  tube. 
Under  these  circumstances  the  patient  may  expel  casts  of  the  air 
passages  after  violent  fits  of  coughing,  several  cases  of  which  are 
on  record. 

It  is  not  easy  to  explain  the  occurrence  of  this  unusual 
symptom  ;  and  indeed  we  are  still  in  want  of  facts  to  throw  light 
on  the  subject.  Why  this  plastic  disposition  is  acquired  by 
mucous  membranes,  in  certain  cases,  while  it  seems  denied  to 
them  in  others,  is  still  a  matter  of  speculation,  and  the  subject 
could  scarcely  be  discussed  here  with  propriety.  When  speaking 
of  croup,  however,  I  shall  return  to  it. 

In  a  case  which  I  lately  saw  along  with  Dr.  Marsh,  this  curious 
symptom  was  present.  The  patient,  a  middle-aged  female,  had 
suffered  from  a  chronic  affection  of  the  chest,  and  had  lately 
become  liable  to  this  form  of  expectoration.  The  casts  expec- 
torated were  several  inches  in  length,  and  seemed  to  have 
occupied  the  bronchial  tubes  from  about  their  third  order  to 
nearly  their  finest  ramifications.  They  were  white,  cylindrical, 
and  not  hollow ;  but  between  their  exterior  surfaces  and  centres 
there  was  a  remarkable  difference,  the  former  being  much  more 
consistent  and  opaque,  while  the  latter  seemed  formed  of  a  soft 
and  transparent  mucus,  with  comparatively  little  tenacity.  This 
conformation  gave  them,  at  first  sight,  the  appearance  of  tubes. 
In  the  centre  of  many  of  them  we  observed  small  chains  of  air 
bubbles,  a  circumstance  to  be  expected  from  the  fact,  that  their 
expulsion  was  extremely  difficult,  and  accompanied  by  violent 
cough. 

The  form  of  these  concretions  was  exactly  similar  to  those  of 
which  a  plate  is  given  in  Dr.  Baillie's  Morbid  Anatomy.  Their 
consistence  was  by  no  means  so  firm  as  what  we  observe  in  cases 
of  true  croup.  They  seemed  to  have  been  originally  formed  as  a 
tremulous  mucus,  which  had  filled  the  tubes,  and  from  some 
cause  had  remained  there  a  long  time,  until  their  outer  surface 
had  become  opaque  and  more  consistent ;  apparently  from  that 
process,  by  which  we  see  the  more  fluid  parts  of  secretions 
absorbed,  and  their  remaining  constituents  consolidated. 

In  another  case  I  have  witnessed  the  expulsion  of  a  cylinder  of 


BRONCHITIS.  57 

an  albuminous  substance  nearly  three  inches  in  length.     This 
was  expelled  after  a  violent  and  long  continued  fit  of  coughing. 

The  science  has  been  lately  enriched  by  a  most  important  memoir 
on  this  subject,  from  the  pen  of  M.  Reynaud,*  a  memoir,  the 
value  of  which  can  be  scarcely  estimated.  From  the  researches 
of  this  eminent  pathologist,  it  appears  that  a  species  of  plastic 
inflammation  of  the  minute  bronchia  is  much  more  frequent  than 
has  been  hitherto  supposed ;  and  that  it  occurs  in  many  cases  of 
phthisis,  and  of  what  has  been  called  pneumonia.  Without 
directly  asserting  that  as  we  approach  the  bronchial  cells,  the 
character  of  the  lining  membrane  changes  from  that  of  a  vascular 
mucous  membrane,  endowed  with  villosities  and  follicles,  to  a 
condition  very  analogous  to  that  of  a  serous  membrane  ;  he  yet 
clearly  inclines  to  this  opinion,  which  has  been  long  entertained 
in  the  school  of  Dublin,  and  he  founds  on  it  an  explanation  of 
the  plastic  or  adhesive  inflammation  of  the  minute  tubes. 

When  I  come  to  consider  the  consequences  of  inflammation  on 
the  air  tubes,  I  shall  avail  myself  of  these  beautiful  researches, 
and  here  only  remark,  with  reference  to  our  original  subject,  that 
if  this  semi-plastic  expectoration  have  any  value  in  diagnosis,  it 
is  that  it  seems  connected,  if  not  with  actual  tubercle  in  the  lung, 
at  least  with  a  decided  tendency  to  that  lesion.  It  apparently 
indicates  a  lymphatic  constitution  of  the  lung ;  a  state  in  which 
the  white  tissues  are  predominant,  and  where  of  course  tin- 
liability  to  the  "formative  inflammations  "  is  more  developed. 
In  the  first  case  to  which  I  have  alluded,  decided  physical  signs 
of  tubercle  existed ;  and  in  the  second,  the  case  was  one  of 
manifest  suppurative  phthisis,  and  the  diagnosis  was  verified  by 
dissection.  Laennec  describes  a  concretion  found  in  a  phthisical 
subject,  and  the  same  has  been  observed  by  other  authors.  But 
further  observations  are  necessary  on  this  interesting  point. t 

Muro-purifovm,  and  puriform  Secretions. 

I  shall  consider  these  forms  of  expectoration  together ;  and  in 
the  first  place  observe,  that  while,  in  bronchitis,  the  expectoration 

*  Translated  and  Edited  by  Dr.  Stokes  in  the  seventh  volume  of  the  Dnhlin  Journal 
of  Medical  Science,  First  Series.    (H.) 

f  Two  interesting  cases  of  plastic  bronchitis,  with  observations  by  Drs.  Cane  and 
Corrigan,  were  published  by  the  former  gentleman  in  the  49th  number  of  the  Dublnt 
Medical  Journal.  Dr.  Cane,  like  Dr.  Walshe,  controverts  the  doctrine  of  its  connexion 
with  tubercle,  and  asserts  that  mercury  is  "a  certain  remedy  for  its  cure."     (H.) 


58  BRONCHITIS. 

of  muco-puriform  matter  is  common,  yet  that  of  unmixed  pus 
seems  to  be  very  rare.  An  absolutely  puriform  expectoration  is 
an  unusual  circumstance  in  any  of  the  pulmonary  diseases,  even 
in  those  in  which  ulcerative  or  suppurative  action  has  taken 
place.  It  is  occasionally  met  with  in  the  advanced  stages  of 
phthisis  and  pneumonia,  but  is  more  often  absent,  and  in 
bronchitis  is  rarely  seen  indeed.  I  do  not  deny  the  important 
fact,  that  the  bronchial  mucous  membrane  is  capable  of  secreting 
pus,  independent  of  any  ulceration  of  the  lung ;  but  all  that  I 
wish  to  observe  is,  that  when,  with  respect  to  frequency,  we 
compare  the  muco-puriform  with  the  puriform  expectorations,  we 
find  the  first  by  far  the  most  common. 

The  muco-puriform  expectoration  is  more  commonly  met  with 
in  the  second  stage  of  acute  than  in  the  chronic  'bronchitis. 
The  disease,  too,  has  commonly  occupied  the  smaller  tubes,  so 
as  to  produce  its  muco-crepitating  rale ;  and  the  appearance  of 
the  purulent  secretion  marks  the  passage  from  the  first  into  the 
second  stage  of  the  disease.  I  may  here  remark,  that  even  in  a 
violent  case  of  bronchitis  we  may,  by  active  treatment,  so  modify 
the  inflammation,  that  the  secretion  of  pus  scarcely  occurs,  we 
having,  as  it  were,  cut  short  the  disease  in  its  first  or  mucous 
stage.  But  this  unfortunately  is  rare,  and  an  abundant  secretion 
of  muco-purulent  matter  is  a  common  sequence  to  the  first 
stage.  If  the  disease,  in  its  earlier  periods,  has  been  neglected, 
or  if  discovered,  yet  has  been  treated  with  timidity,  the  muco- 
purulent secretion  in  the  advanced  stages  will  be  abundant,  and 
may  prove  the  cause  of  a  mechanical  death.  I  have  seen  several 
cases  of  intense  general  bronchitis,  in  which  the  early  treatment 
had  been  injudicious.  The  antiphlogistic  means  had  been 
insufficient,  and  were  combined  with,  or  too  soon  changed  for, 
the  exhibition  of  stimulants.  In  these  cases  the  patients  had  a 
long  and  dangerous  struggle,  with  alternations  of  inflammatory 
fever,  and  a  collapsed  state ;  with  viscid  expectoration  at  one 
time,  and  profuse  muco-purulent  discharges  at  another ;  and 
with  the  stethoscopic  signs  of  a  state  of  the  lung,  not  far  removed 
from  the  third  stage  of  pneumonia. 

In  order  that  the  change  from  the  mucous  to  the  muco-puri- 
form secretion  be  considered  a  favourable  indication,  it  is 
necessary  that  certain  circumstances  shall  attend  it.  These  I 
have  observed  to  be,  the  expectoration  becoming  easier,  the  pulse 


BRONCHITIS.  59 

softer  and  slower,  the  breathing  easier,  and  the  fever  diminishing. 
With  respect  to  the  physical  signs,  we  find  the  muco-crepitating 
rale  becoming  larger,  the  respiration  returning  from  above  down- 
wards, the  action  of  the  heart  quiet,  and  the  sound  on  percussion 
clear,  even  in  the  postero-inferior  portions  of  the  lung. 

But  in  other  cases  the  reverse  of  all  this  is  observed ;  and  we 
have  the  combination  of  a  muco-purulent  expectoration  with  the 
symptoms  and  signs  of  intense  irritation  of  the  lung.  To  this 
case  I  have  just  now  alluded. 

In  a  practical  point  of  view,  the  great  value  of  the  symptoms 
of  the  change  of  character  of  the  expectoration  is,  that  it  is  an 
index  pointing  out  the  time  for  a  change  in  treatment,  of  a 
passage  from  an  antiphlogistic  to  a  stimulating  medication. 
Taken  alone,  however,  it  is  insufficient ;  it  must  be  accompanied 
by  the  favourable  symptoms  and  signs,  and  Ave  may  have  a  case 
in  which,  long  after  the  appearance  of  muco-purulent  secretion, 
it  will  be  right  to  suspend  the  stimulating,  and  resume  the 
antiphlogistic  system. 

Before  concluding  this  part  of  the  subject  it  is  right  to  allude 
to  the  occasional  foetor  of  the  muco-purulent,  or  purulent  expec- 
toration, in  chronic  bronchitis.  As  I  have  seen  but  a  single  case 
of  this,  I  shall  content  myself  with  referring  to  the  writings  of 
Andral  and  Laennec  on  the  subject. 

Serous   Secretions. 

We  meet  with  this  form  of  expectoration  in  a  great  number  of 
cases  of  bronchitis  and  phthisis,  even  where  other,  and  very 
different  secretions,  are  taking  place  from  the  lung.  We  may 
observe  it  in  the  earlier  stages  of  bronchial  inflammation,  before 
much  mucus  has  been  formed,  and  Ave  may  see  it  again  in  the 
advanced  stages,  when  an  opaque  mucous  or  muco-purulent 
matter  is  abundantly  secreted  ;  lastly,  it  occurs  as  the  principal 
secretion,  as  is  seen  in  many  cases  of  humid  asthma,  and  then 
may  be  formed  in  great  quantity  indeed.  Under  these  circum- 
stances Ave  may  have  a  sudden  congestion  of  the  lung,  terminating 
in  a  copious  flux  into  the  bronchial  tubes,  or  may  observe  a 
continual  and  copious  expectoration  of  a  serous  or  sero-mucous 
fluid,  for  a  considerable  period  of  time.  It  is  stated  by  Andral, 
that  patients  labouring  under  this  affection  ultimately  resemble 


60  BRONCHITIS. 

individuals  who  have  suffered  from  great  losses  of  blood.  They 
become  emaciated  ;  there  is  some  swelling  of  the  face,  and  a 
general  aspect  which  is  truly  anemic.  The  other  perspiratory 
secretions  seem  nearly  suppressed,  and.  the  functions  of  the 
stomach  are  languid.  The  same  author  relates  a  case  in  which 
a  sudden  and  most  copious  secretion  of  serous  fluid  from  the 
lung  coincided  with  the  disappearance  of  an  hydrothorax. 

Laennec,  in  his  division  of  bronchitis,  has  described  a  pituitous 
catarrh,  in  which  the  discharge  of  great  quantities  of  sero-mucous 
fluid  from  the  lungs  may  occur  as  an  acute  or  chronic  disease. 
Thus  he  states,  that  in  the  course  of  one  or  two  hours,  from  two 
to  three  pounds  of  fluid  have  been  discharged. 

I  have  seen  but  few  cases  analogous  to  Laennec's  idiopathic 
pituitous  catarrh.  Indeed  in  almost  all  the  cases  of  this  kind 
of  expectoration  which  I  have  witnessed,  there  was  also  a  dis- 
charge either  of  concocted  mucus,  which  was  the  most  common 
complication ;  or  of  muco-puriform  or  puriform  matters,  which 
were  observed  in  cases  of  phthisis,  particularly  where  the  patient 
had  passed  the  meridian  of  life,  and  had  been  long  affected  with 
the  disease.  I  have  not  had  an  opportunity  of  connecting  it 
with  the  simultaneous  development  and  persistence  of  miliary 
tubercles  in  the  lung,  as  remarked  by  Bayle  and  Laennec.  The 
disease,  as  Laennec  mentions,  commonly  terminates  by  oedema 
of  the  lung,  which  may  continue  for  a  considerable  period  of 
time,  ultimately,  however,  ending  in  inability  to  expectorate, 
and  asphyxia. 

Physical  Signs  of  Bronchitis. — Before  proceeding  to  con- 
sider the  other  forms  of  bronchial  irritation,  I  shall  examine  the 
physical  signs  of  the  primary  bronchitis,  in  its  acute  and  chronic 
forms,  in  the  following  order  : — 

First. — The  results  of  percussion. 

Second. —  Signs  discoverable  by  the  sense  of  touch. 

Third. — Signs  discoverable  by  auscultation. 

With  respect  to  the  first  of  these  classes,  it  is  to  be  remarked 
that  there  is  no  direct  sign  derivable  from  percussion,  the  sound 
being  almost  always  of  natural  clearness.  The  principle  already 
laid  down  should  be  recollected,  that  other  things  being  equal, 
the  sound  on  percussion  is  directly  as  the  quantity  of  air  con- 
tained within  the  thorax.  Now  although  the  vascularity  and 
turgescence  of  the  inflamed  mucous  membrane  must,  to  a  certain 


BRONCHITIS.  61 

degree,  diminish  the  aeriform  contents,  yet  we  find  that  this 
diminution  is  not  sufficient  for  the  production  of  sensible  dul- 
ness,  and  hence  the  sound  on  percussion  in  bronchitis,  whether 
acute  or  chronic,  is  almost  always  clear.  It  is  probable  that  if 
our  organs  of  hearing  were  endowed  with  greater  delicacy,  a 
certain  shade  of  difference  could  be  detected,  but  in  their  actual 
condition,  we  cannot  in  most  cases  distinguish  any  variation 
from  the  healthy  sound  of  the  chest.  In  fact  there  is  but  a 
single  case  in  which  simple  bronchitis  is  ever  accompanied  with 
decided  dulness,  namely,  that  in  which  a  vast  secretion  of  mucous 
or  muco-purnlent  fluid  exists  in  the  bronchial  tubes  ;  but  such  a 
case  is  extremely  rare,  for  a  large  proportion  of  the  bronchial 
tubes  may  contain  quantities  of  secretion,  and  yet  the  sound  on 
percussion  shall  continue  without  any  perceptible  diminution. 
When,  however,  the  disease  is  combined  with  affections  which 
have  their  seat  in  the  areolar  structure  of  the  lung,  such  as 
itdema,  congestion,  pneumonia,  or  tubercle,  the  results  are  of 
course  different,  the  amount  and  situation  of  dulness  varying 
according  to  circumstances. 

It  would  be  an  interesting  question,  as  connected  with  the 
want  of  dulness  in  bronchitis,  to  determine  whether,  pending  the 
turgescence  of  the  bronchial  membrane,  some  degree  of  dila- 
tation of  the  air  cells  may  not  exist,  so  that  the  air  thus 
accumulated  might  compensate  for  that  which  has  been  dis- 
placed by  the  state  of  the  mucous  tissue.  Could  we  thus  account 
for  the  clearness  on  percussion,  notwithstanding  an  extensive 
congestion  of  the  minuter  tubes  ? 

Yet  though  percussion  gives  no  direct  result  in  bronchitis,  its 
employment  is  of  importance  in  the  particular  diagnosis.  Thus, 
suppose  that  after  the  existence  for  three  or  four  days  of  fever, 
cough,  hurried  and  difficult  breathing,  the  chest  still  sounds 
well,  the  great  probability  is  that  the  disease  is  bronchitis.  The 
patient  has  had  an  acute  inflammatory  affection  of  the  lung,  and 
but  of  a  few  days'  standing  :  this  must  be  either  bronchitis,  disease 
of  the  serous  membrane,  or  of  the  parenchymatous  tissue  itself. 
Here  the  absence  of  dulness  is  of  the  greatest  importance ;  for 
were  it  a  case  of  pleuritic  effusion,  or  of  disease  of  the  substance 
of  the  lung,  the  great  probability  is,  that  by  this  time  a  degree 
of  dulness  would  be  manifested ;  in  the  one  case  the  lung  would 
be  compressed,  and  its  place  occupied  by  a  liquid  effusion ;  in 


62  BRONCHITIS. 

another,  more  or  less  obliteration  of  the  air  cells  would  take 
place,  from  congestion,  or  from  inflammation.  The  absence  then 
of  dulness,  with  the  existence  of  acute  irritation  of  the  lung,  which 
has  continued  for  several  days,  forms  an  important  argument 
that  the  case  is  one  of  uncomplicated  bronchitis. 

But  the  knowledge  of  the  absence  of  dulness  in  mere  bron- 
chitis may  be  advantageously  applied  in  general  diagnosis.  The 
study  of  symptoms,  independent  of  physical  phenomena,  will  not 
be  sufficient  to  establish  the  diagnosis  of  simple  bronchitis,  for 
there  are  a  vast  number  of  examples  of  disease  of  different  kinds, 
in  which  the  symptoms  are  only  those  of  bronchitis,  or  at  least 
might  be  referred  to  this  lesion.  But  as  we  have  before  said, 
if  we  find,  on  the  examination  of  any  particular  case  of  this 
kind,  a  dulness  on  percussion,  either  of  one  portion  of  the 
chest  as  compared  with  the  other,  or  of  the  whole  chest  as  com- 
pared with  its  sound  at  some  former  period,  we  may  be  certain 
that  something  more  than  mere  bronchitis  exists.  It  may  be 
said  that  a  copious  effusion  of  mucus  into  the  tubes  will  give  a 
dulness  of  sound,  but  I  can  say,  from  an  extensive  experience, 
that  this  only  occurs  in  the  most  extreme  case,  and  in  the  last 
stages  of  the  disease ;  for  I  have  met  with  cases  where  the 
bronchial  system  was  extensively  filled  with  muco-purulent 
matter,  yet  in  which  the  sound  was  generally  clear.  There  is, 
however,  one  case  in  which  dulness  may  be  observed,  namely, 
great  dilatation  of  the  bronchial  tubes,  with  compression  of  the 
intermediate  pulmonary  substance ;  to  this  we  shall  hereafter 
allude,  when  describing  the  disease  in  question. 

From  the  knowledge  of  the  fact,  that  in  simple  bronchitis 
there  is  nothing  to  produce  a  perceptible  dulness  of  sound,  we 
derive  a  most  important  assistance  in  the  diagnosis  of  tubercular 
development,  whether  in  the  acute  or  chronic  form.  The  value 
of  this  will  be  seen  when  we  consider  the  frequent  similarity 
of  symptoms  between  the  diseases  of  tubercular  phthisis  and 
bronchitis,  a  similarity  easily  understood,  when  we  recollect  that 
in  most  cases  of  tubercular  development  there  is  a  co-existing 
catarrh ;  but  as  I  shall  shew  hereafter,  the  occurrence  of  a 
partial,  or  general  and  progressive  dulness,  in  a  case  pre- 
senting the  symptoms  of  bronchial  inflammation,  is  one  of  the 
principal  circumstances  on  which  the  diagnosis  of  tubercle 
depends. 


BRONCHITIS.  63 

Finally,  it  is  plain,  that  the  longer  the  symptoms  of  catarrhal 
inflammation  have  existed,  without  the  occurrence  of  either 
partial  or  general  dulness,  the  greater  will  he  the  probability 
that  the  case  is  an  example  of  uncomplicated  bronchitis.  There 
is  a  sign  discoverable  by  percussion  in  cases  of  bronchitis,  par- 
ticularly in  the  young  subject,  which  has  not  been  sufficiently 
noticed ;  I  allude  to  a  metallic  resonance,  somewhat  analogous 
to  the  cracked  jar  sound  of  cavities,  but  evidently  more  diffused. 
The  history  of  the  case,  the  extent  of  the  phenomenon,  the 
absence  of  dulness,  and  of  the  stethoscopic  signs  of  a  cavity, 
will  be  sufficient  to  distinguish  it  from  the  above  sign. 

With  respect  to  the  signs  discoverable  by  the  sense  of  touch, 
there  is  not  much  to  be  said.  In  a  great  number  cf  cases,  and 
particularly  after  the  disease  has  passed  its  first  stage,  a  distinct 
vibratory  sensation  is  perceptible  when  the  hand  is  laid  on  the 
thoracic  integuments.  This  can  be  detected  both  during 
inspiration  and  expiration,  but  is  generally  more  distinct  in  the 
former  than  in  the  latter.  It  is  more  evident  in  the  child  and 
the  female  than  in  the  adult  male,  although  it  is  not  unfre- 
quently  present  even  in  the  latter  case.  It  seems  to  be  more  an 
indication  of  a  free  secretion  into  the  larger  than  the  more 
minute  tubes,  for  it  will  frequently  disappear  after  a  cough  with 
expectoration,  again  to  return  when  the  secreted  matter  accumu- 
lates, and  if  while  it  is  present  we  apply  the  ear,  the  loud  sonoro- 
mucous  rattle  is  always  perceptible  ;  in  some  cases,  however, 
on  making  the  patient  draw  a  deep  breath,  the  vibration  is 
decidedly  increased.  This  vibration  is  much  more  distinct  in 
the  middle  and  inferior  than  in  the  upper  portions  of  the  lung 
and  is  not  met  with  in  simple  pleurisy  or  pneumonia,  although 
in  the  former  disease  a  phenomenon  may  occur  which  might 
possibly  be  confounded  with  it ;  I  allude  to  the  sensation  of 
rubbing  (frottement)  which  occurs  in  certain  stages  of  the  dry 
pleuritis,  and  which,  like  the  vibration  of  bronchitis,  is  in  accord- 
ance with  the  motions  of  respiration.  But  a  little  practice  will 
enable  us  easily  to  distinguish  them ;  the  bronchial  vibration 
giving  the  idea  of  air  passing  in  many  directions  through  an 
adhesive  fluid,  while  the  rubbing  sensation  of  pleurisy  is  that 
of  two  continuous,  though  roughened  surfaces,  moving  one  upon 
the  other  ;  lastly,  a  momentary  application  of  the  stethoscope 
will  often  determine  the  point,  for  in   the  majority  of  cases  of 


64  BRONCHITIS. 

pleuritic  friction,  the  respiratory  murmur  may  be  heard  without 
any  admixture  of  rale. 

In  considering  the  signs  referrible  to  the  passage  of  air 
during  the  acts  of  respiration,  we  find  that  several  causes  exist 
for  the  modification  of  the  respiratory  murmur  ;  these  may  be 
enumerated  as  follows : 

First. — The  turgescence  of  the  mucous  membrane,  a  cause 
which  principally  affects  the  phenomena  of  the  smaller  tubes 
and  air  cells. 

Second. — The  existence  of  an  anormal  secretion  into  the 
cavity  of  the  tube  itself ;  and 

Third. — The  existence  of  spasm ;  the  amount  of  which  is 
uxceedinglv  variable  in  different  individuals.  All  these  unite  in 
forming  the  numerous  varieties  and  combinations  of  Laennec's 
sonorous,  sibilous,  and  mucous  rales. 

In  the  occurrence  and  combination  of  these  phenomena  there 
sire  the  greatest  possible  differences  in  different  cases,  but  as  a 
general  rule  it  may  be  stated,  that  the  modifications  of  sound 
connected  with  turgescence  of  the  mucous  membrane  and  spasm, 
are  to  be  found  principally  in  the  first  or  dry  stage,  while  those 
produced  by  the  passage  of  air  through  fluid  in  the  tubes,  are 
most  evident  in  the  second  or  secretive  stage,  although  even  at 
this  period  the  cooing  and  sibilous  sounds  may  exist,  though 
combined  with  a  mucous  rattle.  In  some  cases  the  phenomena 
are  universal,  and  so  intense  as  almost  completely  to  obscure  the 
natural  sound  of  respiration,  while  in  others  they  may  be  partial, 
and  only  now  and  then  perceptible,  and  even  degenerate  into  a 
character  of  respiration,  which  can  only  be  appreciated  by  actual 
observation,  but  in  which  it  may  be  stated  that  the  respiratory 
murmur  differs  from  its  healthy  character,  in  having  a  certain 
roughness.  I  may  observe,  however,  that  the  case  in  which  this 
last  character  is  most  often  perceptible  is  that  of  pneumonia,  for 
some  time  after  resolution  has  taken  place  ;  a  state  in  which  there 
is  every  reason  to  believe  that  the  bronchial  mucous  membrane 
still  labours  under  a  certain  degree  of  irritation. 

As  a  general  rule  it  may  be  stated,  that  in  the  acute  stage, 
during  ordinary  respiration,  the  louder  and  more  intense  the 
rales  are,  the  more  severe  is  the  disease.  But  to  this  rule 
there  is  one  remarkable  and  important  exception,  which  I  first 
observed  in  bad  catarrhal  fevers.     In  such  cases  during  ordinary 


BKONCHITIS.  65 

respiration,  we  may  hear  little  or  no  rale,  and  yet  the  disease  be 
in  such  a  state  of  violence  as  to  threaten  the  life  of  the  patient. 
The  reason  of  this  seems  to  be,  that  the  finer  ramifications 
of  the  bronchial  tubes  are  so  turgid,  as  that,  during  ordinary 
respiration,  the  air  does  not  enter  them  with  sufficient  force  to 
produce  a  tone.  But  if,  under  such  circumstances,  we  make 
the  patient  take  a  forced  inspiration,  we  are  astonished  at  the 
intensity,  number,  and  variety  of  the  sounds  produced.  Now, 
in  such  cases  it  commonly  happens,  that  as  the  patient  gets 
better,  the  rale,  during  ordinary  respiration,  becomes  distinct  and 
constant,  so  that  here  an  increase  of  rale  during  ordinary 
breathing  points  out  a  decrease  of  disease. 

In  some  cases  of  chronic  bronchitis,  and  particularly  in  those 
where  a  muco-purulent  secretion  exists,  we  may  hear  nothing  but 
a  mucous  rattle  of  various  degrees  of  intensity  and  extent.  In 
most  instances  the  bubbles  are  large ;  but  they  may  be  so  small 
as  to  produce  a  rale  which  is  almost  crepitating.  Such  cases  are 
not  uncommon  ;  and  as  I  have  known  them,  in  some  instances, 
to  be  confounded  with  phthisis,  I  shall  dwell  shortly  on  their 
diagnosis.  In  both  diseases  a  muco- crepitating  rale,  of  great 
extent  and  intensity,  may  occur,  but  by  attending  to  certain 
circumstances,  the  chances  of  error  will  be  much  diminished. 
The  first,  and  most  important,  is  the  result  of  percussion.  I 
have  already  stated  that  we  may  have  a  great  amount  of  bronchitis 
without  perceptible  dulness  of  sound,  while  in  cases  of  phthisis, 
so  circumstanced  as  to  give  an  extensive  muco-crepitating  rale, 
there  is  in  all  cases  decided  dulness,  either  general  or  partial. 
In  some  cases,  which  were  supposed  to  be  phthisis,  I  have, 
from  the  generally  equable  and  persistent  clearness  of  sound, 
decided  that  nothing  but  bronchitis  existed,  a  conclusion  which 
the  perfect  recovery  of  some  patients,  and  the  -post  mortem 
examination  of  others,  fully  verified. 

Again,  we  may  observe  in  both  diseases,  that  a  partial  dulness 
is  to  be  met  with ;  but  in  phthisis,  even  where  the  whole  lung  is 
tubercular,  this  is  almost  always  greatest  in  the  upper  parts  of 
the  lung,  while  in  the  case  of  bronchitis  the  reverse  occurs;  the 
dulness,  where  it  does  exist,  being  generally  in  the  inferior  lobes. 
This  seems  to  arise  from  the  accumulation  of  mucus  in  the 
more  depending  portions ;  and  in  many  cases  at  least,  from  the 
combination  of  the  disease  with  a  certain  amount  of  congestion  or 


66  BRONCHITIS. 

inflammation  of  the  air  cells  themselves,  a  combination,  not 
unfrequent  in  those  cases  of  intense  bronchitis,  which  produce  a 
general  muco-crepitating  rale. 

The  same  remarks  apply  to  the  occurrence  of  puerile  respiration, 
which  may  be  observed  in  both  affections.  In  bronchitis,  when 
it  does  occur,  (and  it  is  here  much  rarer  than  in  phthisis,)  it  is 
principally  found  in  the  upper  portions  of  the  chest,  while  the 
reverse  is  almost  always  the  case  in  phthisis.  Other  points  of 
distinction  might  be  described,  but  they  will  be  better  examined 
when  we  treat  of  the  diagnosis  of  phthisis. 

I  have  already  alluded  to  the  kind  of  exacerbation  so  likely  to 
occur  in  certain  cases  of  intense  bronchitis,  when  the  opaque 
muco-puriform  expectoration  changes  its  character,  and  becomes 
transparent  and  viscid.  Now  this  change  is  generally  accompanied 
by  corresponding  stethoscopic  phenomena.  The  muco-crepitating 
rale  becomes  smaller,  sharper,  and  the  extinction  of  the 
respiratory  murmur  is  more  complete,  so  that  there  is  a  close 
approximation  to  the  phenomena  of  pneumonia  in  its  permeable 
stages.  The  clearness,  however,  of  the  sound  on  percussion,  and 
the  want  of  the  bronchial  respiration,  so  common,  and  so 
remarkable  in  the  third  stage  of  pneumonia,  are  differences  of 
great  importance ;  and  in  most  cases,  even  on  our  first  seeing  the 
patient,  will  prevent  us  from  forming  an  erroneous  judgment  of 
the  case. 

Before  concluding  my  remarks  on  the  diagnosis,  from  the 
secretion  into  the  tubes,  I  may  state,  that  I  have  observed  a 
distinct  agitation  of  the  muco-purulent  secretion  in  the  tubes  from 
the  action  of  the  heart.  This  was  most  evident  in  a  case  of 
intense  bronchitis  of  the  left  lung,  when  the  heart  was  acting 
strongly.  Each  pulsation  caused  a  corresponding  sound,  or  rale, 
continuing  when  the  patient  held  his  breath,  and  forming  with 
the  respiratory  phenomena  a  distinct  rhythm  in  the  succession 
of  sounds.  This  phenomenon  is  obviously  analogous  to  that 
produced  in  a  cavity  by  the  action  of  the  heart,  or  to  the  cardiac 
friction  sound  of  dry  pleurisy. 

We  now  come  to  another  physical  sign  in  cases  of  bronchitis, 
namely,  the  complete  suspension  of  any  sound  of  respiration  in 
certain  parts  of  the  lung.  In  most  cases  this  phenomenon  is  but 
temporary,  but  it  may  be  permanent.  In  the  first  instance,  it 
will  often  disappear  after  a  fit  of  coughing,  a  circumstance  which 


BRONCHITIS.  67 

led  Laeimec  to  believe  that  it  depended  on  a  temporary  obstruc- 
tion by  mucus ;  but  it  is  possible  tbat  spasm  may  have  some 
effect  in  producing  it,  as  a  similar  phenomenon  has  been  observed 
in  cases  of  hysteria.     This  is  rare  in  ordinary  bronchitis. 

But  Andral  and  Reynaud  have  shewn  that  in  consequence  of  a 
hypertrophy  of  the  bronchial  mucous  membrane,  the  sound  of 
respiration  may  be  remarkably  modified  in  the  affected  portion  of 
the  lung.  This  modification  may  vary  from  a  slight  comparative 
feebleness,  to  an  almost  complete  absence  of  the  respiratory 
murmur.  Of  the  latter  circumstance,  the  following  case  is  an 
instructive  instance:  A  patient,  aged  31,  entered  the  hospital  of 
La  Charite,  presenting  the  symptoms  of  an  organic  affection  of 
the  heart.  The  respiration  was  heard  posteriorly,  and  over  the 
anterior  surface  of  the  left  lung,  with  considerable  intensity,  and 
a  mixture  of  mucous  rale ;  while  under  the  right  clavicle  it  was 
extremely  feeble,  the  sound  on  percussion  being  generally  equal. 
The  patient  stated,  that  for  a  length  of  time  he  had  felt  a  con- 
striction a  little  above  the  right  breast,  and  that,  to  use  his  own 
expression,  he  did  not  breathe  with  the  right  side  of  his  chest. 
From  the  stethoscopic  phenomena,  it  was  supposed  that  emphy- 
sema of  the  superior  lobe  of  the  right  lung  existed.  The  patient 
died  in  a  little  more  than  a  month,  with  the  signs  and  symptoms 
of  hydrothorax.  On  dissection,  the  upper  lobe  of  the  right  lung- 
presented  no  trace  of  emphysema,  its  tissue  appearing  healthy, 
though  but  little  crepitating.  At  a  few  lines  from  the  origin  of 
the  principal  bronchus  of  this  lobe,  a  constriction,  so  great  as  to 
scarcely  admit  the  passage  of  a  probe,  was  discovered,  beyond 
which  the  calibre  of  the  tube  became  again  of  its  natural  diameter. 
This  partial  thickening  was  owing  to  a  hypertrophy  of  the  mucous 
membrane,  as  the  subjacent  fibrous  tissue  was  found  natural ;  the 
remaining  tubes  in  this  lobe  presented  their  natural  calibre. 

Here  we  find  that  the  pathological  appearances  were  in  exact 
accordance  with  the  signs  observed  during  life ;  no  cause  existed 
to  produce  any  dulness  of  sound,  and  accordingly  this  phenomenon 
was  wanting,  and  the  diminution  of  the  respiratory  murmur  was 
clearly  accounted  for  by  the  constriction  of  the  bronchus.  But, 
as  Andral  remarks,  the  phenomenon  cannot  be  considered  as  a 
pathognomonic  sign,  inasmuch,  as  it  may  proceed  from  other 
causes.  It  may  be  produced,  as  I  have  seen,  by  a  localized 
dilatation  of  the    cells.     Other   causes    for    the    production    of 


f  2 


68  BRONCHITIS. 

comparative  feebleness  of  respiration,  with  equality  of  sound  on 
percussion,  may  be  enumerated,  but  as  far  as  I  know,  in  all  these, 
the  feebleness  of  respiration  in  one  lung  has  been  general, 
differing  in  this  from  the  case  mentioned.  Thus,  either  bronchus 
may  be  compressed  by  melanotic  tumours,  tuberculous  ganglia, 
or  aneurisms  of  the  aorta,  and  lastly,  the  existence  of  a  foreign 
body  within  the  tube  may  produce  the  phenomenon  in  question. 

In  other  cases  this  narrowing  of  the  bronchial  tubes  is  more 
general,  but  as  yet  no  pathognomonic  stethoscopic  sign  has  been 
observed.  In  a  case  of  this  description,  given  by  Andral,  the 
respiratory  murmur  was  not  diminished,  though  a  loud  rhonchus 
was  audible  in  the  affected  lung. 

But  this  difference  of  respiratory  murmur  with  equality  of 
sound  on  percussion  of  both  sides,  may  proceed  from  obstruction 
by  the  secretions  of  the  tube  itself.  Of  this,  two  remarkable 
examples  are  given  by  Andral.  In  the  first  case  the  patient,  who 
had  laboured  for  some  time  under  the  symptoms  and  signs  of 
bronchitis  with  mucous  secretion,  was  suddenly  seized,  during  a 
violent  fit  of  coughing,  with  extreme  difficulty  of  breathing, 
which  continued  during  the  whole  of  that  day  and  the  following 
night ;  on  being  seen  the  next  morning,  he  seemed  on  the  point  of 
death  from  suffocation.  On  percussion,  the  chest  sounded  every- 
where clear,  with  puerile  respiration  over  the  whole  of  the  left 
lung,  and  the  postero-inferior  portion  of  the  right ;  but  on  this 
side  anteriorly,  and  in  the  sub-spinous  fossa,  neither  respiration 
nor  rale  was  audible.  He  shortly  after  expired,  and  on  dissection, 
the  bronchus  leading  to  the  upper  lobe  was  found  completely 
obstructed  by  a  mass  of  concrete  mucus,  which  thus  prevented 
the  entrance  of  air  into  that  portion  of  the  lung,  and  afforded  a 
satisfactory  explanation  of  all  the  phenomena. 

Here,  as  Andral  remarks,  the  obstruction  of  a  certain  portion 
of  the  lung  caused  a  sudden  and  fatal  dyspnoea,  which  is  the  more 
remarkable,  that  in  many  patients,  after  a  large  portion  of  both 
lun°s  has  become  impermeable,  life  may  be  continued  for  a 
length  of  time,  even  without  much  dyspnoea.  This  apparent 
difficulty  is  explained  by  recollecting,  that  in  these  latter  cases 
the  permeability  of  the  lungs  has  been  gradually  diminished  ; 
while  in  the  above  case  the  obstruction  was  sudden.  To  this 
point  I  shall  return  hereafter. 

The  second  case  was  also  one  of  chronic  catarrh,  with  abundant 


BRONCHITIS.  69 

puriform  expectoration,  but  in  which  there  was  hut  little  dyspnoea 
until  the  very  last  day  of  existence.  This  patient  had  been 
frequently  examined,  and  presented  an  equable  respiration,  with 
the  different  varieties  of  bronchial  rales.  In  the  course  of  a 
night,  after  a  violent  fit  of  coughing,  the  respiration  became 
suddenly  and  violently  oppressed,  and  on  the  next  day  no 
murmur  of  respiration  could  be  heard  in  the  upper  lobe  of  the 
right  lung ;  the  parts  still  sounding  clear  on  percussion.  The 
patient  died  on  the  following  night,  and  on  dissection,  the 
principal  bronchus  of  the  superior  lobe  was  found  completely 
obstructed  by  a  polypiform  mucous  concretion,  which  extended 
into  several  other  bronchial  ramifications  of  this  lobe.  On  these 
cases  the  author  makes  the  following  observations  :  "  The  at- 
tention being  directed  to  the  case  just  described,  the  diagnosis 
should  not  seem  difficult.  "We  should  be  led  to  suspect 
obstruction  of  one  bronchus,  if,  on  a  simple  bronchitis,  a  severe 
dyspnoea  suddenly  supervenes,  and  if,  at  the  same  time,  respi- 
ration ceases  to  be  heard  over  a  certain  extent  of  lung  ;  percussion 
still  giving  a  clear  sound  in  that  region.  Pulmonary  emphysema 
is  the  only  disease  which  can  be  confounded  with  this  group  of 
signs." 

As  I  have  had  no  opportunity  of  studying  the  cases  of  bron- 
chial obstruction  described  by  Andral  and  Reynaud,  I  cannot  put 
forward  any  original  observation  upon  them.  Yet  I  can  scarcely 
agree  with  the  first  of  these  authors,  in  his  opinion  that  they 
may  be  confounded  with  Laennec's  emphysema,  for  although 
this  particular  form  of  bronchial  obstruction  has  not  come  before 
me,  yet  in  cases  of  foreign  bodies  in  the  trachea  and  bronchial 
tubes,  and  in  compression  of  either  bronchus  by  external 
tumours,  I  have  had  many  opportunities  of  studying  the  stetho- 
scopic  signs  which  result  from  complete  or  partial  obstruction  of 
a  large  tube,  and  of  convincing  myself  that  between  the  pheno- 
mena thus  produced,  and  those  of  bronchitis  with  dilatation  of 
the  air  cells,  there  are  generally  remarkable  differences. 

We  may  divide  the  cases  of  this  kind  of  bronchial  obstruction 
into  two  classes ;  first,  those  in  which  it  is  complete,  and  next, 
those  where  it  is  only  partial.  Now,  in  the  first  of  these  cases, 
the  physical  signs  are  totally  different  from  those  of  Laennec's 
emphysema  ;  for  we  have  complete  absence  of  respiratory  mur- 
mur, and  of  the  other  signs  which  indicate  permeability  of  the 


70  BRONCHITIS. 

lung,  the  sound  on  percussion  remaining  unaffected ;  circum- 
stances the  very  opposite  to  those  in  emphysema,  in  which  there 
is  never  complete  impermeability,  and  in  which  the  sound  on 
percussion  becomes  increased  in  proportion  to  the  extent  of  the 
disease. 

In  the  second  class,  the  phenomena  of  which  may  be  studied 
in  cases  of  foreign  bodies  not  completely  obstructing  the  bron- 
chus, and  in  those  of  partial  compression  of  the  tube  by  external 
tumours ;  the  signs,  in  the  early  periods  at  least,  are  also  dif- 
ferent from  those  of  emphysema.  The  respiration  indeed  is 
feeble,  but  pure,  the  sound  on  percussion  unaltered,  and  the 
peculiar  crepitating,  sibilous,  and  mucous  rales  altogether  want- 
ing. There  is  no  evidence  of  increase  of  volume  of  the  lung,  and 
if  signs  of  bronchial  irritation  supervene,  they  are  consequent  to 
the  feebleness  of  respiration  ;  the  very  reverse  of  what  occurs  in 
dilatation  of  the  ceils,  which,  in  almost  all  cases,  is  produced 
and  preceded  by  a  bronchial  irritation. 

Lastly,  the  history  of  the  case,  the  accompanying  symptoms, 
and  the  period  of  duration  of  the  physical  signs,  will  greatly 
assist  us  in  forming  a  correct  opinion. 

Before  proceeding  to  some  of  the  other  varieties  and  results 
of  bronchitis,  I  shall  endeavour,  according  to  the  plan  of 
this  work,  to  throw  into  separate  propositions  the  state  of  our 
knowledge  with  respect  to  the  physical  diagnosis  of  simple 
bronchitis. 

1st.  That  in  almost  all  cases  percussion  gives  no  direct  sign. 
2nd.  That  an  accumulation  of  mucus  in  the  inferior  portions 
of  the  lung  may  give  a  certain  degree  of  dulness. 

3rd.  That  in  the  great  majority  of  cases,  in  which  there  is  a 
co-existence  of  the  signs  and  symptoms  of  bronchitis  with  dul- 
ness, we  may  infer  the  existence  of  some  disease,  either  of  the 
parenchyma  or  of  the  pleura. 

4th.  That  conversely,  the  absence  of  dulness  with  the  exist- 
ence of  irritation  of  the  lung,  gives  a  great  probability  that  the 
case  is  one  of  simple  bronchitis. 

5th.  That  a  copious  effusion  of  muco-purulent  matter  may 
exist  in  the  bronchial  tubes,  without  perceptible  dulness  of 
sound  on  percussion. 

6th.  That  in  certain  cases  of  bronchitis  with  effusion,  a 
metallic  sound  may  be  produced  on  percussion.     This  is  some- 


BRONCHITIS.  71 

what  similar  to  the  bruit  de  pot  file  of  caverns,  but  is  to  be 
distinguished  from  it  by  the  clearness  of  sound,  its  greater 
diffusion,  and  the  absence  of  the  stethoscopic  signs  of  a  cavity. 

7th.  That  in  many  cases,  on  application  of  the  hand,  a  dis- 
tinct vibration  is  felt  in  accordance  with  the  motions  of  res- 
piration. 

8th.  That  the  modifications  of  respiration,  as  observed  by  the 
stethoscope  in  bronchitis,  seem  to  be  connected  with  mechanical 
obstruction  more  or  less  complete,  and  which  may  proceed  from 
one  or  all  of  the  following  causes  :  turgescence  or  hypertrophy  of 
the  mucous  membrane,  the  existence  of  various  secretions,  and 
lastly,  the  occurrence  of  spasm. 

9th.  That  in  the  mode  of  occurrence  of  the  various  phenomena 
there  are  the  greatest  possible  differences  in  different  individuals. 

10th.  That  as  a  general  rule  it  may  be  stated,  that  the  more 
intense  the  sonorous,  sibilous,  or  mucous  rales,  or  any  combina- 
tion of  them,  be  during  ordinary  respiration,  the  more  severe 
may  the  disease  be  considered. 

11th.  But  that  in  certain  cases  of  intense  bronchitis  of  the 
minuter  tubes,  the  sounds  during  ordinary  respiration  cease  to  be 
a  measure  of  the  intensity  of  disease,  as  they  become  louder 
during  the  convalescence  of  the  patient. 

12th.  That  in  the  secretive  stage  of  bronchitis  the  mucous 
rattle  may  occur,  on  the  one  hand,  with  large  and  isolated 
bubbles,  and  on  the  other,  may  pass  into  a  rale  almost  crepi- 
tating, the  sound  on  percussion  still  continuing  clear. 

13th.  That  in  consequence  of  bronchial  inflammation  the 
entrance  of  air  into  a  certain  portion  of  the  lung  may  be  pre- 
vented, under  which  circumstances  the  signs  are  nullity  of 
respiration,  with  persistence  of  clearness  of  sound. 

14th.  That  this  obstruction  may  result  from  an  organic  change 
of  the  mucous  membrane,  or  from  the  plugging  up  of  the  tubes 
by  their  own  secretion. 

15th.  That  in  the  first  of  these  cases  the  absence  or  dimi- 
nution of  the  respiratory  murmur  is  permanent,  while  in  the 
second  it  may  be  temporary,  and  removable  by  a  fit  of  coughing ; 
yet  even  in  this  case  the  obstruction  by  a  concrete  mucus  has 
continued  from  the  period  of  its  occurrence  until  the  fatal 
termination. 

16th.  That  if  in  a  case  of  mucous  catarrh  a  sudden  dyspnoea 


72  BRONCHITIS. 

supervenes,  with  absence  or  diminution  of  the  respiratory  mur- 
mur in  a  particular  portion  of  the  lung,  this  portion  also 
preserving  its  clearness  of  sound  on  percussion,  we  may  make 
the  diagnosis  of  obstruction  of  the  bronchial  tube  by  its  own 
secretion. 

ACUTE  SECONDARY  BRONCHITIS. 

Having  now  considered  the  symptoms  and  signs  of  the  primary 
bronchial  inflammation,  in  other  words,  of  that  form  of  disease 
in  which  the  affection  of  the  mucous  membrane  seems  to  be  the 
first  link  in  the  chain  of  morbid  action,  and  the  fever  consequently 
sympathetic,  I  proceed  to  consider  the  disease  in  its  secondary 
form,  when  we  find  it  either  as  the  result  of  an  influence  which 
seems  to  act  on  the  whole  economy ;  a  specific  poison  which 
produces  various  organic  and  functional  lesions,  among  which 
that  of  the  respiratory  mucous  membrane  is  by  no  means  the 
least  important ;  or  as  proceeding  from  a  sympathetic  irritation, 
the  consequence  of  local  disease  in  some  other  system.  I  shall, 
in  the  first  place,  examine  into  the  history  of  the  catarrh  of 
typhus  fever ;  next,  into  that  of  the  exanthematous  diseases ; 
and  lastly,  make  some  observations  on  those  forms  of  bronchitis 
which  occur  in  other  specific  contaminations  of  the  system,  and 
which  may  be  denominated  the  chronic  secondary  catarrhs  ;  and 
on  the  sympathetic  coughs  from  irritation  of  the  digestive 
system. 

Bronchitis  of  Typhus  Fever. — The  occurrence  of  bronchitis 
in  cases  of  typhus  is  not  constant ;  and  even  when  it  exists,  it  is 
often  slight,  and  easily  manageable.  But  on  the  other  hand, 
the  pulmonary  system  may  be  severely  attacked,  and  death 
induced  by  asphyxia  from  excessive  secretion  of  the  bronchial 
membrane.  We  commonly  meet  with  this  severe  form  under 
two  circumstances  ;  the  one  where  the  symptoms  are  manifest 
and  distressing,  the  other  in  which  the  disease  is  latent  and 
insidious.  But  in  one  respect  both  these  forms  agree,  namely, 
that  at  an  earlier  period  than  in  the  idiopathic  catarrh,  secretion 
generally  comes  on  in  enormous  abundance,  and  is  too  often  the 
immediate  cause  of  death.  As  far  as  I  have  seen,  the  great 
majority  of  patients  in  fever,  who  have  died  with  what  is  called 
effusion  into  the  chest,  owe  their  death  to  this  disease,  which 


BRONCHITIS.  73 

has  been  overlooked,  or  insufficiently  treated.  This  fact 
illustrates  the  want  of  proportion  which  commonly  exists  in 
typhus  fever  between  the  functional  alteration  and  the  organic 
change.  With  symptoms  of  an  apparently  trifling  character  we 
may,  after  death,  find  universal  bronchitis,  great  congestion,  or 
pneumonia. 

In  many  cases,  as  Laennec  has  observed,  a  bronchitis  shall 
exist  through  the  whole  course  of  a  fever,  yet  so  slight  as  to 
merit  little  notice.  But  in  all  these  cases  we  must  pay  a  careful 
attention  to  the  chest,  for  we  know  not  the  moment  at  which 
this  trivial  disease  may  assume  a  dangerous  character ;  and 
hence,  when  we  discover  any  increase  in  the  bronchitic  symptoms 
we  should  immediately  direct  our  attention  to  the  lung,  and,  if 
possible,  arrest  the  progress  of  the  local  disease. 

In  other  cases,  as  I  have  before  mentioned,  the  bronchitis  is  a 
prominent  and  formidable  symptom ;  and  in  addition  to  the 
other  phenomena  of  fever,  we  find  the  patient  with  lividity  of 
countenance,  cough,  hurried  breathing,  and  expectoration. 
Finally,  though  these  symptoms  be  but  slightly  marked,  yet  the 
patient  may  be  labouring  under  a  bronchitis,  of  the  intensity 
and  extent  of  which  nothing  but  a  physical  examination  can 
convince  us.  Such  a  patient  may  continue  for  days  with  but 
little  apparent  suffering  of  the  respiratory  system,  and  be 
suddenly  cut  off  by  a  super-secretion  from  the  bronchial  mucous 
membrane. 

This  form  of  disease  is  commonly  co-existent  with  more  or 
less  of  gastro-enteric  inflammation,  thus  forming  one  of  the  most 
fatal  varieties  of  fever  in  this  country.  In  some  instances  the 
disease  predominates  in  the  respiratory,  in  others  in  the  digestive 
system ;  and  I  have  often  observed  a  remarkable  alternation  of 
this  predominance  of  disease  between  the  thoracic  and  abdominal 
cavities.  Thus,  suppose  to-day  we  observe  the  breathing  hurried 
and  laborious,  the  cough  troublesome,  the  expectoration  difficult, 
and  the  stethoscopic  signs  well  marked,  the  chances  are  that  the 
abdominal  symptoms  are  less  severe,  the  abdomen  is  less  swelled 
and  painful,  diarrhoea  has  ceased,  the  tongue  has  improved,  and 
that  characteristic  prostration  which  attends  gastro-enteric 
inflammation  has  remarkably  disappeared.  In  two  or  three 
days,  however,  the  abdominal  symptoms  return,  with  decided 
diminution  of  those  of  the  chest,  and  in  the  course  of  a  single 


74  BRONCHITIS. 

case  several  alternations  of  this  kind  ma}"  occur.  In  such 
instances  death  generally  takes  place  by  asphyxia ;  and  I  have 
known  cases  in  which  the  gastro-intestinal  mucous  membrane 
was  found  in  so  favourable  a  state  as  to  leave  little  doubt,  that, 
as  far  as  its  organic  change  was  concerned,  the  patient  would 
have  recovered,  but  for  the  bronchitis.  I  think  Ave  may  state, 
with  respect  to  the  pathology  of  mucous  membranes  in  fever, 
that  although  the  gastro-intestinal  mucous  surface  may  be,  and 
often  is  affected,  while  but  little,  if  any,  disease  exists  in  the 
respiratory  organs  ;  yet  that  the  converse  of  this  proposition  is 
seldom  true,  a  point  of  the  utmost  importance  in  practical  medi- 
cine, as  bearing  on  the  application  of  general,  local,  and  specific 
treatment. 

Physical  Signs. — In  this  form  of  disease  it  is  often  difficult 
to  draw  the  line  of  distinction  between  the  disease  in  the  mucous 
membrane,  and  a  congested  or  even  inflamed  state  of  the  pul- 
monary parenchyma  ;  and  hence,  the  physical  signs  cannot  be 
so  accurately  defined  as  in  cases  of  simple  idiopathic  bronchitis. 
Thus,  although  the  sound  on  percussion  is  generally  clear 
throughout  the  whole  disease,  yet  in  certain  cases  we  observe 
a  diminution  of  sound  generally  occupying  the  lower  portion 
of  one  side,  but  never  amounting  to  complete  dulness.  In  some 
cases,  indeed,  it  is  so  slight  as  only  to  be  ascertained  by  careful 
comparison.  This  is  an  unfavourable  sign,  as  shewing  that  we 
have  something  more  to  contend  with  than  bronchitis,  and  point- 
ing out  that  congested  state  of  viscera  so  dangerous  in  the 
progress  of  a  typhus  fever.  The  stethoscopic  signs  are  subject  to 
the  same  irregularities,  and  the  rales  become  sometimes  so  fine 
as  to  be  hardly  distinguishable  from  those  of  pneumonia,  a 
circumstance  attributable  to  the  complication  with  pulmonary 
congestion.  We  may  also  observe  that  the  position  of  the 
patient  has  a  remarkable  influence  on  the  physical  signs,  which 
is  rarely  observable  in  the  idiopathic  bronchitis.  Thus,  if  the 
patient  has  lain  all  night  on  the  left  side,  we  may  find  this 
portion  of  the  chest  somewhat  duller  on  percussion,  with  more 
intense  rales,  and  less  vesicular  murmur.  To  this  subject  I 
shall  return  when  speaking  of  pneumonia,  and  shall  merely 
remark,  that  the  fact  is  explicable  by  the  debility  of  the  patient, 
and  probably  also  by  the  dissolution  of  the  fluids  which  occurs 
in  such  cases  ;  and  accordingly  on  dissection,  we  find  the  lower 


BRONCHITIS.  75 

portions  of  the  lung,  more  or  less  in  a  state  of  congestion, 
bordering  upon  hepatization  :  the  tissues  also  present  a 
remarkably  livid  hue,  and  are  generally  softened. 

In  describing  the  stethoscopic  signs  of  this  form  of  bronchitis, 
I  may  observe,  that  there  is  no  essential  difference  between 
them  and  those  of  the  primary  species.  All  the  varieties  and 
combinations  of  the  dry  and  humid  rales  are  met  with,  their 
intensity  being  regulated  by  that  of  the  diseased  action.  But 
independent  of  the  mere  characters  of  physical  phenomena,  we 
find  some  accompanying  circumstances  of  difference  between  the 
two  affections. 

The  first  and  most  important,  is  the  want  of  proportion 
between  the  intensity  of  the  phenomena  and  the  sufferings  of 
the  patient ;  the  former  being  extreme,  while  the  latter,  at  least 
until  the  last  stage,  are  comparatively  trifling.  This  we  find  in 
that  variety  of  the  disease,  where  the  bronchitis,  quoad  its 
symptoms,  is  nearly  latent,  thus  constituting  a  remarkable  dif- 
ference in  the  disease,  as  compared  with  the  primary  form,  in 
which  the  proportion  between  the  symptoms  and  signs  is  much 

more  direct. 

The  second  point  of  difference  is  closely  connected  with  the 
former.  It  is  that  the  intensity  of  the  rale  during  ordinary 
breathing  is,  in  many  cases,  not  a  measure  of  the  violence  of  the 
inflammation  or  congestion  of  the  air  tubes.  Thus,  during 
ordinary  breathing  the  rales  may  be  but  slight  and  diffused, 
and  yet  on  a  forced  respiration  become  most  intense.  This 
seems  owing  to  the  great  obstruction  of  the  minute  tubes, 
coupled  with  the  debility  of  the  patient.  But  as  the  disease 
subsides,  we  have  a  loud  rale  during  ordinary  respiration,  so  that 
then  the  increase  of  rale  points  out  a  decrease  of  disease.  To 
this  point  I  have  already  alluded  when  speaking  of  the  signs  of 
bronchitis. 

A  third  distinction  may  be  made  with  respect  to  the  frequency 
of  the  occurrence  of  certain  characters  of  rale.  In  the  primary 
bronchitis,  a  mucous  rale,  so  fine  as  to  be  scarcely  distinguishable 
from  crepitus,  is  by  no  means  uncommon,  and  shews  that  the 
disease  has  affected,  if  not  the  air  cells,  at  least  those  finer  tubes 
which  pass  into  them.  Now  in  the  bronchitis  of  typhus,  unless 
when  complicated  with  congestion  or  pneumonia,  when  the  sound 
becomes  dull,  the  rales  are  much  more  of  the  musical  than  of  the 


76  BRONCHITIS. 

crepitating  character;  from  which  I  would  conclude,  that  the 
disease  more  especially  affects  the  large  tubes,  where  the  lining 
membrane  has  the  proper  characters  of  a  mucous  structure. 
Louis  has  shewn,  that  of  the  different  tissues  the  serous  mem- 
branes are  the  least  liable  to  disease  in  typhus  ;  and  if  the  struc- 
ture of  the  minuter  tubes  and  and  air  cells  approach  to  that  of  the 
white  tissues,  we  may  understand  why  such  parts  of  the  lung  are 
less  liable  to  the  secondary  diseases  of  typhus. 

Lastly,  we  find  that  in  the  severe  bronchitis  of  typhus  fever, 
the  morbid  phenomena  predominate  more  remarkably  in  the 
lower  and  posterior  parts  of  the  lung ;  where,  as  I  have  before 
mentioned,  they  are  occasionally  combined  with  signs  indicative 
of  a  congested  state  of  the  cellular  structure  of  the  lung. 

I  shall  next  proceed  to  consider  bronchitis  in  relation  to  the 
exanthematous  diseases. 

It  seems  now  established  that  we  may  consider  these  affections 
as  examples  of  specific  fevers,  characterized  by  the  production  of 
secondary  irritations,  not  only  of  the  surface,  but  of  the  internal 
parts,  the  disease  of  the  skin  thus  forming  but  a  single  link  in  the 
chain  of  morbid  actions.  Nor  is  the  cutaneous  irritation  the  first 
of  the  secondary  affections,  at  least  in  the  greatest  number  of 
cases,  for  the  viscera  seem,  in  almost  all  instances,  to  be  the 
first  to  suffer,  a  fact  proved  by  the  occurrence  of  signs  of  this 
irritation,  superadded  to  the  general  symptoms  of  the  precur- 
sory fever.  In  this  way  all  the  viscera  may  be  affected,  and 
convulsions,  cough,  vomitting,  or  diarrhoea  are  met  with.  On 
the  appearance  of  the  cutaneous  eruption,  however,  this  internal 
irritation  either  subsides,  or  becomes  greatly  modified ;  while 
in  other  cases,  where  the  eruption  is  either  wanting  or  insuffi- 
cient, the  visceral  disease  may  run  on  to  a  fatal  termination. 
We  find,  further,  that  if  the  cutaneous  irritation,  which  may 
be  considered  as  a  natural  revulsion  from  the  viscera  to  the 
surface,  be  repressed,  visceral  inflammation  is  again  lighted 
up,  and  that  this  may  occur  even  at  the  natural  period  of  the  sub- 
sidence of  the  affection  of  the  skin. 

But  while,  in  the  actual  state  of  medicine,  we  must  disbelieve 
the  doctrine  of  these  affections  being  purely  cutaneous,  so,  on  the 
other  hand,  we  cannot  admit  the  opinion  of  the  pure  solidists, 
who  explain  all  the  phenomena  by  the  sympathetic  effects  of 
primary   visceral    irritation.      All   the    arguments    against   the 


BRONCHITIS.  77 

doctrine  of  the  localization  of  fever  apply  equally  in  the  case  of 
the  exanthematous  diseases,  for  they  agree  with  typhus  in  the 
circumstance  of  periodicity ;  and  in  the  local  affections  not 
being  primary,  constant,  or  in  proportion  with  the  general 
symptoms ;  so  that  we  must  consider  their  local  irritations 
as  generally  analogous  in  their  pathology  to  those  of  typhus 
itself. 

But  between  these  affections  we  may  draw  one  line  of  distinc- 
tion, although,  after  all,  it  amounts  but  to  a  difference  in  degree. 
The  secondary  irritations  in  the  exanthemata  are  more  violent,  more 
constant,  and  consequently  of  more  importance  in  these  diseases 
than  in  typhus.  The  inflammations,  too,  have  (at  least  in  measles 
and  the  ordinary  scarlatina)  more  of  the  sthenic  character ;  and 
the  liability  to  inflammatory  action  seems  to  continue  longer 
after  the  subsidence  of  the  original  disease. 

This  complication  with  visceral  disease  was  not  unknown  to  the 
older  authors,  but  it  is  to  Broussais  that  modern  medicine  owes  the 
most  important  illustrations  of  the  subject ;  and  if  we  leave  aside 
the  conclusions  into  which  his  pure  solidism  led  him,  we  find  a 
mass  of  important  observations  on  the  diseases  in  question. 
After  describing  the  progress  of  a  case  of  measles,  he  observes, 
"  Such  is  the  natural,  or,  more  properly  speaking,  normal  pro- 
gress of  measles,  but  how  many  are  the  chances  that  cause  it  to 
deviate  !  Sometimes  inflammation,  and  the  spasm  consequent 
upon  it,  predominate  in  the  bronchial  tubes,  and  destroy  the 
patient  by  suffocation ;  at  other  times,  the  bronchitis,  which  was 
supposed  to  be  near  a  termination,  involves  the  parenchyma,  and 
is  converted  into  a  pneumonia  or  pleuritis.  In  other  cases, 
particularly  in  adults,  whose  digestive  organs  have  been  long- 
subject  to  irritation,  gastro-enteritis  becomes  the  predominant 
phenomenon,  or  combines  with  the  pulmonary  inflammation  in 
producing  a  fatal  result.  Occasionally  the  irritation  is  trans- 
mitted to  the  encephalon,  and  the  patient  suffers  from  all  the  con- 
sequences of  such  a  metastasis.  Finally,  there  are  circumstances 
in  which  the  inflammation  becomes  chronic  and  apyrexial,  at  one 
time  in  the  air  passages,  where  it  causes  phthisis,  at  others,  in 
the  digestive  tube,  where  it  maintains  a  chronic  inflammation  of 
the  stomach,  small  intestines,  and  colon.  Hence  comes  the 
accredited  opinion  of  the  older  phyiscians,  (who  knew  no  other 
practice   than    the   evacuation   of  the  humours,)   that  measles 


78  BRONCHITIS. 

require,  after   their   disappearance,  the  repeated  use  of  purga- 
tives." 

I  have  quoted  this  passage,  as  it  forcibly  and  truly  describes 
the  circumstances  which  attend  so  many  cases  of  these  eruptive 
diseases,  and  strongly  directs  the  mind  of  the  practitioner  to  the 
state  of  the  viscera.  It  is  to  be  regretted  that  as  yet  the  import- 
ance of  these  considerations  has  not  been  sufficiently  insisted  on 
in  our  schools  of  medicine,  and  that  so  many  practitioners  con- 
tinue to  regard  these  diseases  merely  as  affections  of  the  skin, 
forgetting,  that  as  it  is  by  the  viscera  we  live,  so  it  is  by  them 
we  die.  Almost  all  the  erroneous  practice  in  these  affections  can 
be  traced  to  the  overlooking  of  this  most  essential  point.  Here, 
however,  I  feel  happy  in  bearing  my  testimony  to  the  fact,  that 
among  the  British  systematic  writers  on  medicine,  Dr.  Mackin- 
tosh is  the  only  one  who  has  fully  developed  the  general  patho- 
logy of  the  exanthemata ;  and  his  writings  on  this  subject  must 
be  productive  of  the  most  extensive  and  still  increasing  benefit. 

When  we  consider  the  phenomena  of  the  different  exanthemata, 
we  must  observe,  that  although  there  is  no  constant  relation 
between  their  separate  species,  and  the  affections  of  particular 
viscera;  yet  that,  in  many  cases,  there  is  evidence  of  some 
greater  connexion  with  disease  of  certain  organs  than  with  that  of 
others.  Thus,  with  respect  to  the  pulmonary  system,  its  irrita- 
tions are  more  commonly  met  with  in  measles  and  scarlatina  than 
in  variola  or  erysipelas,  which  seem  more  closely  connected  with  the 
digestive  system.  That  we  may  have  pulmonary  irritations,  occur- 
ring with  these  latter  diseases,  and  abdominal  affections  with  the 
former,  is  fully  admitted  ;  but  still  the  rule  seems  to  hold  good, 
that  the  poisons  of  measles  and  scarlatina,  in  their  operations  on 
the  economy,  fall  more  on  the  respiratory  than  on  the  digestive 
system.  We  find  that  previous  to  the  eruption,  in  almost  all 
cases,  and  in  some,  even  before  any  fever  is  established,  there 
are  signs  of  irritation  of  the  bronchial  mucous  membrane. 
These  often  go  on  increasing  until  the  eruption  makes  its  appear- 
ance ;  when,  as  it  were,  by  the  revulsion  to  the  surface,  a  degree 
of  relief  is  afforded  to  the  pulmonary  system.  Should  the  erup- 
tion be  repelled,  we  see  the  bronchitis  again  lit  up ;  and  even  at 
the  period  when  the  cutaneous  efflorescence  should  naturally 
subside,  there  is  the  greatest  liability  to  dangerous  inflammation 
of  the  chest. 


BRONCHITIS.  79 

An  interesting  question  here  presents  itself:  is  the  inflam- 
mation of  the  mucous  membrane  in  these  diseases  specifically 
different  from  that  in  idiopathic  bronchitis  ?  This  is  a  point 
on  which  anatomy  sheds  no  light,  nor  is  it  probable  that  it  ever 
will.  We  want  a  series  of  observations  on  the  symptoms  and 
history  of  the  pulmonary  irritations  of  the  exanthemata,  as  com- 
pared with  idiopathic  affections,  which  might  throw  great  light 
on  the  subject.  Until  this  is  done,  we  can  only  conjecture. 
But  this  much  may  be  said,  that  while,  on  the  one  hand,  Ave 
meet  with  many  instances  in  which  the  visceral  irritation  is  mild 
and  not  extensive,  so,  on  the  other,  we  find  that  some  of  the 
most  violent  and  intractable  cases  of  bronchitis,  and  its  con- 
secutive pulmonary  irritations,  are  met  with  in  connexion  with 
these  diseases. 

Under  these  circumstances  we  find  intense  bronchial  inflam- 
mation ;  the  combination  of  this  with  pneumonia ;  or,  as  I  have 
witnessed  more  than  once,  pleuritis,  with  a  copious  and  rapid 
sero-purulent  effusion.  We  may  also  have  a  general  development 
of  tubercle,  in  which  case  its  connexion  with  the  inflammatory 
action  is  too  obvious  to  be  overlooked. 

I  have  before  alluded  to  the  differences  in  the  several 
characters  of  the  secondary  irritations  of  the  ordinary  measles 
and  scarlatina,  as  compared  with  those  of  typhus,  and  have  shewn 
that  they  have  more  of  a  sthenic  character.  But  in  one  respect 
they  may  be  said  to  differ  anatomically,  namely,  that  in  these 
affections  there  is  a  much  greater  likelihood  of  the  serous 
membranes  becoming  engaged  than  in  typhus.  Arachnitis, 
pleuritis,  and  peritonitis  are  not  unfrequent ;  a  fact  of  great 
importance  in  our  prognosis  and  treatment,  and  one  of  interest 
in  connexion  with  the  statement  of  Louis,  to  which  I  have 
already  alluded,  when  speaking  of  the  physical  signs  in  the 
bronchitis  of  typhus  fever. 


CHRONIC    SECONDARY   BRONCHITIS. 

In  discussing  this  subject  I  shall  content  myself  with  briefly 
pointing  out  the  most  remarkable  instances  of  bronchial  irritation 
connected  with  those  slower  actions  which  result  from  chronic 
constitutional  disease,  and  then  notice  the  subject  of  the  sym- 


80  BRONCHITIS. 

pathetic  affections  of  the  lung  consequent  upon  abdominal 
irritations. 

I  quite  agree  with  Dr.  Graves  in  regretting  that  this  essential 
question  in  the  pathology  of  bronchitis  should  have  been  so 
much  neglected  by  investigators  on  the  subject.  We  have  seen 
what  an  important  part  the  affections  of  the  bronchial  membrane 
take  in  those  contaminations  of  the  system  which  we  call  fevers  ; 
and  there  can  be  no  doubt,  that  in  many  other  specific  affections 
there  are  corresponding  diseases  of  this  tissue.  Thus,  the  gouty, 
scrofulous,  syphilitic,  and  scorbutic  contaminations,  may,  and  no 
doubt  do,  produce  their  specific  forms  of  bronchial  inflammation. 
And  even  though  as  yet  pathological  anatomy  has  not  revealed 
any  organic  differences  in  these  lesions,  whether  as  compared 
with  the  idiopathic  disease,  or  among  one  another,  yet  that  their 
peculiar  character  is  shewn  in  their  history,  symptoms,  and  the 
result  of  treatment,  every  unprejudiced  and  practical  man  must 
allow. 

Thus,  in  the  gouty  habit  we  see  attacks  of  irritation  in  various 
organs,  among  which  the  bronchial  membrane  may  be  affected, 
and  the  patient  labour  under  a  severe  and  obstinate  cough. 
And  even,  as  has  been  well  remarked,  an  attack  of  bronchitis 
from  cold,  in  the  same  diathesis,  will  often  shew  itself  with  the 
peculiar  characters  of  a  gouty  affection. 

The  gouty  irritations  of  the  lung  occur  under  various  forms 
and  circumstances.  Thus,  cough,  dyspnoea,  and  expectoration 
may  precede  a  fit  of  gout,  and  rapidly  and  completely  subside  on 
its  appearance ;  on  the  other  hand,  these  symptoms  may  follow 
the  subsidence  of  the  arthritic  attack.  A  patient  may  present 
all  the  symptoms  which  have  been  supposed  to  belong  to 
hydrothorax,  but  which  are  really  the  consequence  of  pulmonary 
congestion  and  inflammation,  and  these  shall  alternate  with 
gout.  Or  we  may  see  a  case,  in  ivhich  such  symptoms  having 
been  removed  by  appropriate  treatment,  a  fit  of  gout  has  imme- 
diately appeared.  We  may  further  observe  more  complicated 
cases,  such  as  the  succession  of  epilepsy,  gout,  and  fatal  bron- 
chitis ;  or  inflammation  of  the  trachea,  slight  general  arthritis, 
glandular  enlargements,  gout.  Other  examples  might  be  given, 
but  enough  has  been  stated  to  prove,  that  the  respiratory  system 
may  be  affected,  either  primitively  or  consecutively,  by  the  gouty 
irritation.     Whether  in  such  cases  the  lesion  is  in  any  anato- 


BRONCHITIS.  81 

mical  character  different  from  idiopathic  bronchitis  is  still  to  be 
determined,  but  it  seems  probable,  that  like  other  analogous 
affections,  its  specific  character  will  be  found  more  in  its  mode 
of  invasion  and  amenability  to  certain  remedies,  than  in  its 
anatomical  nature  or  seat.* 

I  shall  next  allude  to  a  form  of  secondary  bronchitis,  which, 
though  as  yet  little  understood,  demands  a  full  and  most  careful 
investigation,  I  mean  a  peculiar  bronchial  irritation,  arising  in 
consequence  of  the  syphilitic  contamination  of  the  system,  a 
disease  which  seems  by  no  means  unfrequent. 

That  the  syphilitic  virus  should  affect  the  viscera,  seems  so 
probable  from  analogy,  that  it  is  strange  how  this  part  of  its 
history  should  have  been  so  long  unexplored.  In  fevers,  in  the 
exanthemata,  in  scrofula,  in  gout,  and  other  constitutional  affec- 
tions, we  see  visceral  diseases  taking  a  most  prominent  part  in 
the  morbid  phenomena  ;  and  that  syphilis  should  constitute  an 
exception  to  a  law  so  general  seems  in  the  highest  degree  impro- 
bable. The  pathologist  has  examined  its  effects  on  the  external 
parts,  and  the  bones,  &c,  but  has  done  little  indeed  in  a  field 
perhaps  equally  important.  His  researches  on  internal  syphilitic 
disease  have  been  crude  and  scanty ;  and  the  affections  of  the 
pharynx,  the  windpipe,  the  rectum,  and  the  genito-urinary  sys- 
tem, are  all  that  have  arrested  his  attention. 

It  seems  to  have  been  believed  by  those  authors  who  have 
opposed  the  doctrine  of  a  syphilitic  virus,  that  the  viscera 
escaped  the  disease.t  "  Nothing,"  says  Broussais,  "  proves 
that  such  a  virus  may  be  preserved  and  reproduced  in  the 
economy,  so  as  to  cause  visceral  inflammations  or  sub-inflam- 
mations.'3 Yet  the  same  author  soon  after  speaks  doubtingly 
on  the  subject,  and  declares,  that  new  researches  and  experiments 
are  necessary.  We  might  suppose,  from  the  general  silence  of 
authors  on  the  subject,  that  these  specific  visceral  irritations 
were  rare,  and  probably  often  confounded  with  idiopathic 
affections.  Yet  the  records  of  medicine  are  not  deficient  in 
examples   of   cures    of  pectoral    and    abdominal    consumptions, 

*  An  interesting  case  in  which  crystals  of  lithic  acid  were  detected  in  the  sputa  of 
a  gouty  patient,  was  published  by  Dr.  J.  "W.  Moore  in  the  Irish  Hospital  Gazette. 
July  15,  1873.     (H.j 

t  "  As  far  as  my  information  goes."  says  Dr.  Walshe  "  the  credit  of  originally 
shewing  that  the  virus  of  syphilis  may  affect  the  bronchial  mucous  membrane 
belongs  to  Drs.  Graves  and  Stokes,  followed  by  Dr.  Munk." 

G 


82  BRONCHITIS. 

presumed  to  be  syphilitic,  by  the  use  of  mercury.  The  opposers 
of  the  doctrine  of  a  virus  refer  the  occurrence  of  such  diseases  to 
the  treatment  as  much  as  to  the  disease,  but  give  a  melancholy 
instance  of  bad  reasoning  and  prejudice,  in  also  attributing  the 
cure  by  mercury  to  a  revulsive  counter-irritation.  Mercury  then, 
according  to  them,  produced  the  disease  which  they  afterwards 
cannot  deny  that  it  cured. 

In  these  diatheses,  or  morbid  constitutional  states,  we  may 
observe  the  occurrence  of  local  disease  under  two  circumstances  : 
in  the  one,  it  seems  to  be  the  immediate  effect  of  the  contami- 
nation, as  we  see  in  the  pustules  of  variola  ;  and  in  the  other, 
we  find  that  in  a  system  already  contaminated,  other  causes 
acting,  a  disease  may  be  developed,  which  is  so  modified  by  the 
constitutional  state  as  to  show  itself  in  some  different  form  from 
its  idiopathic  characters.  Thus,  in  the  scrofulous  or  gouty 
diathesis,  common  exciting  causes  will  produce  inflammations 
of  peculiar  characters,  and  so  it  is  probably  in  the  syphilitic 
state.. 

But  to  come  to  our  subject,  the  syphilitic  poison,  in  its  action 
on  the  viscera,  seems  more  often,  or  at  least  more  prominently, 
to  affect  the  respiratory  system.  Thus,  the  frequency  of 
laryngeal  affections  in  syphilis  has  been  long  admitted,  to  which 
I  shall  again  allude,  in  speaking  of  the  diseases  of  the  windpipe. 
With  respect  to  the  bronchial  system,  we  may  observe  the 
disease  as  an  acute,  or  more  chronic  affection.  In  the  first 
instance,  it  is  analogous  to  the  bronchial  irritations  of  the 
exanthemata,  of  which  I  have  seen  a  few  interesting  examples  ; 
while  in  the  second,  there  is  a  chronic  irritation,  which,  when 
combined  with  the  syphilitic  hectic,  and  with  periostitis  of  the 
chest,  closely  resembles  true  pulmonary  phthisis. 

In  the  first  of  these  cases  I  have  observed,  that  after  a  period 
of  time  from  the  first  contamination,  the  duration  of  which  has 
not  been  determined,  the  patient  falls  into  a  feverish  state,  and 
presents  the  symptoms  and  signs  of  an  irritation  of  the  bronchial 
membrane.  These  having  continued  for  a  few  days,  a  copious 
eruption,  of  a  brownish  red  colour,  makes  its  appearance  on  the 
skin,  and  the  internal  affection  either  altogether  subsides,  or 
becomes  singularly  lessened.  Here  we  see  the  bronchial 
membrane  taking  on  an  action  which  is  peculiar,  and  very  different 
from  its  ordinary  irritations.     There  is  an  inflammation,  only 


BRONCHITIS.  83 

analogous  to  that  of  the  exanthemata,  and  no   doubt  can  exist 
that  it  is  connected  with  the  syphilitic  poison. 

My  friend,  Dr.  Byrne,  whose  situation  as  medical  officer  to  the 
Lock  Hospital,  gives  him  the  greatest  opportunities  of  observation, 
informs  me,  that  he  has,   in  many  instances,  seen  patients,  who 
had  been  formerly  diseased,   and  who    had  come  into  hospital 
either  for  new  sores,   or  for    gonorrhoea,   attacked  with  intense 
bronchitis,  and  fever.     This  attack  would  come  on  suddenly,  and 
the  distress  was  so  great,    that  bleeding  had  to  be  performed. 
The  effect  of  which  was,    that  soon    after   a    copious    eruption, 
often  combining  the  lichenous  and   squamous  forms,  made   its 
appearance,  Avith  complete  relief  of  the  chest.     In  some  of  these 
patients,  on  the   day  before  the  eruption,  the  stethoscopic  signs 
had  been  those  of  the  most  intense  mucous  irritation ;  and  yet, 
when  the   skin  disease  appeared,   the  respiration  became  either 
perfectly  pure,  or  only  mixed  with  an  occasional  rhonchus  in  the 
large  tubes.     The  same  gentleman  has  observed  the  reverse  of 
this :  as   when  a    syphilitic    eruption    has    been    repressed,  the 
bronchial  membrane  has  become  much  engaged,  and  the  patient 
affected    with    general    febrile    symptoms.     These    phenomena 
subsided  after  bleeding  and  mild  diaphoretics,  which  had  the  effect 
of  restoring  the  cutaneous  eruption.     Here  we  have  an  additional 
evidence  in  favour  of  the  analogy  between  this  syphilitic  bronchitis 
and  that  of  the  exanthemata.     No   doubt  the  occurrence  of  an 
idiopathic  bronchial  irritation   might  cause  the  temporary  sus- 
pension of  the  skin  disease,  but  still  the  fact  above  stated  adds 
great  weight  to   the  opinions  which    I   have  advocated.     Other 
medical  friends  have  mentioned  to  me,  that  they  have  observed 
similar  cases  ;  and  I   shall  only  add,  that  the  subject  promises  a 
fair  field  for  pathological  inquiry,  and  practical  improvement. 

The  attention  of  the  profession  has  been  recently  called  to  the 
more  chronic  form  of  the  disease,  by  Dr.  Graves,  in  his  pub- 
lished lectures.  He  remarks,  that  the  possibility  of  syphilis 
attacking  the  pulmonary  system  was  not  unknown  to  the  older 
authors,  but  that  since  it  had  been  placed  by  systematic  writers 
among  the  diseases  of  the  skin,  this  idea  seems  to  be  abandoned 
or  forgotten.  He  entertains  a  firm  conviction,  that  the  syphilitic 
poison  may  affect  the  pulmonary,  as  well  as  the  osseous, 
cutaneous,  or  mucous  tissues,  a  point  of  doctrine  which  I  look 
upon  to  be  completely  established.     Dr.  Graves'  observations  on 

g  2 


84  BRONCHITIS. 

the  diagnosis  are  too  important  to  be  omitted  here.  He  says, 
"  If  the  patient's  sufferings  have  commenced  at  the  period  of 
time,  after  primary  ^sores  on  the  genitals,  when  secondaiy 
symptoms  usually  make  their  appearance  ;  if  some  of  his  com- 
plaints are  clearly  traceable  to  this  source ;  if,  along  with 
debility,  night-sweats,  emaciation,  nervous  irritability,  and 
broken  rest  at  night,  we  find  cough  ;  and  if  this  group  of  symp- 
toms have  associated  themselves  with  others,  evidently  syphilitic, 
such  as  periostitis,  sore  throat,  and  eruption  on  the  skin,  then 
we  may,  with  confidence,  refer  all  to  the  same  origin,  and  may  look 
upon  the  patient  as  labouring  under  a  syphilitic  cachexy,  affecting 
the  lungs  as  well  as  other  parts.  In  forming  this  diagnosis 
much  caution  and  care  are  necessary,  and  we  must  not  draw  our 
conclusion  until  we  have  repeatedly  examined  the  chest  by  means 
of  auscultation  and  percussion ;  if  these  fail  to  detect  any 
tangible  signs  of  tubercles,  we  may  then  proceed  to  act  upon  our 
decision  with  greater  confidence,  and  may  advise  a  sufficient  but 
cautious  use  of  mercury.  Under  such  circumstances  it  is  most 
pleasing  to  observe  the  speedy  improvement  in  the  patient's 
looks  and  symptoms  ;  the  fever,  night-sweats,  and  watchfulness 
diminish,  he  begins  to  get  flesh  and  strength,  and,  with  the 
symptoms  of  lues,  the  cough  and  pectoral  affection  disappear. 
I  am  not  prepared  to  say  which  of  the  pulmonary  tissues  is  most 
usually  attacked  by  the  venereal  poison,  but  I  believe  that  it 
chiefly  tends  to  the  bronchial  mucous  membrane,  although,  like 
other  animal  poisons,  e.g.,  those  of  measles  and  scarlatina,  it 
may  also  occasionally  produce  pneumonia." 

To  these  valuable  observations  it  is  unnecessary  for  me  to 
express  my  assent ;  but  I  cannot  sufficiently  impress  the  import- 
ance of  making  a  careful  physical  examination  of  the  chest.  The 
great  frequency  of  phthisis,  and  the  liability  to  its  supervention 
in  the  strumous  habit,  when  syphilis  and  mercury  combine  to 
undermine  the  constitution,  are  circumstances  never  to  be  lost 
sight  of.  To  this  point  I  shall  return  when  I  describe  phthisis, 
and  here  only  remark,  that  the  principal  ground  on  which  I  rely 
for  the  diagnosis  between  this  syphilitic  irritation  of  the  bronchi, 
and  tubercle,  is  the  want  of  aecordance  betiveen  the  physical  sign* 
and  the  constitutional  symj)toms.  The  latter  are  often  those  of 
phthisis  in  an  advanced  stage,  while  the  former  point  out  no 
amount   of  disease   at   all  commensurate  with   the  symptoms. 


BRONCHITIS.  85 

The  value  of  this  is  at  once  seen  when  we  recollect,  that  in  almost 
all  cases  of  true  phthisis,  which  have  gone  on  to  the  production 
of  decided  hectic  and  emaciation,  there  are  manifest  physical 
signs  of  tubercle. 

In  concluding  my  observations  on  the  secondary  constitutional 
irritations  of  the  bronchial  membrane,  I  feel  that  I  have  by  no 
means  done  justice  to  this  most  important  subject.  Thus  I  have 
not  dwelt  on  the  connexion  of  bronchitis  with  scrofula  and  scor- 
butus, as  alluded  to  by  Dr.  Graves,  or  with  erysipelas,  which  has 
been  so  strongly  dwelt  on  by  Dr.  Mackintosh.  But  if  what  I 
have  said  be  sufficient  to  draw  attention  to  the  general  history 
and  pathology  of  the  constitutional  affections  of  the  lung,  I  shall 
be  satisfied,  and  conclude  by  pointing  out  what  seem  to  me  to  be 
the  desiderata  of  the  subject.     These  are — 

First.  To  determine  what  are  the  tissues  engaged  in  each  of 
these  cases. 

Second.  To  ascertain  whether  any  anatomical  difference  can  be 
shewn  between  these  diseases  and  the  idiopathic  bronchitis ;  and 

Third.  To  determine  how  far  the  ordinary  treatment  of  bron- 
chitis should  be  modified  according  to  its  constitutional  exciting 
cause. 

Sympathetic  Cough. — Under  this  head  I  shall  notice  two 
principal  forms  of  this  affection,  in  both  of  which  the  primary 
irritation  resides  in  the  digestive  system.  These  are,  first,  the 
cough  which  results  from  gastric  inflammation,  and  next  that 
from  intestinal  worms. 

Much,  if  not  all,  of  our  knowledge  on  the  first  of  these  varieties 
is  owing  to  Broussais,  who  has  so  successfully  developed  the 
general  subject  of  sympathies,  and  has  shewn  how  by  their 
preponderance  a  disease  of  the  digestive,  respiratory,  circulating, 
or  nervous  systems  may  be  simulated.  Among  these  morbid 
sympathies,  one  of  the  most  remarkable  is  that  under  considera- 
tion ;  for  an  acute  or  sub-acute  gastritis  may  produce  cough, 
and  if  this  be  violent  or  long-continued,  actual  inflammation  of 
the  lung. 

Before  giving  the  results  of  my  experience  on  this  subject,  I 
shall  examine  some  of  M.  Broussais's  cases,  which  he  has 
published  in  his  Phlegmasies  Chroniques.  In  the  first  case,  the 
patient  had  been  exposed  to  great  mental  and  bodily  fatigue,  and 
for  some  time  had  used  red  wine  for  his  breakfast  in  place  of 


86  BRONCHITIS. 

coffee.  He  became  attacked  with  fever,  and  in  the  course  of  a 
few  days  complained  of  severe  pain  in  the  chest,  and  epigastric 
constriction.  There  was  a  constant  desire  to  cough,  but  the  pain 
prevented  its  indulgence.  On  the  eighth  day,  the  fits  of  coughing 
were  violent  and  unceasing,  and  the  epigastric  pain  worse.  Some 
leeches  were  applied  to  the  epigastrium,  which  removed  the 
pectoral  symptoms  almost  completely,  but  in  two  days  the  fever 
was  again  lit  up,  and  the  cough  reappeared.  Violent  symptoms 
now  set  in,  unconsciousness,  sighing,  stupor  alternating  with 
restlessness,  and  fruitless  attempts  to  cough.  The  patient  died 
on  the  eighteenth  day. 

On  dissection  the  lungs  were  perfectly  healthy,  but  the  stomach 
was  found  greatly  contracted,  and  its  mucous  membrane  of  so 
deep  and  livid  a  colour  as  in  many  points  to  be  almost  black. 
The  intestines  were  also  contracted,  and  with  great  vascularity 
of  the  mucous  membrane. 

The  next  case  detailed  by  this  author  is  not  clearly  illustrative 
of  the  point  in  question,  as  it  seems  one  of  those  constitutional 
affections,  marked  by  diffuse  cellular  inflammation,  and  the 
occurrence  of  inflammatory  action  in  many  of  the  viscera. 

In  his  third  case  M.  Broussais  gives  the  history  of  a  young 
man  who  was  attacked  with  bilious  derangement,  and  distressing 
cough ;  on  the  sixth  day  he  had  high  fever,  dyspnoea,  redness  of 
the  malar  eminences,  and  a  violent  cough,  not  in  fits,  but  in 
single  shocks  at  each  inspiration.  This  caused  great  pain,  and 
an  expectoration  of  some  frothy  and  bloody  mucus.  He  had  no 
fixed  pain,  but  the  anterior  portion  of  his  chest  was  very  tender. 
There  was  great  anxiety,  and  the  patient  uttered  plaintive  cries, 
and  complained  of  extremely  disagreeable  sensations  in  the 
mouth. 

The  patient  was  twice  freely  bled,  and  a  blister  applied  to  the 
thorax,  but  although  the  vascular  action  was  reduced,  the  other 
symptoms  continued,  and  he  died  on  the  sixteenth  day  of  his 
illness. 

On  dissection  the  lungs  were  found  engorged,  but  not  indu- 
rated; the  stomach  was  intensely  inflamed. 

From  these  cases,  as  well  from  others,  which  are  not  given, 
M.  Broussais  gives  the  following  as  the  characters  of  this  gastric 
cough. 

It  comes  on  with  violent  shocks,  (a  secousses),  which  occur  at 


BRONCHITIS.  87 

each  inspiration,  and  those  violent  paroxysms,  which  would  pro- 
duce swelling  and  lividity  of  the  countenance,  are  never  observed. 
It  is  more  alleviated  by  cooling  and  slightly  acidulated  drinks 
than  by  bleeding ;  and  lastly,  with  reference  to  the  expectoration, 
it  may  be  present  or  absent  according  to  the  degree  of  the  bron- 
chial irritation,  but  its  excretion  may  be  suspended  by  means 
calculated  to  relieve  gastritis,  and  this  suspension  is  advantageous 
to  the  patient. 

I  shall  now  state  the  results  of  my  experience  on  this  interest- 
ing subject. 

As  the  sympathetic  irritations  of  gastritis  vary  according  to  the 
intensity  of  the  disease  and  the  local  and  general  susceptibility  of 
the  patient,  it  is  obvious  that  they  will  shew  themselves  under 
different  characters  in  different  individuals  ;  and  while,  in  the 
one  case  there  may  be  high  excitement  of  the  cerebrospinal,  in 
another  the  same  may  occur  with  respect  to  the  respiratory  or 
circulatory  systems.  Of  the  cause  of  these  peculiar  predisposi- 
tions we  are  at  present  ignorant. 

The  nature  of  these  sympathetic  affections  seems  to  be  that  they 
are  at  first  only  lesions  of  function,  but  that  when  violent,  or 
long-continued,  they  become  complicated  with  organic  change ; 
or,  in  the  language  of  Andral,  the  lesion  of  innervation  is  followed 
by  that  of  circulation,  nutrition,  and  secretion  :  under  these  cir- 
cumstances, cough,  or  palpitation,  or  cerebral  symptoms,  which 
were  at  first  only  sympathetic  and  uncomplicated  with  organic 
change  in  the  suffering  organ,  may  become  combined  with  actual 
disease,  the  violence,  or  long-continuance  of  the  symptom,  being 
the  conditions  for  this  modification. 

Now,  with  respect  to  the  lungs,  we  find  that  their  functions 
may  be  injured,  and  a  sympathetic  cough  excited,  either,  by  an 
acute  or  chronic  disease  of  the  gastro-intestinal  surface.  In  the 
first  case  the  symptom  is  generally  more  violent ;  and,  from  the 
frequent  existence  of  fever,  much  more  likely  to  become  com- 
plicated with  pulmonary  inflammation.  For  it  seems  certain, 
that  the  supervention  of  inflammation  in  mere  functional  lesion 
is  much  more  probable  when  a  febrile  state  exists. 

We  may  see  a  patient  with  the  most  aggravated  cough,  yet 
with  a  chest  clear  on  percussion,  and  the  murmur  either  pure, 
or  mixed  here  and  there  with  a  little  sonorous  or  mucous  rattle. 
This  want  of  proportion   between  the  physical  signs  and  the 


88  BRONCHITIS. 

functional  lesion  leads  us  at  once  to  the  principle  of  diagnosis, 
which  may  be  announced  to  be,  That  when  distressing  pectoral 
symptoms  exist,  the  morbid  physical  signs  being  either  absent,  or 
if  present,  yet  revealing  an  amount  of  disease  too  slight  to  account 
for  the  symptoms,  ivc  may  make  the  diagnosis  of  sympathetic 
irritation. 

Here  the  period  of  duration  of  symptoms  will  often  be  an 
important  element  in  deciding  the  question ;  for  it  is  plain,  that 
the  longer  the  symptoms  have  lasted,  without  corresponding 
physical  signs,  the  less  is  the  chance  of  acutal  disease  of  the 
lung.  If  a  patient  has  had  fever,  cough,  and  hurried  breathing, 
for  three  or  four  days,  and  that  even  then  no  commensurate 
signs  exist,  we  may  be  tolerably  sure  that  there  is  no  actual  or 
progressive  inflammation,  for  if  there  were,  it  would  have  by 
that  time,  at  least,  fully  manifested  itself. 

The  negative  results  of  the  examination  in  this  case  are  of  the 
greatest  value ;  indeed  a  more  beautiful  and  practical  application 
of  the  stethoscope  can  hardly  be  mentioned.  From  the  similarity 
of  the  symptoms  the  disease  is  constantly  mistaken  for  bronchitis 
and  pneumonia.  The  characteristic  symptoms  of  gastritis  are 
overlooked,  and  its  sympathetic  relations  alone  attended  to.  In 
consequence  of  this  error  in  diagnosis  the  most  fatal  mistakes 
are  committed.  Patients  labouring  under  gastritis,  or  gastro- 
enteritis, have  been  largely  bled,  and  thus  thrown  into  a  typhoid 
state ;  or  the  abdominal  inflammation  has  been  exasperated 
by  the  use  of  remedies  intended  to  relieve  the  pulmonary 
irritation. 

In  making  this  diagnosis  the  following  are  the  principal  points 
which  must  be  attended  to  in  order  to  avoid  error  : 

First.  Whether  the  symptoms  or  signs  of  incipient  tubercle 
are  absent. 

Second.  Whether  there  is  reason  to  suspect  disease  of  the 
larynx  or  trachea. 

Third.  Whether  the  uvula  be  or  be  not  relaxed. 

Fourth..  Whether  the  patient  (if  a  female)  be  subject  to 
hysteria. 

I  have  given  the  above  cases,  as  they  constitute  the  principal 
sources  of  phenomena  similar  to  those  in  the  sympathetic  cough 
of  gastritis,  or  of  worms.  If  the  result  of  the  investigation  is 
against  the    existence  of  any  of  these  causes,  we  may  safely, 


•V 


BRONCHITIS.  89 

indeed,  conclude  upon  the  abdominal  origin  of  the  cough ;  and 
it  will  not  be  difficult  to  decide  between  gastritis  and  the  irri- 
tation of  worms. 

I  have  observed  this  sympathetic  disturbance  of  the  lung 
from  gastric  irritation  or  inflammation,  more  often  as  an  acute 
than  a  chronic  disease.  And  in  all  these  patients  the  cough 
was  relieved,  and  the  pectoral  distress  removed,  by  treatment 
directed  to  the  stomach.  In  most  of  the  cases  which  I  have 
seen,  the  disease  had  not  been  modified  by  any  previous  treat- 
ment, and  these  yielded  to  the  usual  means  for  the  cure  of 
gastritis.  In  others,  the  efforts  of  the  practitioner  had  been 
entirely  directed  to  the  lung,  and  general  bleeding  performed. 
Leeches,  cupping,  or  counter-irritation  had  been  used  to  the 
chest,  and  the  ordinary  internal  remedies  successively  and 
unavailingly  employed.  Under  these  circumstances,  the  omis- 
sion of  all  internal  stimulants,  the  application  of  leeches  to  the 
epigastrium,  the  use  of  iced  water,  and  a  bland  diet,  have  com- 
pletely and  rapidly  removed  a  cough  which  had  resisted  the 
means,  which,  in  the  primary  catarrh,  would  have,  in  all  pro- 
bability, succeeded. 

Lastly,  I  have  observed,  that  in  cases  of  gastritis  with  sympa- 
thetic cough,  and  acceleration  of  breathing,  which  had  done 
well,  an  excess  in  diet,  during  convalescence,  brought  back  the 
original  symptoms  ;  and  these  again  yielded,  in  some  cases, 
merely  to  a  change  in  regimen,  while  in  others,  more  decided 
measures  had  to  be  employed. 

But  the  discovery  of  a  sympathetic  cough  should  not  put  the 
practitioner  off  his  guard  with  respect  to  the  chest,  for  so  long  as 
this  continues,  the  lungs  will  be  liable  to  organic  disease.  In  an 
acute  case,  he  must,  from  day  to  day,  examine  the  chest,  so  as  to 
assure  himself  that  the  change  from  functional  to  organic  disease 
has  not  occurred. 

I  have  seen  this  change  to  occur  so  rapidly  that  decided  dulness 
has  been  produced  in  a  single  day.  Here  the  importance  of 
physical  diagnosis  is  obvious,  for  there  is  often  no  characteristic 
change  in  the  symptoms. 

In  the  chronic  irritations  there  is  reason,  among  other  lesions, 
to  suspect  the  growth  of  pulmonary  tubercle. 

I  shall  lastly  make  some  observations  on  the  sympathetic 
cough,  which  occurs  from  the  irritation  of  intestinal  worms,  and 


90  BRONCHITIS. 

which,  although  not  a  constant,  is  hy  no  means  an  unfrequent 
symptom.  Thus,  most  of  the  systematic  works  contain  examples 
of  cough  apparently  connected  with  this  affection,  inasmuch  as  it 
resisted  the  ordinary  means  directed  to  the  chest,  and  subsided 
under  the  use  of  anthelmintics.  But  the  subject  has  not  been 
investigated  with  sufficient  attention,  and  I  regret  that  in  this 
place  I  can  only  give  the  result  of  my  passing  observations, 
rather  than  that  of  any  connected  inquiries  on  the  point. 

This  affection  seems  to  exist  under  two  principal  forms  ;  in  one 
of  which  there  is  decided  inflammation  or  irritation  of  the  mucous 
membrane,  while  in  the  other,  this  is  either  absent,  or  if  pre- 
sent, seems  so  inadequate  for  the  production  of  the  pulmonary 
distress,  that  we  cannot  help  looking  upon  it  as  accidental,  and 
probably  consecutive  to  the  functional  disturbance.  Under  the 
latter  circumstances  there  may  be  a  great  variety  in  the  cough,  but 
in  general  its  character  is  more  or  less  spasmodic,  occurring  in 
fits,  or  it  may  be  solitary,  hard,  and  loud ;  and  it  is  generally 
either  dry,  or  with  a  very  scanty  mucous  expectoration.  This 
cough  may  co-exist  with  the  other  symptoms  of  worms,  or  may 
be  the  prominent  indication  ;  and  in  most  cases  that  I  have  seen, 
it  occurred  without  fever. 

Such  cases  are  often  mistaken,  and  the  patient  injured  by 
a  variety  of  ineffective  and  violent  treatment ;  and  until  the 
history  of  the  disease  is  more  accurately  determined,  such 
errors  will  be  unavoidable.  We  may  enumerate,  however,  certain 
circumstances,  which  should  lead  us  to  suspect  the  true  cause 
of  the  cough.     These  are  : 

First.  Its  character,  the  cough,  whether  it  be  laryngeal  or 
pulmonary,  being  generally  spasmodic,  often  violent,  and  almost 
always  dry. 

Second.  The  absence  of  physical  signs  of  pulmonary  disease ; 
or  if  they  be  present,  their  want  of  proportion  to  the  symptoms. 
In  this  investigation  both  the  active  and  passive  signs  must  be 
carefully  examined.  It  is  obvious  that  the  longer  this  want  of 
accordance  between  the  physical  signs  and  functional  lesion  has 
existed,  the  greater  will  be  the  probability  that  the  cough  does 
not  proceed  from  primary  irritation  of  the  lung. 

Third.  The  absence  of  symptoms  of  laryngitis,  or  organic 
disease  in  the  vicinity  of  the  trachea. 

Fourth.  The  healthy  state  of  the  pharynx. 


BRONCHITIS.  91 

Fifth.  The  failure  of  treatment  directed  to  the  chest,  whether 
of  an  antiphlogistic  or  antispasmodic  nature. 

The  combination  of  these  circumstances  in  a  young  person, 
and  particularly  one  in  whom,  from  other  considerations,  we 
might  suspect  worms,  should  lead  us  strongly  to  the  belief  in 
their  existence.  If  the  patient  be  a  female  we  should  carefully 
examine  whether  she  has  been  of  an  hysterical  habit,  or  whether 
any  symptoms  of  hysteria  accompany  the  cough  ;  for  although 
this  protean  disease  may  itself  proceed  from  worms,  yet  this  is 
comparatively  rare  ;  so  that  the  combination  of  hysterical  symp- 
toms with  the  cough  would  tend  to  invalidate  the  diagnosis. 

But  in  the  first  variety  there  is  such  an  amount  of  mucous 
irritation,  as  to  give  a  character  to  the  disease  quite  distinct 
from  the  last.  I  have  observed  this  sympathetic  bronchitis 
principally  in  children ;  and  have  found  that  it  was,  in  some 
cases,  a  continued,  while  in  others  it  shewed  itself  as  a  dis- 
tinctlv  remittent  inflammation. 

In  the  first  case  a  decided  bronchitis  may  be  established,  which 
may  go  on  to  the  production  of  parenchymatous  disease  ;  and  in 
this  way  I  have  seen  it  to  induce  chronic  pneumonia  and 
emphysema  of  the  lung.  In  several  cases,  too,  I  think  I  have 
been  able  to  trace  the  occurrence  of  phthisis  to  this  cause.  This 
form  of  pulmonary  irritation  from  worms  seems,  however,  the 
rarest ;  that  which  I  am  about  to  describe  appears  much  more 
common. 

It  is  now  several  years  since  I  first  observed  the  existence  of 
this  remittent  irritation  of  the  lung,  and  connected  it  with  the 
existence  of  intestinal  irritation.  The  following  case  will  give  a 
good  idea  of  its  characters. 

A  child  of  a  lymphatic  constitution  had  laboured  for  some  time 
under  a  severe  cough,  with  frothy  mucous  expectoration,  which 
was  always  worse  at  night,  when  a  violent  exacerbation  came  on, 
accompanied  with  great  dyspnoea,  wheezing,  restlessness,  and 
high  fever.  These  exacerbations  had  of  late  become  better 
marked.  After  his  admission  into  hospital  I  found  that  there 
were  the  greatest  differences  in  the  stethoscopic  signs,  according 
to  the  period  when  the  examination  was  performed.  If  the 
chest  was  examined  at  night,  when  the  constitutional  and 
local  symptoms  were  severe,  the  most  intense  sonorous  rale 
was  audible  over  the  entire  chest,  so  as  to  obscure  all  vesicular 


92  BRONCHITIS. 

respiration  ;  but  as  the  day  advanced,  and  the  fever  sub- 
sided, this  phenomenon  also  disappeared,  leaving  the  respira- 
tory murmur  almost  free.  When  the  child  was  seen  in  the 
afternoon  he  was  quiet  and  cheerful,  and  appeared  free  from  all 
pulmonary  disease  ;  but  as  night  approached  the  symptoms  and 
physical  signs  would  return,  and  for  a  period  of  twelve  hours  or 
upwards  the  stethoscope  indicated  the  most  acute  bronchial 
inflammation.  These  symptoms  continued  for  many  days,  during 
which  the  ordinary  treatment  for  bronchitis  was  carried  into  the 
fullest  effect,  but  without  the  slightest  success.  At  this  time  an 
accidental  circumstance  led  me  to  take  a  different  view  of  the 
case  ;  the  belly  had  become  swollen  and  tympanitic,  and  to  relieve 
this  condition  I  administered  a  dose  of  castor  oil  and  turpentine, 
which  was  followed  by  the  evacuation  of  a  number  of  small  thread 
worms  (oxyuris  vermicularis) :  that  night  the  breathing  was  less 
difficult,  and  the  sonorous  rale  not  so  intense  as  previously.  The 
nature  of  the  case  was  now  more  evident,  and  reflecting  on  the 
failure  of  our  former  treatment,  I  thought  it  probable  that  the 
case  was  really  one  of  worm  fever,  with  a  sympathetic  bronchitis 
occurring  at  each  exacerbation.  Under  these  circumstances,  I 
determined  on  following  up  the  anthelmintic  plan,  and  the 
turpentine  having  produced  too  severe  a  purging,  with  prolapsus 
ani,  the  syrup  of  cowhage,  alternately  with  small  doses  of  castor 
oil,  was  substituted.  He  continued  to  pass  the  worms  in  enor- 
mous quantities,  and  each  morning  the  bronchitic  rales  were  less 
and  less  evident.  In  about  twelve  days  the  symptoms  and  signs, 
which  from  their  severity  had  threatened  the  life  of  the  patient, 
had  completely  disappeared,  leaving  the  respiratory  murmur 
perfectly  natural. 

Since  the  occurrence  of  this  case  I  have  seen  many  others  pre- 
senting the  same  phenomena,  though  not  in  so  violent  a  degree ; 
and  in  several  of  them  the  remittence  of  the  bronchial  irritation 
has  been  a  most  important  element  in  the  discovery  of  the 
nature  of  the  disease. 

There  is  lastly  one  remark  to  be  made,  which  applies  to  all 
these  forms  of  bronchial  irritation,  namely,  that  the  more  severe 
be  the  sympathetic  affection,  the  less  the  likelihood  of  our  finding 
the  usual  symptoms  of  gastritis  in  the  one  case,  or  of  worms  in 
the  intestines  in  the  other.  This  is  merely  an  illustration  of 
one  of  the  most  important  and  extensively  applicable  laws  in 


BRONCHITIS.  93 

pathology ;  that  when  the  sympathetic  affections  of  any  local 
irritation  become  prominent  and  severe,  the  proper  or  usual 
symptoms  are  proportionally  diminished  or  obscured.  Their 
absence,  then,  in  such  a  case,  does  not  necessarily  imply  the 
absence  of  the  disease,  which  may  be  present,  but  shew  itself  by 
other  functional  lesions. 

Having  now  examined  into  the  symptoms  and  physical  signs 
of  the  simple  bronchitis,  and  taken  a  sketch  of  it  in  its  secondary 
forms,  I  should  proceed  to  examine  into  some  of  the  more 
remarkable  consequences  of  this  lesion,  such  as  the  obliteration 
of  the  tubes,  their  opposite  condition,  or  dilatation,  and  lastly, 
the  dilatation  of  the  air  cells.  But  as  these  lesions  may  be 
described  separately,  and  as  they  are  peculiar  results,  I  shall 
reserve  their  consideration  until  we  have  examined  into  the 
treatment  of  the  disease  itself. 


TREATMENT  OF   BRONCHITIS. 

In  discussing  the  treatment  of  bronchitis,  we  shall  first  handle 
that  of  the  simple  and  mild  form,  which  is  commonly  met  with 
about  the  period  of  the  first  dentition  of  children.  I  have  already 
stated  my  opinion  that  this  is  not  a  primary  disease,  but  rather 
secondary  to  the  constitutional  disturbance  of  dentition.  Yet  as 
the  treatment  of  the  bronchitis  scarcely  involves  the  determination 
of  this  question,  I  shall  speak  of  it  here.  I  have  already  described 
the  symptoms  of  this  affection,  and  have  only  to  add,  that  on 
percussion  the  chest  sounds  clear,  and  that  the  wheezing  rales, 
of  various  intensity,  mixed  with  puerile  respiration,  may  be  heard  ; 
these  rales  are  sometimes  partial,  in  others  more  general,  and 
often  disappear  for  a  time,  although  the  constitutional  symptoms 
continue. 

In  the  treatment  of  this  affection  the  physician  should  first 
satisfy  himself  as  to  the  existence  or  absence  of  fever  ;  for  if  this 
be  absent  his  apprehensions  need  not  be  much  excited,  and  milder 
treatment  will  suffice. 

In  the  apyrexial  form  our  first  step  is  to  have  the  gums  freely 
and  completely  divided.  If  it  seem  probable  that  more  than 
one  tooth  will  soon  appear,  the  incision  should  have  a  corres- 
ponding extent,  by  which  the  chances  of  subsequent  attacks  will 
be   lessened.     Objections  have  been  made  to  this  operation,  in 


94  BRONCHITIS. 

consequence  of  the  danger  of  haemorrhage  ;  yet  this  must  he  a 
very  rare  occurrence.  I  have  never  myself  witnessed  it,  though  I 
have  seen  the  operation  performed  hundreds  of  times.  It  will, 
however,  be  advisable  that  the  child's  mouth  be  examined  at 
short  intervals  of  time,  after  the  operation,  so  as  to  detect  any 
haemorrhage,  should  it  occur.  The  child  should  be  restricted  to 
the  use  of  breast  milk,  and  take  some  of  the  hydrargyrus  c.  creta, 
with  rhubarb,  followed  by  a  little  castor  oil,  if  necessary.  These 
measures  having  been  premised,  we  then  find  that  the  exhibition 
of  ipecacuan  in  minute  doses,  has  an  excellent  effect.  I  direct  a 
grain  of  ipecacuan  with  twenty-four  of  sugar,  to  be  divided  into 
eight  parts,  one  of  them  to  be  given  every  hour;  this  remedy  will, 
in  a  few  days,  generally  effect  a  cure.  In  cases  where  the  cough 
is  troublesome,  and  the  child  restless,  I  have  seen  great  advantage 
from  the  exhibition  of  a  grain,  or  a  grain  and  half  of  Dover's 
powder,  and  the  same  of  James's  powder,  at  bed-time ;  this  I 
have  constantly  given  with  the  greatest  safety. 

But  we  meet  with  bronchitis  in  the  infant  under  a  much  more 
severe  form,  where  it  is  accompanied  with  fever  and  with  the 
greatest  danger  to  life.  This  disease  is  most  commonly  met 
with  in  children  who  are  kept  within  doors  for  months  from  their 
birth,  from  which  an  extreme  susceptibility  to  bronchial  irritation 
is  created.  The  necessity  and  the  safety  of  bringing  the  young 
infant  into  the  open  air,  in  the  course  of  a  few  days  after  its  birth, 
is  not  sufficiently  known,  and  many  lives  are  thus  sacrificed  to 
an  absurd,  ignorant,  and  destructive  prejudice.  In  such  cases 
we  find  the  child  fretful,  and  with  an  anxious  expression  of 
countenance.  The  face  is  often  swelled  and  livid ;  the  breathing 
is  hurried  and  high ;  the  cough  often  frequent ;  the  respiration 
wheezing ;  the  skin  hot :  and  the  pulse  full  and  strong.  In 
some  cases  the  digestive  system  is  deranged,  and  the  child 
labours  under  thirst,  vomiting,  or  diarrhoea  ;  while  in  others  these 
s.ymptoms  are  absent,  and  the  case  may  be  looked  upon  as  simple 
pulmonary  irritation,  with  sympathetic  fever.  We  often  observe 
that  the  child  has  great  difficulty  in  sucking,  a  circumstance 
explicable  by  the  dyspnoea  which  forces  it  to  let  go  the  nipple, 
and  to  inhale  by  the  mouth.  In  some  of  these  cases  the 
schneiderian  membrane  is  irritated,  so  that  the  breathing  through 
the  nose  cannot  be  effected  by  the  patient. 

In  the  treatment  of  such  a  case,  the  first  consideration  must 


BRONCHITIS.  95 

be  the  employment  of  bloodletting.  When  the  disease  occurs  in 
a  robust  child,  and  particularly  when  it  has  passed  the  age  of  a 
year,  it  will  be  often  proper  to  bleed  both  generally  and  locally. 
Blood  may  be  taken  from  the  arm,  the  back  of  the  hand,  or  the 
jugular  vein ;  but  we  are  not  to  look  upon  this  remedy  otherwise 
than  as  a  preparative  for  local  bleeding,  for  this  seems  to  be  the 
most  important  remedy  we  can  have  recourse  to. 

We  almost  always  find  that  after  the  leeching  the  child's 
breathing  becomes  easier,  the  face  less  swelled,  and  the  skin 
cooler ;  and  I  have  frequently  observed  the  physical  signs  of 
bronchitis  to  be  distinctly  modified  immediately  after  the  opera- 
tion. 

The  next  thing  we  have  to  consider  is  the  use  of  internal 
remedies  ;  the  two  principal  of  which  are  the  tartrate  of  antimony, 
and  the  combination  of  calomel  and  ipecacuan.  With  respect  to 
the  relative  advantages  of  these,  I  have  little  doubt  that  in  simple 
bronchitis,  and  where  the  inflammatory  symptoms  are  high,  the 
first  is  the  most  important.  Indeed  there  is  no  remedy  that 
possesses  such  a  decided  power  over  acute  bronchitis  as  this.  It 
may  be  administered  in  small  or  in  the  larger  doses,  according  to 
circumstances,  but  success  will  depend  on  the  proper  selection  of 
the  case.  If  the  disease  be  simple,  and  in  particular  free  from 
any  gastric  complication,  if  it  be  in  the  early  stages,  before  much 
secretion  has  taken  place,  and  if  bloodletting  has  been  premised, 
then,  indeed,  we  may  often  observe  an  heroic  action.  The 
remedy  may  be  persevered  in  for  two,  three,  or  four  days, 
according  to  circumstances,  and  should,  in  general,  be  omitted 
gradually. 

As  the  principles  of  treatment  of  the  second,  or  secretive  stage 
of  the  disease  in  children,  are  the  same  as  those  of  a  similar 
condition  in  the  adult,  we  shall  omit  their  mention  in  this  place, 
merely  observing,  that  in  the  employment  of  blisters,  we  must 
use  the  greatest  caution ;  that  they  should  almost  never  be 
applied  in  the  first  instance,  and  that  their  efficacy  will  be  always 
insured  and  increased  by  the  previous  employment  of  blood- 
letting, and  the  exhibition  either  of  the  tartrate  of  antimony,  or 
the  combination  of  calomel  and  ipecacuan. 

Treatment  of  Bronchitis  in  the  Adult.— In  describing 
the  treatment  of  any  disease  it  is  obvious,  that  to  lay  down  a  plan 
applicable  to  all  cases  is  impossible  ;  all  that  we  can  do  is  to 


96  BRONCHITIS. 

inculcate  the  mode  of  treatment  which  experience  has  shown  to 
be  adapted  to  the  majority  of  cases.  This  may  serve  as  a 
landmark,  from  which  in  practice  we  may  deviate,  according  to 
circumstances.  Thus,  although  the  general  principle  be  the 
same,  its  application  must  vary  in  the  young  and  the  robust,  in 
the  old  and  weakly  subject,  or  when  the  disease  is  complicated 
with  some  acute  or  chronic  affection  of  the  lung  or  other  parts. 
Let  us  for  the  standard,  take  the  inflammatory  form  of  the 
disease ;  occurring  in  a  young  and  robust  man,  at  an  early  period, 
and  before  the  affection  has  been  modified  by  treatment.  This 
.1.  is  a  case  which  often  demands  the  use  of  the  lancet;  and  here, 
as  in  inflammatory  affections  of  the  digestive  tube,  we  bleed  with 
the  view  of  reducing  the  general  fever,  and  preparing  the  patient 
for  local  treatment ;  and  by  diminishing  the  congestion  of  the 
lung,  we  diminish  the  chance  of  pneumonic  complication.  It 
must  always  be  recollected,  however,  that  by  general  bleeding  we 
seldom  succeed  in  cutting  short  an  inflammation  of  a  mucous 
tissue  ;  and  hence  it  is,  that  to  other  means  we  must  look  for  the 
reduction  and  removal  of  the  disease.* 

It  will  always  be  advisable  to  empty  the  patient's  bowels  as 
speedily  as  possible,  so  as  to  allow  the  free  descent  of  the  dia- 
phragm. I  have  seen  some  cases,  in  which  the  emplo}7ment  of 
judicious  means,  directed  to  the  chest,  totally  failed  in  giving 
relief  until  this  measure  was  adopted.  But  the  remedy  which 
will  least  often  disappoint  the  practitioner  is  local  bleeding,  which 
should  scarcely  ever  be  omitted.  There  can  be  no  doubt,  that 
the  local  detraction  of  blood  has  a  more  powerful  influence  on 
the  disease  than  the  general.  Its  efficacy,  however,  will  be 
enhanced  by  being  preceded  by  general  bloodletting.  In  severe 
cases  the  patient  should  be  cupped  under  the  clavicles,  or  between 
the  scapulas,  or  a  number  of  leeches  may  be  applied  under  the 
clavicles,  or  into  the  axillae.  As  a  general  rule  it  may  be  stated, 
that  local  depletion  will  be  more  advantageous  when  exercised 
over  the  upper  than  the  lower  parts  of  the  chest.  It  is  not  easy 
to  say  why  this  should  be  the  case,  but  the  efficacy  of  depletions 
of  the  larger  bronchial  tubes  in  pulmonary  disease,  and  the  great 

*  In  this  respect  we  observe  a  remarkable  difference  between  mucous  membranes, 
and  the  parenchymatous  organs,  or  even  the  serous  membranes.  For  in  these  two 
last  cases,  experience  shews  that  general  bleeding  has  a  much  more  direct  influence  on 
the  disease,  in  some  cases  indeed  so  complete,  that  the  inflammation  is  cut  short  by 
the  bleeding  alone. 


BRONCHITIS.  97 

utility  of  treatment  directed  to  the  upper  lobes  of  the  lung,  both 
in  relieving  the  symptoms  of  bronchial  inflammation  and  in 
preventing  the  development  of  tubercle,  were  long  since  pointed 
out  by  Broussais,  although  subsequent  authors  have  advocated 
this  mode  of  practice  as  if  it  were  original  with  them.  He  has 
shewn  the  intimate  relation  that  exists  between  bronchitis  of 
the  superior  lobes,  pneumonia,  and  the  development  of  tubercle  ; 
and  has  announced,  that  in  many  cases  of  incipient  phthisis  the 
disease  may  be  put  an  end  to  by  local  depletion  of  the  upper 
portions  of  the  lung.  Such  a  proposition  as  this  is  full  of 
importance,  and  my  experience  tends  strongly  to  confirm  its 
truth.  When  speaking  of  phthisis,  I  shall  return  to  this 
important  subject. 

It  is  scarcely  necessary  to  remark,  that  under  certain  circum- 
stances, local  bleeding  maybe  repeated  even  in  an  advanced  stage 
of  the  disease.  As  for  instance,  suppression  of  expectoration, 
when  this  coincides  with  increase  of  fever  and  irritation ; # 
increase  of  dyspnoea,  when  this  is  not  produced  by  over  secretion, 
a  point  easily  determined  by  the  stethoscope ;  and  lastly,  the 
occurrence  of  local  dulness,  which  in  cases  of  intense  bronchitis 
may  occur,  and  is  owing  to  congestion  of  the  substance  of  the 
lung. 

Next  to  the  means  already  detailed,  we  have  the  employment 
of  internal  remedies ;  there  seems  to  be  but  little  doubt,  that  in 
cases  adapted  for  it  the  solution  of  the  tartar  emetic  has  by  far 
the  pre-eminence,  but  in  its  exhibition  certain  considerations 
must  always  be  attended  to  :  thus,  the  more  robust  the  patient ; 
the  more  acute  the  disease  ;  the  more  bloodletting  has  been 
indicated,  and  the  better  it  has  been  borne ;  the  more  inflam- 
matory be  the  blood  ;  the  earlier  the  period  at  which  the  disease 
has  been  met  by  treatment ;  and  last,  though  not  least,  the  more 
simple  and  uncomplicated  the  affection,  particularly  with  abdominal 
diseases,  the  greater  will  be  the  certainty  of  this  remedy  exer- 
cising that  singularly  sanative  action,  which  has  justly  obtained 
for  it  the  name  of  heroic.  On  the  other  hand,  where  the  disease 
has  occurred  in  a  debilitated  constitution,  where  the  pulse  has 
not  been   strong,  nor  the   skin  very  hot,   where  the  teeth  are 

*  I  use  here  the  term  suppression  in  contradistinction  to  that  of  retention.  The 
first  of  these  terms  has  been  long  misapplied,  with  respect  to  the  chest ;  for  it  is 
obvious,  that  we  should  use  it  with  the  same  signification  as  in  urinary  affections. 

H 


98  BKONCHITIS. 

affected  with  sordes,  and  the  tongue  in  a  very  morbid  condition ; 
where  the  belly  is  swelled  and  tender  in  the  epigastric  and  ileo- 
ccecal  regions  ;  where  there  have  been  diarrhoea  or  vomiting,  and 
pain  in  the  abdomen  ;  in  such  a  case,  the  tartar  emetic  will  either 
not  be  borne  at  all,  or  if  retained  on  the  stomach,  will  exercise 
comparatively  little  influence  on  the  pulmonary  disease,  and  too 
often  increase  the  gastric  symptoms.  It  is  on  the  existence  of 
these  symptoms  of  gastro-intestinal  irritation  that  the  question 
of  the  exhibition  of  the  remedy  in  any  case,  in  a  great  measure, 
must  turn.  Laennec,  indeed,  has  declared,  that  the  co-existence 
of  the  gastro-enteritis  of  fever  with  pneumonia,  does  not  contra- 
indicate  the  employment  of  tartar  emetic,  for  which  he  has  been 
censured,  perhaps  too  severely  ;  and  it  is  supposed,  that  he 
allowed  his  better  judgment  to  be  warped,  from  his  hostility  to 
the  doctrines  of  the  physiological  school.  To  this  point  I  shall 
return  hereafter. 

It  would  seem,  however,  that  mere  prostration  should  not 
necessarily  prevent  us  from  having  recourse  to  the  remedy. 
Indeed  cases  are  recorded,  in  which  the  patient,  at  the  time 
he  was  ordered  the  tartar  emetic,  was  almost  in  artlculo  mortis. 
I  have  never  seen  such  a  case,  but  have  often  found  in  the 
advanced  stages  of  acute  diseases  of  the  pulmonary  parenchyma 
and  mucous  membrane,  when  other  means  have  either  failed,  or 
proved,  in  a  great  measure,  inefficient,  and  where  the  patient  was 
necessarily  much  debilitated,  that  the  exhibition  of  the  tartar 
emetic  was  followed  by  the  happiest  results.  My  experience,  at 
present,  leads  me  to  conclude,  that  where  the  debility  is  merely 
traceable  either  to  the  disease  or  to  antiphlogistic  treatment, 
and  not  the  result  of  its  complication  with  decided  abdominal 
inflammation,  we  may  often  have  recourse  to  the  antimonial 
solution  ;  and  we  shall  find,  that  when  managed  with  judgment 
and  caution,  it  will  then,  perhaps,  more  than  at  another  time, 
exhibit  its  almost  specific  power  on  the  capillaries  of  the  lung. 

In  the  formula  which  we  have  used  for  some  years  at  the 
Meath  Hospital,  we  have  to  a  certain  degree  imitated  that  of 
Laennec.  It  is  so  constituted  as  to  contain  an  aromatic  and  an 
opiate  combined  with  the  antimony,  and  of  this  solution  each 
ounce  contains  a  grain  of  the  remedy.*      Of  this  solution  we 

*  The  following  is  the  formula  :  R  Tartratis  antimonii  gr.  vi.     Aq.  cirmamomi  5vi. 
Tincturae  opii  acetalis  gutt.  xii.  m. 


BRONCHITIS.  99 

begin  by  ordering  half  an  ounce  every  hour,  or  second  hour,  so 
that,  if  possible,  the  whole  of  the  six  grains  may  be  consumed 
in  the  course  of  the  twenty-four  hours.  In  many  cases,  from 
various  accidental  circumstances,  this  quantity  is  not  exhibited, 
but  even  where  from  three  to  four  grains  have  been  used,  we  have 
often  seen  marked  benefit  to  follow. 

The  results  of  this  treatment  are  various.  In  a  few  cases 
violent  vomiting  with  purging  is  produced ;  but  in  a  great 
majority  there  is  only  a  degree  of  nausea  felt,  principally  when 
the  patient  moves.  Either  of  these  results  is  seldom  seen  after 
the  first  day,  and  the  "  interval  of  tolerance"  of  Easori  com- 
monly occurs.  In  other  cases,  as  Laennec  has  noticed,  almost 
no  apparent  effect  is  produced,  and  the  remedy  might  be  con- 
sidered as  inert,  were  it  not  for  the  disappearance  of  the  symptoms 
and  signs  of  the  pulmonary  disease.*  In  the  management  of 
the  remedy,  as  to  dose,  &c,  I  have  pretty  closely  followed  the 
instructions  of  Laennec,  though  but  few  cases  have  occurred  to 
me  in  which  it  was  necessary  to  increase  the  dose  beyond  eight 
or  ten  grains  in  the  twenty-four  hours ;  in  the  event  of  too 
violent  vomiting  or  purging  this  remedy  is  at  once  omitted,  and 
an  opiate  exhibited.  But  in  all  cases  in  which  its  action  has 
been  salutary,  and  particularly  where  it  has  been  found  necessary 
to  continue  its  use  for  several  days,  its  omission  must  be  con- 
ducted gradually.  For  I  have  seen  many  cases  in  which  the 
sudden  leaving  off  of  the  remedy  was  followed  by  a  return  of  the 
symptoms.  This  remark,  however,  is  more  applicable  to  cases 
of  pneumonia  and  congestion,  than  to  those  of  mere  bronchitis. 

As  far  as  I  have  seen,  the  effect  of  this  medicine  on  bronchitis 
is  two-fold.  It  may  either,  as  it  were,  cut  short  the  inflammation, 
so  as  to  leave  hardly  a  symptom  or  sign  behind  it,  or  it  may 
cause  its  early  passage  into  the  second  or  secretive  stage.  In  the 
first  case  the  oppression  and  wheezing  cease,  the  cough  becomes 
trifling,  the  lividity  disappears,  the  pulse  falls  to  its  natural 
standard,  and  the  respiration  is  found  everywhere  pure,  equal, 
and  healthy,  with  the  exception,  perhaps,  of  a  slight,  sonoro- 
mucous  rale,  which  is  now  and  then  audible  :  the  patient  recovers 
his  appearance,  and  declares  that  he  is  quite  well. 

In  the  second  case,  after  the  use  of  the  remedy  for  several  days, 

*  I  have  frequently  seen  patients  who  were  using  from  six  to  ten  grains  of  the 
t-artar  emetic  daily,  yet  with  a  good  appetite  for  their  food. 

h2 


100  BRONCHITIS. 

we  find  the  patient  looking  pale  and  miserable ;  lie  perspires 
copiously,  and  has  often  a  rapid,  small  pulse  ;  the  breathing, 
though  less  difficult,  is  hurried,  and  the  cough,  though  less 
painful,  is  so  frequent  as  to  allow  of  but  little  rest.  It  is  followed 
by  a  copious  expectoration  of  opaque  mucus,  or  of  a  muco- 
purulent secretion.  On  percussion  the  chest  sounds  clear,  but 
the  respiration  is  generally  marked  by  mucous  rales,  of  various 
intensities,  in  some  cases  combined  with  the  sonorous,  in  others 
passing  almost  into  the  crepitating  character ;  at  this  period 
antiphlogosis  can  be  used  no  longer,  and  a  cautious  but  decided 
employment  of  the  stimulating  and  tonic  treatment  must  be  had 
recourse  to.  But  even  in  this  instance,  though  the  exhibition  of 
the  tartar  emetic  has  not,  as  in  the  former  case,  restored  the 
lung  to  a  state  of  health,  yet  it  has  not  been  without  its  advan- 
tages, inasmuch  as  experience  shows  that  now  the  exhibition  of 
stimulants  and  tonics  will  have  the  best  possible  effect.  This 
fact,  among  many  others,  seems  to  me  illustrative  of  a  general 
rule  in  therapeutics,  that  in  almost  all  local  diseases  the  successful 
employment  of  stimulation  depends  on  the  previous  use  of  a 
general  or  local  antiphlogistic  treatment. 

Treatment  of  the  Second  Stage  of  Bronchitis. — Before 
entering  on  the  mode  of  treatment,  which  experience  has  pointed 
out  as  best  for  this  affection,  I  find  it  necessary  to  premise  some 
general  pathological  observations.  I  do  not  propose  entering 
into  the  hackneyed  question  of  the  nature  of  inflammation,  but 
shall  employ  the  attention  of  my  readers  much  better  in  the 
examination  of  certain  circumstances  connected  with  it,  which  are 
of  the  utmost  importance  in  practical  medicine.  We  find  that  in 
a  vast  number  of  general  and  local  diseases  two  stages  are 
observed,  the  nature  of  which  cannot  be  expressed  by  any  know- 
ledge to  which  the  mere  anatomist  can  arrive,  but  whose  existence, 
duration,  and  succession  are  pointed  out  by  the  results  of  treat- 
ment. With  the  first  of  these,  pathologists  have  long  been 
familiar  ;  but  of  the  existence,  nature,  and  frequent  occurrence 
of  the  second,  they  have  not  yet  taken  sufficient  notice.  In  the 
first  of  these  stages  antiphlogosis  is  necessary,  and  stimulation 
injurious.  In  the  second,  antiphlogosis  is  insufficient,  and  often 
injurious,  while  stimulation  becomes  necessary. 

Although   much    had   been    done    in    this    field   before,    yet 
Broussais  had  the  great  merit  of  shewing,  that  a  vast  number  of 


BRONCHITIS.  101 

local  diseases,  before  supposed  to  be  separate  entities,  could  be 
reduced  to  the  first  of  these  stages,  the  difference  of  symptoms 
being  principally  referrible  to  the  sympathies  of  organs ;  but  his 
great  error  was  in  stopping  short  here,  and  in  not  recognizing 
the  existence,  in  almost  all  local  diseases,  of  a  state  in  which 
the  symptoms  do  not  yield  to  that  treatment  which  was  found 
advantageous  in  the  earlier  periods  of  the  case ;  or  if  they  do 
yield,  it  is  only  at  a  great  expense  to  the  constitution.  As  a 
result  of  this  omission,  the  treatment  of  local  diseases  by  the 
physiological  school,  was  for  too  great  a  length  of  time,  purely 
antiphlogistic,  and  hence  their  repeated  bleedings  and  protracted 
starvations  in  almost  all  diseases,  and  their  unfounded  dread  of 
any  thing  which  could  have  the  slightest  stimulating  effect. 

But  experience  has  shewn,  that  this  treatment,  though  so 
applicable  in  the  first,  is  often  inapplicable  or  insufficient  in 
the  more  advanced  stages  of  the  disease  ;  that  its  effects  will 
be  to  reduce  the  powers  of  life,  while  effusions  and  super-secre- 
tions are  running  down  the  patient,  and  throwing  the  nervous 
system  into  extreme  asthenia.  It  has  also  shewn,  that  these 
symptoms  must  be  met  by  an  omission  of  all  reducing  treatment, 
and  by  the  employment  of  remedies,  the  use  of  which  would 
be  highly  injurious  in  the  first  stages  of  the  disease :  but 
as  the  period  of  supervention,  and  the  symptoms  of  this 
second,  or  asthenic  state,  vary  in  different  individuals,  according 
to  a  vast  variety  of  circumstances,  it  is  plain,  that  in  the  detec- 
tion of  this  passage  from  the  first  into  the  second  stage,  and  in 
the  omission  of  one  kind  of  treatment  and  the  adoption  of 
another,  the  skill  and  success  of  the  experienced  physician  will 
be  best  seen. 

Of  the  different  tissues,  the  mucous  membranes,  in  their 
pathological  state,  best  illustrate  the  foregoing  propositions, 
and  next  to  them  the  skin  ;  but  I  have  almost  no  doubt  that 
they  will  be  found  to  apply  to  the  parenchymatous  organs,  both 
in  cases  of  local  and  more  general  disease.  Andral  has  sug- 
gested that  the  success  of  tonics  and  stimulants,  in  the  advanced 
stages  of  fever,  may  be  thus  explained ;  and  when  we  consider 
that  in  most  cases  of  that  disease  there  are  affections  of  the 
mucous  membranes,  and  also  of  the  parenchymatous  organs, 
there  seems  to  be  great  reason  for  adopting  his  opinion. 

As  yet  we    know  but  little  of  the   laws  which  regulate  the 


102  BRONCHITIS. 

passage  of  the  first  of  these  stages  of  disease  into  the  second  ; 
but  of  the  truth  of  the  following  views,  an  investigation,  con- 
ducted with  the  greatest  accuracy  that  I  was  capable  of,  has 
fully  convinced  me. 

It  is  obvious  that  any  change  in  the  nature  of  a  local  disease, 
which  would  render  it  not  only  less  amenable  to  antiphlogistic 
treatment,  but  in  which  such  a  treatment  would  lose  all  effect 
except  in  lowering  the  powers  of  life,  must  be  of  the  utmost 
importance.  Now  when  we  inquire  what  are  the  circumstances 
which  seem  to  govern  this  change,  we  find  that  they  are  various. 
In  some  cases  the  chronicity  of  the  disease  is  presumptive 
evidence  that  such  a  change  has  occurred ;  in  others,  we  find  it 
a  very  early  period  of  the  morbid  state  ;  and  in  a  third,  the  first 
stage  continues  for  an  indefinite  length  of  time.  The  state  of 
the  constitution  too,  has  a  decided  influence,  for  in  some 
individuals  a  local  inflammation  will  require  tonics  and  stimu- 
lants much  sooner  than  in  others,  although  the  seat  and  nature 
of  the  disease  be  apparently  the  same.  Nor  are  these  the  only 
circumstances,  for  we  find  much  to  depend  on  the  previous 
treatment,  and  on  the  seat  of  irritation. 

I  shall  conclude  this  digression,  by  stating,  in  the  form  of 
propositions,  those  points  of  doctrine  which  seem  to  bear  most 
directly  on  the  treatment  of  pulmonary  disease. 

First.  That  in  some  cases  an  antiphlogistic  treatment  may 
cut  short  the  disease  in  its  first  stage  ;  but  that  in  most  in- 
stances, particularly  in  the  affections  of  mucous  membranes,  its 
effect  is  to  bring  on  the  occurrence  of  the  second  stage. 

Second.  That  the  principal  circumstance  on  which  the  suc- 
cess of  stimulants  depends,  is  their  having  been  preceded  by 
antiphlogistic  treatment. 

Third.  That  in  many  cases  disease  will  continue  for  a  great 
length  of  time,  and  yet  (as  shewn  by  the  result  of  treatment)  be 
in  its  first  stage.  Although  chronic  as  to  its  period  of  duration, 
it  is  still  acute  when  tested  by  the  effect  of  treatment. 

Fowrili.  That  this  result  is  most  frequently  seen  under  the 
following  circumstances  : 

(a)  Cases  of  local  disease,  with  but  little  injury  to  the 
general  health. 

(b)  Diseases  of  tissues,  where  there  is  but  little  relief  by 
secretion. 


BRONCHITIS.  103 

(c)  Diseases  of  organs  which  have  been  neglected,  or  exas- 
perated by  too  early  stimulation. 

Fifth.  That  in  many  cases,  where  the  disease  has  been 
neglected  or  exasperated,  it  will  be  necessary  to  precede  all  stimu- 
lants by  an  antiphlogistic  treatment,  either  general  or  local. 

I  wish  to  be  clearly  understood,  as  not  putting  these  views 
forward  as  very  original.  I  shall  be  content  if  they  are  thought 
important.  In  the  treatment,  not  only  of  the  pulmonary,  but  I 
believe  of  all  other  forms  of  the  diseases  of  irritation,  they  will 
be  found  so  applicable,  as  to  furnish  the  true  key  to  successful 
management,  and  on  the  importance  of  any  principle  which  has 
a  general  application  in  the  science  of  medicine  I  need  not  here 
dilate.  The  overlooking  of  this  second  stage,  and  the  doctrine 
that  disease  did  not  change  in  its  characters  or  nature,  seems 
to  me  to  have  been  one  of  the  greatest  errors  of  the  physiological 
school.  It  was,  however,  but  one  of  many  false  conclusions, 
which  the  attempt  to  simplify  disease,  by  reducing  it  to  a 
common  formula,  rendered  inevitable  ;  and  the  doctrine,  which 
led  to  the  denial  of  specific  affections,  is  the  same  as  that  which 
declares  for  an  antiphlogistic  treatment  throughout  the  course 
of  a  disease,  and  that  one  of  the  most  injurious  maxims  of 
medicine  is  that  which  refers  to  the  necessity  of  tonics  in  the 
advanced  stages  of  bronchitis. 

We  shall  find,  that  the  foregoing  views  have  an  important 
application  in  the  treatment  of  the  second  stage  of  bronchitis, 
which  we  may  now  examine. 

We  shall  first  speak  of  counter-irritation,  which  may  be  con- 
sidered inapplicable  in  the  earlier  periods  of  the  disease,  so  long 
as  the  skin  is  hot,  the  pulse  strong,  the  expectoration  scanty 
and  difficult ;  in  fact,  so  long  as  the  first  stage  of  the  affection 
continues,  that  stage  in  which  bleeding  and  tartar  emetic  are 
useful,  blisters  are  inefficacious,  and  often  hurtful.  It  may  be 
laid  down  as  a  general  rule,  that  the  longer  we  can  with  safety 
postpone  the  application  of  a  blister,  the  greater  certainty  will 
there  be  of  its  favourable  action.  I  have  always  found  that 
blisters  acted  best  when  they  were  applied  shortly  after  the 
change  from  the  first  to  the  second  stage  of  the  disease ;  but 
even  then  they  might  be  injurious,  if  the  affection  had  not  been 
sufficiently  modified  by  preceding  antiphlogistic  treatment.  It 
is  to   be  regretted,   that  in  this   country  blisters  are  too  often 


4 


104  BRONCHITIS. 

employed  with  erroneous  views  of  their  mode  of  action.  They 
are  commonly  applied  in  the  early  periods,  and  even  before 
any  antiphlogistic  means,  capable  of  modifying  the  inflam- 
mation, or  reducing  the  general  febrile  state,  have  been  em- 
ployed ;  and  hence,  as  might  be  expected,  their  application  so 
far  from  relieving,  not  unfrequently  aggravates  the  local  disease.* 

In  employing  blisters,  I  find  that  the  method  of  Bretonneau  is 
by  far  the  best,  as  saving  the  patient  from  much  torture  during 
the  process  of  vesication,  but  particularly  in  the  after  stages  of 
the  sore.  In  the  mode  alluded  to,  the  blister  is  not  allowed  to 
remain  on  after  its  action  has  been  distinctly  felt  by  the  patient. 
The  part  is  then  dressed,  and  full  vesication  subsequently  occurs. 
Another  great  improvement  by  the  same  physician  is  the  cover- 
ing the  blister  with  a  single  sheet  of  fine  silver  paper,  through 
which  the  vesicating  principle  from  its  solubility  in  oil  easily 
acts  ;  and  all  the  evils  which  result  from  the  mechanical  action 
of  the  cantharides  are  prevented.  Stranguary  almost  never 
occurs ;  and  I  think  it  will  be  found  that  in  many  cases  this 
mode  of  blistering  may  be  used  at  a  much  earlier  period  of 
disease  than  under  the  old  system. 

In  selecting  the  situation  for  the  blister  we  should  be  guided 
principally  by  the  physical  signs,  and  in  particular  by  the  active 
and  passive  auscultatory  phenomena. 

I  have  found  it  necessary  in  a  few  cases  to  employ  the  seton, 

*  It  has  often  struck  me  that  we  take  but  a  limited  view  of  the  operation  of  blisters. 
We  have  contented  ourselves  with  considering  their  revulsive  action  merely,  but  have 
not  sufficiently  investigated  another  result,  namely,  their  stimulating  effect  on  the 
diseased  organ.  That  this  effect  does  occur  is  known  to  all  practical  men,  but  it  is 
only  the  injurious  result  which  is  recognized,  and  we  never  chink  that  there  may  be  a 
time  when  this  stimulation  may  have  the  best  effect.  The  experience  of  the  stimulat- 
ing action,  at  all  events,  proves  the  fact  in  question ;  but  whether  the  stimulation  be 
the  consequence  of  the  excitation  of  the  whole  system  reacting  on  the  suffering  organ, 
or  whether  it  is  more  directly  transmitted,  we  at  present  know  not.  But  we  find 
that  at  a  period  when  other  stimulations  are  injurious,  a  blister  may  do  harm ;  and 
it  seems  most  probable,  that  when  the  second  stage  of  a  disease  sets  in  that  then, 
at  least,  the  utility  of  blistering  is  in  part  explicable  by  the  stimulus  given  to  the 
affected  capillaries,  and  that  it  acts  in  the  same  salutary  manner  as  internal  tonics  and 
stimulants. 

It  might  be  urged  in  opposition  to  this  view,  that  it  seems  improbable  that  a  blister, 
which  on  the  surface  produces  heat,  determination  of  blood,  vesication,  &c,  should 
exercise  any  salutary  influence  on  the  capillaries  of  the  lung  ;  but  the  answer  to  this 
is  found  in  the  different  results  of  stimulation  at  different  periods,  according  to  the 
state  of  the  organ  ;  and  thus  a  stimulus,  which  may  produce  the  worst  results  on  a 
healthy  surface,  or  on  one  in  the  first,  or  acute  stage  of  inflammation,  may  produce 
the  best  effects  when  exercised  on  a  tissue  in  that  state  which  is  no  longer  accessible 
to  antiphlogosis. 


BRONCHITIS.  105 

and  it  has,  in  these  instances,  answered  all  my  expectations.  The 
cases  which  seem  to  require  it  are  those  where  the  minute  tubes 
have  been  affected,  where  the  convalescence  is  slow  and  doubtful, 
and  where  there  are  alternations  of  an  hectic  and  inflammatory 
state.  In  some  of  these  cases  the  early  treatment  had  not  been 
judicious,  and  the  antiphlogistic  had  been  too  soon  changed  for 
the  stimulating  plan.  The  physical  signs  were,  persistent  muco- 
crepitating  rale,  and  often  a  degree  of  dulness  in  the  lower  or 
middle  portion  of  one  side. 

Here  I  may  allude  to  the  practice  of  applying  large  poultices 
to  the  chest,  so  strongly  recommended  by  Broussais.  I  have 
little  doubt  that  in  certain  cases  this  measure  would  be  found 
most  efficacious,  but  having  no  experience  of  it,  I  can  only  give 
the  statements  of  others.  The  above  author  relates  a  case  of 
bronchitis,  which  for  thirty-six  days  had  resisted  the  applica- 
tion of  five  or  six  blisters,  placed  in  different  parts  of  the  chest, 
yet  which  yielded  almost  immediately  to  a  large  cataplasm  applied 
over  the  front  of  the  chest.  Fomentations,  according  to  this  author, 
have  nearly  the  same  effect ;  but  the  danger  of  giving  the  patient 
additional  cold  renders  them  not  so  advisable  as  the  cataplasms. 

From  the  decided  advantage  obtained  from  emollient  applica- 
tions on  the  abdomen  in  the  treatment  of  enteritis,  it  seems  more 
than  probable  that  the  same  practice,  directed  to  the  chest,  would 
be  useful  in  bronchial  and  pneumonic  inflammations. 

In  discussing  the  subject  of  the  internal  remedies  adapted 
to  this  stage  I  shall  do  little  more  than  point  out  generally  the 
class  of  agents  best  adapted  to  the  disease.  These  may  be 
stated  to  be  tonics,  and  general  and  local,  or  specific  stimulants. 

Among  the  two  first  classes  may  be  enumerated,  improvement 
in  regimen,  change  of  air,  the  use  of  wine,  and  in  some  cases  of 
bark,  or  the  preparations  of  iron.  Of  the  local  or  specific 
stimulants,  on  the  other  hand,  so  many  have  been  proposed, 
that  I  shall  merely  mention  those  to  which,  from  experience,  I 
have  become  most  attached.  Among  these  remedies  I  know 
none  to  be  compared  with  the  decoction  of  the  polygala  senega, 
in  combination  with  carbonate  of  ammonia  and  the  camphorated 
tincture  of  opium  and  squill.* 

*  The  formula  which  I  commonly  employ  is  as  follows : — 

$  Decoct.  Polygal.  jv.  Syrup.  Tolut.   sss.  Tinct.  Op.  Camp.  Tinct.  Scill.  aa.  jii. 
Carb.  Ammon.  ct.  xv.  vel.  xx.  at. 


106  BRONCHITIS. 

I  may  safely  state,  that  of  all  the  remedies  for  the  second  stage 
of  bronchitis,  this,  when  exhibited  at  the  proper  period,  has 
least  often  disappointed  me.  Under  its  influence  the  expectora- 
tion diminishes  without  increase  of  dyspnoea  ;  the  pulse  becomes 
slower  and  fuller,  the  respiration  in  the  upper  portions  of  the 
lung  becomes  pure  ;  and  this  change,  extending  from  above 
downwards,  we  may  find  that,  in  a  very  few  days  indeed,  all 
morbid  signs  will  disappear  fron  the  lung. 

The  whole  nicety  of  the  treatment  consists  in  not  having 
recourse  to  the  remedy  too  soon,  in  previously  modifying  the 
disease  by  general  and  local  antiphlogistic  measures,  and  by  the 
use  of  the  antimonial  or  mercurial  treatment,  as  the  case  may 
be. 

I  need  scarcely  observe,  that  the  above  remarks  apply  not 
merely  to  the  exhibition  of  the  polygala,  but  to  that  of  the 
other  remedies  of  this  class.  Among  these  the  following  are 
most  important  :  the  balsams,  and  the  preparations  of  gum 
ammoniac,  myrrh,  and  squill.  I  have  placed  the  balsams  first, 
as  I  look  on  them  to  be  next  in  value  to  the  senega.  But  I 
must  state  here,  that  the  use  of  this  class  of  remedies  by  inhala- 
tion has  always  seemed  to  me  full  of  danger.  I  have  now  known 
several  cases  where  a  chronic  bronchitis  was  converted  into  an 
acute,  and,  as  might  be  expected,  fatal  pneumonia,  by  the  use  of 
the  turpentine  inhalations. 

It  is  not  difficult  to  know  whether  these  remedies  will  be 
serviceable,  even  at  an  early  period  of  their  exhibition  ;  and  it  is 
the  duty  of  the  physician  to  carefully  watch  their  effects,  at  least 
for  the  first  few  days.  He  must  never  forget,  that  in  all  those 
cases  where  the  cure  consists  in  the  arrest  of  a  secretion  from 
an  extensive  surface,  there  is  a  danger  either  that  a  new  inflam- 
mation will  be  set  up  in  the  affected  tissue,  or  that  some  other 
disease,  generally  of  an  acute  nature,  will  be  produced  ;  for  as 
the  sudden  arrest  of  a  diarrhoea  may  produce  ascites,  or  perito- 
nitis, or  hepatitis,  so  that  of  a  bronchial  flux  may  induce  a  fatal 
pneumonia,  a  pleurisy,  or  an  hydrothorax,  and  to  this  our  atten- 
tion must  always  be  directed.  Experience  tells  us  that  these 
distressing  consequences  are  best  avoided  by  attending  to  the 
following  circumstances  : — 

First.  To  provide  that  the  stimulating  remedy  shall  be  pre- 
ceded by  a  fit  antiphlogistic  treatment. 


BKONCHITIS.  107 

Second.  To  combine  it  with  a  revulsive  plan,  such  as  blister- 
ing, cupping,  warm  bathing,  &c. 

Third.  To  omit  the  remedy  on  the  slightest  appearance  of  new 
irritation,  either  in  the  affected  part  or  in  any  other  vital  organ. 

On  the  importance  of  the  first  of  these  I  have  already  suffi- 
ciently dilated  ;  and  shall  only  add  here  that  in  a  single  case 
we  may  have  to  return  to  the  antiphlogistic  treatment,  even 
more  than  once.  The  combination  of  counter-irritation  with 
the  internal  remedy  seems  to  have  the  best  effect  in  preventing 
these  accidents  ;  and  the  same  may  be  said  of  means  calculated 
to  promote  perspiration.  In  these  cases,  with  this  view,  I  always 
order  the  patient  to  wear  flannel  so  as  to  promote  the  insensible 
perspiration.  At  this  period  of  the  case  the  exhibition  of  stimu- 
lants may  not  produce  that  happy  result  which  I  have  above 
described.  A  state  of  new  irritation  may  be  produced,  rendering 
their  omission  necessary,  or  the  hectic  condition  and  the  super- 
secretion  may  continue.  The  indication  in  the  first  of  these 
cases  is  obvious  ;  in  the  second,  however,  we  find  that  this  will 
be  the  time  for  a  change  of  air,  the  remedies  being  still  continued, 
and  we  may  then  see  recoveries  under  apparently  the  most  hope- 
less circumstances. 

I  shall  next  make  a  few  observations  on  the  treatment  of  the 
apyrexial  form  of  chronic  primary  bronchitis,  considering  it 
merely  as  an  affection  of  the  mucous  membrane,  independent  of 
any  of  its  other  consequences  on  the  organisation  of  the  lung. 
In  these  cases,  when  the  disease  has  continued  for  a  length  of 
time,  we  often  find  that  a  cure  is  impossible,  and  our  efforts 
must  be  directed  merely  to  palliate,  and  to  delay  the  further 
progress  of  disease. 

In  cases  where  the  disease  has  not  lasted  more  than  a  year  or 
two,  in  which  the  summer  remission  has  been  complete,  or  nearly 
so,  we  may  hope  to  do  good.  And  if  we  find  no  evidence  of 
tubercle,  dilated  tubes,  or  enlarged  air  cells,  our  prognosis  will 
be  still  more  favourable.  If,  on  the  other  hand,  the  affection 
has  lasted  several  years,  that  the  summer  remission  has  become 
extremely  slight,  that  there  is  permanent  dyspnoea,  and  that  on 
examination  we  find  the  signs  of  the  above  diseases,  or  of 
morbus  cordis,  then  indeed  we  must  not  hope  for  cure,  but  we 
may  palliate  suffering,  and,  in  many  cases,  prolong  life  to  a 
great  extent. 


108  BRONCHITIS. 

The  physical  signs  which  are  favourable  may  be  stated  to  be, 
that  the  bronchial  rales  are  of  a  musical  rather  than  a  crepi- 
tating character ;  that  they  are  not  very  intense,  nor  increased 
on  the  patient's  taking  a  deep  breath ;  that  the  respiratory 
murmur  may  be  heard  of  equable  strength,  free  from  the 
character  of  puerility  on  the  one  hand,  or  feebleness  on  the 
other ;  that  the  sound  on  percussion  is  equal,  without  local 
dulness,  or  the  morbid  clearness  of  dilatation  of  the  cells ;  that 
there  are  no  morbid  phenomena  of  voice ;  and  lastly,  that  the 
motions  and  sounds  of  the  heart  are  tranquil  and  natural. 

Under  these  circumstances  the  indications  are  to  change  the 
action  of  the  mucous  membrane  at  the  slightest  possible  risk  to 
the  constitution.  I  have  nothing  to  add  to  the  therapeutic 
means  already  so  well  known ;  but  I  shall  make  a  few  brief 
remarks  on  the  various  classes  of  remedies  which  have  been 
found  useful  in  the  disease. 

On  the  subject  of  revulsives  it  may  be  stated,  that  their 
employment  is  generally  useful,  and  that  we  may  thus  by  per- 
severance often  produce  the  best  effects.  The  remarks  which  I 
have  already  made  on  this  point  will  be  found  to  apply  in  this  form 
of  disease,  as  well  as  in  the  second  stage  of  the  acute  bronchitis. 

I  have  been  for  some  time  in  the  habit  of  employing  a 
mode  of  treatment,  which  I  can  recommend  strongly,  not  only 
in  this  disease,  but  even  in  confirmed  phthisis.  It  consists  in 
sponging  a  large  surface  of  the  chest  daily  with  a  liniment  com- 
posed of  the  spirit  of  turpentine  and  acetic  acid,  so  as  to  keep 
out  an  erythematous  state  of  the  skin ;  and  I  do  not  know 
a  more  easily  manageable  or  efficacious  remedy.  From  nume- 
rous observations  I  have  concluded,  that  this  liniment  not 
only  acts  beneficially,  by  its  counter-irritating  properties,  but 
that  the  ingredients  are  absorbed  by  the  surface,  so  as  to  act  on 
the  mucous  membrane  as  direct  stimuli.  My  reasons  for  this 
opinion  are,  that  I  have  seen  it  to  produce  effects  of  the  most 
favourable  description,  even  when  but  little  redness  of  the  surface 
was  produced ;  the  relief  being  much  more  than  could  have  been 
expected  from  the  mere  amount  of  counter-irritation.  In  several 
cases  too  the  secretion  of  the  kidneys  has  been  increased.* 

«        *  The  following  is  the  formula  which  I  employ  : — 

R  Sp.  Terehinth.  =iii.  Acid.  Acet.  =ss.  Vitell.  Ovi.  i.  Aq.  Rosar.  jiiss.  01.  Limon. 

5i-  »». 


BRONCHITIS.  109 

In  addition  to  this  treatment,  I  have  often  ordered  the  patient 
to  inhale  the  vapour  of  water  impregnated  with  a  narcotic. 
Twelve  or  fifteen  grains  of  the  extract  of  hemlock  are  diffused 
in  a  proper  inhaling  apparatus,  and  the  vapour  drawn  into  the 
lungs  for  a  quarter  of  an  hour,  once  or  twice  a  da}". 

Many  other  remedies  of  the  stimulant,  tonic,  astringent,  and 
sedative  classes  are  found  useful  in  this  disease.  I  shall  allude 
briefly  to  those  of  whose  efficacy  there  appears  good  evidence. 

Among  the  most  efficacious  of  the  stimulants  the  terebin- 
thinate  preparations  stand  prominent.  The  various  balsams, 
exhibited,  either  alone,  or  in  combination  with  a  sedative  and 
tonic,  often  act  well ;  and  next  to  them  we  have  the  gum  resins, 
such  as  ammoniac  and  myrrh.  From  the  efficacy  of  strychnine 
in  the  analogous  affection  of  the  digestive  mucous  membrane, 
there  seems  good  reason  to  hope,  that  in  the  pulmonary  disease 
it  would  prove  useful.  Its  remarkable  power  too,  of  stimulating 
the  muscular  tissue  to  contract,  may  be  found  of  great  utility  in 
many  chest  affections ;  and  we  might  hope  that  effects  would  be 
produced  similar  to  those  of  galvanism  in  asthma  in  the  hands 
of  Dr.  Philip,  or  in  chronic  mucous  catarrh,  as  stated  by  Dr. 
Forbes.  The  tonics  which  may  be  often  employed  when  the 
powers  of  life  are  low,  and  particularly  in  cases  where  a  strict 
antiphlogistic  system  has  been  pursued,  are  principally  the  pre- 
parations of  quinine  and  iron.  Of  the  utility  of  both  these 
remedies  I  have  seen  many  examples.  The  combination  of  the 
myrrh  and  iron  mixture  with  the  laurel  water  has  been  a  favourite 
with  me  in  such  cases  for  a  length  of  time. 

I  have  very  seldom  employed  the  directly  astringent  sub- 
stances in  this  disease.  But  in  cases  where  the  flux  is  excessive 
there  seems  reason  for  their  cautious  exhibition.  From  the 
great  powers  and  safety  of  the  acetate  of  lead,  I  would  prefer  it 
to  most  others ;  and  there  is  abundant  evidence  in  favour  of  its 
astringent  action  on  the  capillaries  of  the  lung.  Thus  in  the 
passive  bronchial  haemorrhage  nothing  can  be  more  striking 
than  its  powers  over  the  disease ;  and  on  the  continent  it  has 
been  exhibited  with  such  great  success  in  cases  of  chronic 
puriform  expectoration,  as  to  be  looked  on  as  a  means  of  curing 
consumption. 

But  in  cases  of  super- secretion,  unless,  from  age  or  disease, 
the  patient  be  in  a  state  of  extreme  debility,  the  emetic  plan 


110  BKONCHITIS. 

is  always  to  be  preferred  to  the  astringent.  There  can  be  no 
doubt  that  the  emetic  class  of  medicines  act  most  beneficially 
on  the  diseased  bronchial  tubes,  and  not  only  get  rid  of  the 
super- secretion  mechanically,  but  also  exert  a  favourable  action 
on  the  cause  of  its  production.  These  remarks  apply  more 
particularly  to  the  preparations  of  antimony  and  ipecacuan  ; 
and  it  is  often  excellent  practice  to  administer  an  emetic  fre- 
quently in  the  treatment  of  a  chronic  catarrh,  where  the  secretion 
is  superabundant.  By  this  means  the  tubes  are  emptied,  so 
that  an  emetic  is  often  to  the  lungs  what  a  laxative  is  to  the 
digestive  tube  ;  the  air  is  freely  admitted,  and  the  arterialization 
of  the  blood,  as  shewn  by  the  rapid  subsidence  of  lividity,  again 
takes  place  with  freedom  ;  the  bronchial  muscles  are  stimulated, 
and  time  and  opportunity  gained  for  other  treatment. 

After  speaking  of  cases,  in  which  the  use  of  means,  really 
efficacious,  is  too  soon  given  up  by  the  practitioner,  Laennec 
says:  "Among  these  means  there  is  no  one  more  frequently 
useful  than  emetics,  repeated  according  to  the  patient's  strength, 
and  his  power  of  supporting  their  action.  I  have  cured  in  this 
way  catarrhs  of  very  long  standing  in  old  persons,  and  still  more 
in  adults,  and  children.  In  the  case  of  an  old  lady  of  eighty- 
five,  who  had  laboured  under  a  chronic  catarrh  for  eighteen 
months,  with  an  expectoration  amounting  to  two  pounds  daily,  I 
prescribed  fifteen  emetics  in  one  month,  and  with  complete 
success,  as  the  patient  lived  eight  years  afterwards,  free  from 
the  complaint."  This  author  further  recommends,  that  after 
the  use  of  the  emetics,  tonics  should  be  exhibited,  and  in  this  I 
fully  concur. 

The  latest  authority  on  the  use  of  emetics  in  this  disease  is 
Dr.  Giovanni  de  Vittis,  and  as  his  treatment  consisted  almost 
entirely  in  their  employment,  the  results  have  great  interest. 
In  a  recent  number  of  the  Annali  Universali  di  Med.  we  find 
that  his  mode  of  proceeding  is  to  administer  as  much  of  a 
solution  of  tartar  emetic,  in  the  proportion  of  half  a  grain  to  the 
ounce,  as  will  produce  vomiting.  This  is  repeated  morning  and 
evening,  and  the  patients  are  supported  on  a  farinaceous  and 
milk  diet.  When  it  produced  too  much  action  on  the  bowels  it 
was  suspended,  and  grain  doses  of  roasted  ipecacuan,  with  the 
same  quantity  of  digitalis,  were  given  at  short  intervals  until  the 
diarrhoea  ceased. 


BRONCHITIS.  HI 

The  author's  account  of  his  success,  not  only  in  chronic 
catarrh  but  in  phthisis,  is  almost  too  favourable.  In  all  pro- 
bability many  of  his  cases  were  only  examples  of  that  form 
of  bronchitis  to  which  I  have  already  alluded,  where  the  minuter 
tubes  are  engaged,  and  the  disease  but  little  removed  from 
suppurative  pneumonia.  In  such  cases,  when  we  consider  both 
the  specific  and  the  emetic  action  of  the  remedy,  I  feel  certain 
that  the  practice  is  probably  the  best  that  could  be  adopted. 

When  I  speak  of  the  treatment  of  the  secondary  bronchitis 
of  typhus  I  shall  return  to  the  subject  of  emetics  in  this 
disease. 

The  last  point  of  treatment  to  which  I  shall  allude  is  the 
use  of  the  sedative  and  narcotic  medicines.  Of  these  there  are 
few  that  have  not  the  best  effect  in  the  variously  modified  cases 
of  chronic  catarrh.  Their  use,  however,  is  particularly  demanded 
when  the  cough  is  severe,  and  the  expectoration  not  abundant. 
We  may  use  the  various  preparations  of  opium,  hyosciamus, 
or  hemlock ;  and  the  combination  of  these,  with  a  small  por- 
tion of  belladonna,  will  be  found  to  have  excellent  effects.  I 
have  found  the  combination  of  small  doses  of  ipecacuan  with 
hemlock  and  belladonna  to  be  most  useful  in  a  vast  number 
of  cases. 

We  may  also  use  this  class  of  remedies  by  inhalation.  To 
this  I  have  already  alluded. 

It  has  been  already  shewn  that  the  success  of  stimulants 
and  tonics,  in  mucous  irritations,  depends  greatly  on  the  pre- 
vious employment  of  an  antiphlogistic  system.  And  in  the 
disease  before  us,  we  are  not  to  refrain  from  thus  preparing  the 
patient  for  the  specific  stimulant  merely  on  account  of  its  chro- 
nicity.  It  is  only  in  cases  where  there  is  hectic  fever,  and  that 
the  patient  is  emaciated,  that  the  above  treatment  will  be  hazard- 
ous. Yet  even  here,  local  depletion,  by  means  of  cupping,  will 
often  have  the  best  effect. 

Finally,  we  have  to  consider  a  point  of  considerable  interest ; 
but  it  must  be  confessed,  that  further  and  more  exact  researches 
are  necessary  for  its  elucidation.  It  is,  that  the  more  the 
disease  approximates  to  a  parenchymatous  affection,  the  less 
will  be  the  influence  of  the  stimulating  treatment.  In  these 
cases  there  exists  a  condition  closely  approaching  to  chronic 
pneumonia  or   tubercle.      The    murmur  of  respiration   is  sup- 


112  BRONCHITIS. 

planted  by  a  fine  muco-crepitating  rale,  and  there  is  a  degree 
of  dulness  on  percussion,  circumstances  which  point  out  that 
the  minuter  tubes  are  engaged.  In  such  cases,  and  particularly 
when  the  above  signs  were  partial,  I  have  often  found  that 
after  the  failure  of  a  stimulating  treatment,  the  disease  yielded 
to  an  antiphlogistic  one  ;  on  the  other  hand,  my  observations 
lead  me  to  conclude,  that  the  more  the  disease  predominates 
in  the  larger  tubes  the  sooner  may  we  have  recourse  to  the 
stimulating  treatment.  It  seems  as  if  the  insufficiency  of  mere 
antiphlogosis,  for  the  removal  of  disease,  is  most  evident  in  the 
vascular  tissues,  such  as  the  skin  and  the  mucous  membranes, 
properly  so  called.  And  hence  we  may  understand  why  one 
principle  of  treatment  applies  more  to  the  disease  of  the  large 
tubes,  and  another  apparently  to  that  of  the  minuter  ramifi- 
cations. 

Treatment  of  Secondary  Bronchitis. — In  discussing  this 
part  of  our  subject  I  shall  merely  speak  of  the  treatment  of  the 
disease  as  occurring  in  typhus  fever.  For  although  there  can 
be  little  doubt  that  its  existence,  under  other  morbid  conditions 
of  the  system,  will  be  found  to  require  special  modifications  of 
practice,  yet  as  this  field  is  but  little  explored,  I  refrain  from 
entering  it,  as  it  is  much  better,  in  a  work  like  this,  to  dwell  on 
points  which  are  ascertained  with  greater  certainty. 

Now,  although  the  principles  of  treatment  in  the  catarrh  of 
typhus,  are  the  same  as  in  the  idiopathic  disease,  yet  in  their 
application  to  practice,  certain  variations  are  to  be  attended  to. 
These  may  be  stated  as  follows  : 

First.  That  the  antiphlogistic  treatment  is  not  to  be  employed 
so  boldly  nor  so  long. 

Second.  That  the  stimulating  treatment  may  be  resorted  to 
at  an  earlier  period,  and  with  much  greater  boldness. 

Third.  That  the  use  of  blisters  may  be  employed  also  at  an 
earlier  period. 

Fourth..  That  as  a  general  rule  we  are  not  to  expect  so  much 
from  internal  remedies,  as  in  the  idiopathic  affection.  The  cause 
of  this  is  often  the  complication  with  abdominal  disease. 

The  employment  of  the  lancet  in  this  disease  requires  great 
caution.  Indeed  for  many  years  I  never  had  recourse  to  it,  but 
contented  myself  with  the  use  of  local  bleeding ;  more  lately, 
however,  I  have  used  the  lancet  in  a  few  cases,  with  advantage, 


BRONCHITIS.  113 

and  certainly  without  injury.  In  these  instances  the  disease 
existed  in  young,  and  extremely  robust  subjects,  was  in  its  early 
stage,  not  exasperated  by  neglect,  or  modified  by  bad  treatment. 
But  when  it  occurs  in  the  advanced  stages  of  a  low  typhoid 
fever,  with  stupor,  lividity,  and  prostration,  the  lancet  is  to  be 
avoided,  and  we  are  to  trust  principally  to  local  depletion. 
Indeed,  in  both  these  cases,  it  is  from  local  depletion,  and 
particularly  by  cupping,  that  the  patient  seems  to  derive  the 
greatest  relief.  In  bad  cases  I  commence  by  cupping  on  both 
sides  of  the  chest,  and  the  depletions  are  afterwards  repeated 
in  different  situations,  according  to  the  stethoscopic  signs  of 
predominance  of  disease.  Should  the  belly  be  tympanitic,  a 
foetid  and  turpentine  enema  is  to  be  employed,  the  operation 
of  which  will  be  followed  by  great  relief  to  the  respiratory 
symptoms. 

These  measures  having  been  pursued,  we  may  at  once  apply 
blisters  to  the  chest;  and  I  may  remark,  that  I  have  always 
found  that  their  application  between  the  scapulae  or  to  the  sides, 
gave  more  relief  than  to  the  front  of  the  chest.  If  the  patient, 
however,  be  much  prostrated,  and  lying  on  the  back,  it  is  better 
to  apply  them  to  the  sides,  or  anterior  portion.  As  a  general 
rule  it  may  be  stated,  that  the  lower  the  patient  be,  and  the 
cooler  the  skin,  the  sooner  may  we  employ  this  treatment,  which, 
as  well  as  the  cupping,  will  require  to  be  repeated  frequently  in 
most  cases. 

It  is  of  the  greatest  importance  to  attend  to  the  strength  of 
these  patients ;  and  it  will  not  unfrequently  happen,  that  we 
mast  administer  wine  and  nourishing  broths,  while  we  are 
depleting  the  congested  lung. 

The  question,  as  to  the  best  internal  treatment  in  this  disease, 
is  still  somewhat  uncertain.  I  have  employed  both  the  mer- 
curial and  antimonial  plans  in  a  vast  number  of  instances,  and 
the  result  of  my  experience  leads  me  to  conclude,  that  where 
there  is  a  decided  complication  with  enteric  inflammation,  it  is 
better  to  use  the  mercurial  preparations,  so  as  slightly  to  affect 
the  gums,  and  then  at  once  to  have  recourse  to  the  stimulants, 
such  as  the  polygala,  with  carb.  ammonia,  or  others  of  that 
class.  On  the  other  hand,  where  the  digestive  system  is  free, 
I  have  little  hesitation  in  recommending  the  antimonial  treat- 
ment, even  in  advanced  stages  of  typhus,  and  its  exhibition  for 

i 


114  BRONCHITIS. 

a  time  varying  from  a  clay  to  three  or  four  days,  will  often  bring 
the  disease  under  the  control  of  the  stimulating  treatment. 
That  the  tartar  emetic  may  be  used  without  injury,  even  in  the 
advanced  stages  of  fever,  has  been  satisfactorily  established  by 
my  colleague,  Dr.  Graves,  who  has  successfully  employed  it  in 
combination  with  opium,  for  the  removal  of  nervous  delirium 
and  restlessness.  To  this  subject  I  shall  return,  when  speaking 
of  the  treatment  of  the  typhoid  pneumonia. 

Among  the  stimulants,  which  we  may  exhibit  after  the  mer- 
curial or  antimonial  treatment,  I  think  that  the  polygala  mixture, 
of  which  I  have  already  given  the  formula,  and  the  turpentine 
emulsion  are  the  most  preferable.  In  one  case,  where  the 
symptoms  were  apparently  hopeless,  the  latter  remedy  had 
most  surprising  effect. 

It  is  of  the  utmost  importance  to  preserve  a  warm  state  of  the 
surface,  and  promote  the  insensible  perspiration  ;  and  hence  I 
order  all  my  patients,  particularly  those  in  hospital,  to  wear  a 
new  flannel  shirt  next  the  skin,  and  have  had  repeated  occasion 
to  observe  its  good  effects.  We  may  use  wine  freely,  particularly 
when  the  skin  is  cool  and  clammy,  and  the  pulse  small,  rapid, 
and  compressible,  and  its  good  effect  will  be  shewn  by  this,  that 
while  the  skin  becomes  warm,  the  pulse  diminishes  in  frequency 
and  increases  in  volume,  and  these  favourable  circumstances 
correspond  with  improvement  in  the  respiratory  symptoms. 

Patients  labouring  under  this  disease  should  be  as  much  as 
possible  prevented  from  lying  on  their  back ;  they  should  be 
turned  from  side  to  side,  and  propped  by  means  of  soft  pads  ; 
and  should  the  stethoscope  indicate  a  decided  predominance  of 
disease  in  either  lung,  it  will  be  advisable  to  keep  them  from 
lying  on  that  side.  The  smaller  the  rales  the  greater  will  be  the 
necessity  for  this  precaution. 

But  it  occasionally  happens,  that  notwithstanding  all  our 
endeavours,  a  super- secretion  shall  come  on  at  an  advanced  period 
of  the  fever,  and  the  patient  rapidly  fall  into  a  state  of  imminent 
suffocation  ;  he  then  lies  on  his  back,  the  sputa  rattle  in  his 
throat,  he  is  nearly  insensible,  and,  if  not  relieved,  must  in- 
evitably perish.  Under  these  circumstances,  emetics  have  been 
strongly  recommended  by  Dr.  Mackintosh.  But  my  hopes  from 
the  use  of  these  remedies  have  been  so  often  disappointed,  that 
although  I  would  administer  them  in  all  such  cases,  yet  I  would 


BRONCHITIS.  115 

estimate  the  chance  of  recovery  as  exceedingly  small.  The  cases 
in  which  I  have  used  this  practice  myself,  or  seen  it  employed  by 
others,  may  be  divided  as  follows  : 

First.   Those  in  which  the  action  of  the   emetic  was  followed 
by  recovery,  this  is  by  far  the  smallest  class. 

Second.  Those  in  which  the  emetic  produced  full  vomiting, 
and  the  patient  appeared,  as  it  were,  to  be  snatched  from  the 
jaws  of  death,  so  great,  and  for  a  time  so  complete,  was  the 
relief  produced.  Yet  in  the  course  of  twenty-four  or  thirty- six 
hours,  the  accumulation  again  recurred,  and  the  situation  of  the 
patient  was  as  bad  as,  or  worse  than,  before.  Under  these  cir- 
cumstances the  emetic  may  again  and  again  produce  its  full 
effect,  but  at  length  the  disease  is  triumphant,  and  a  protracted 
struggle  closes  this  melancholy,  and  to  the  thinking  physician, 
most  humbling  scene.  In  one  of  my  cases  the  disease  occurred 
in  a  young  and  robust  girl,  and  great  relief  was  given,  no  less 
than  four  times,  by  the  use  of  emetics,  while  in  the  intervals  no 
means  that  my  ingenuity  could  devise,  were  neglected  to  moder- 
ate the  disease.  But  our  efforts  were  in  vain,  and  the  patient 
ultimately  sunk  with  tracheal  rattle.  On  dissection,  the  whole 
bronchial  system  was  filled  with  reddish  frothy  mucus,  and  the 
lining  membrane  was  universally  red. 

Third.  Those  in  which  no  vomiting  whatever  was  produced, 
even  by  the  administration  of  the  most  powerful  emetics ;  of 
these  cases  I  have  seen  a  considerable  number.  In  some  the 
powers  of  life  were  certainly  much  sunk,  and  the  blood  in  a  very 
unarterialized  state ;  but  I  have  also  seen  cases  where  there  was 
still  much  vigour,  and  where  not  the  slightest  action  was  pro- 
duced on  the  stomach,  even  by  the  most  powerful  emetics.  Can 
this  be  explained  by  the  doctrine  of  the  physiological  school,  that 
the  plus  vitality  or  irritation  of  one  organ  implies  a  minus  state 
of  others  '?  In  such  cases  I  have  observed,  that  no  apparent 
effect  either  on  the  pulmonary  symptoms,  or  on  the  gastro- 
intestinal system,  was  produced  by  the  emetic ;  and  I  have  seen 
ipecacuan  wine,  tartar  emetic,  sulphate  of  zinc,  and  sulphate  of 
copper,  administered  successively  to  the  same  patient. 

The  latest  writer  on  this  important  subject  is  Dr.  Graves,  who 
has  proposed  the  employment  of  a  combination  of  tonics  and 
opium  in  the  form  of  enema,  with  the  intention  of  checking  the 
superabundant  secretion.     In  the   epidemic  influenza  of  1833, 

i  2 


116  BRONCHITIS. 

many  examples  of  this  '  suffocative  catarrh  occurred ;  and  in 
several  of  them  the  administration  of  an  enema,  containing  ten 
grains  of  sulphate  of  quinine,  and  twenty  drops  of  laudanum, 
had,  in  his  hands,  the  happiest  effects.  He  gives  the  detail 
of  three  cases  where  the  patient  was  moribund,  and  in  whom 
life  was  distinctly  saved  by  this  treatment.  Before  leaving 
this  subject  I  cannot  do  better  than  insert  his  concluding  ob- 
servations. 

"  To  conclude,  I  must  observe  that  this  form  of  disease  will 
often  baffle  the  most  skilful  practitioner,  and  therefore  the  reme- 
dies I  recommend  will  of  course,  like  all  others,  frequently  fail. 
An  accumulation  of  mucous  secretions  in  the  air  passages  pro- 
ducing the  rattles,  forms  the  closing  scene  of  almost  all  diseases, 
however  different  in  their  nature.  To  exhibit  remedies  for  this 
would  be  ridiculous  ;  it  is  only  when  this  accumulation  is  the 
direct  consequence  of  actual  disease  attacking  the  air  passages 
themselves  that  we  can  hope  for  its  removal.  In  such  cases  we 
must  try  every  thing  that  experience  has  proved  to  be  even  occa- 
sionally useful,  and  must  carefully  watch  the  effect  of  each  new 
medicine,  for  it  must  not  be  concealed  that  very  different  results 
are  obtained  from  the  same  remedies  under  circumstances 
apparently  similar.  The  injection  of  sulphate  of  quinine  and 
laudanum  possesses,  as  appears  from  the  cases  I  have  detailed, 
veiw  great  powers,  and  for  that  very  reason  must  be  used  with 
circumspection,  for  if  exhibited  at  an  improper  period  of  the 
disease,  or  in  cases  where  expectoration  is  at  all  scanty  and  diffi- 
cult, it  may  produce  dangerous  consequences." 

We  have  now  examined  into  the  history  of  the  primary  and 
secondary  forms  of  bronchitis,  but  it  must  be  considered  in  a 
different  point  of  view,  namely,  as  a  complication  with  other 
diseases  of  the  thoracic  viscera.  It  is  obvious,  however,  that 
were  we  now  to  examine  the  complications  of  the  various  diseases 
of  the  heart  and  lungs  with  bronchitis,  Ave  should  feel  a  difficulty 
from  not  having  yet  investigated  these  subjects  alone.  And 
hence  it  will  be  better  to  describe  the  complication  with  bronchitis 
in  the  separate  affections  as  they  come  before  us. 


BRONCHITIS.  117 


0RC4ANIC    CHANGES    OF    THE    TUBES    AND    AIR    CELLS   CONSIDERED  IN 

RELATION    TO    BRONCHITIS. 

These  mav  be  enumerated  as  follows  : 

First.  Narrowing  of  the  calibre  ;  obliteration. 

Second.  Dilatation  of  the  tubes. 

Third.  Ulcerative  destruction  of  the  tubes. 

Fourth.  Enlargement  of  the  air  cells. 

Fifth.  Atrophy  of  the  lung. 

Before  proceeding  to  examine  these  lesions  I  must  premise, 
that  I  do  not  contend  fo^  their  inflammatory  origin  in  every  case. 
I  do  not  deny  that  a  process,  different  from  the  inflammatory, 
may  produce  obliteration  or  dilatation  of  the  tubes  or  air  cells ; 
but  when  we  look  at  the  whole  subject,  these  instances  seem  to 
form  the  exception  to  a  general  rule,  and  a  great  amount  of 
evidence  goes  to  shew  that  the  connexion  between  these  lesions 
and  an  inflammatory  process  is  seen  in  a  vast  majority  of  cases. 

It  will  be  necessary  here  to  take  a  brief  view  of  the  structure 
of  the  lung,  as  connected  with  the  bronchial  tubes.  The  views 
of  Malpighi,  subsequently  confirmed  by  Beissessen,*  and  more 
lately  established  by  Reynaud,t  must  be  now  adopted.  Indeed 
the  opinions  of  Helvetius,  Haller,  and  others,  which  held  that  at 
the  termination  of  the  bronchi  they  ceased  to  exist  as  ramifying 
tubes,  but  were  lost  in  a  spongy  tissue,  Avhose  cells  communi- 
cated in  all  directions,  were  not  only  at  variance  with  accurate 
anatomy,  but  opposed  to  that  analogy  of  structure  which  Muller 
has  shewn  to  exist  in  all  glandular  organs,  among  which  the 
lung,  from  its  structure  and  functions,  must  be  classed,  and  the 
coincidence  between  two  such  anatomists  as  Reissessen  and 
Muller,  each  on  a  separate  path  of  investigation,  was  all  that  was 
wanting  to  set  the  cpiestion  at  rest. 

This  structure,  so  far  as  the  air  tubes  or  excretory  ducts  of 
the  gland  are  concerned,  may  be  stated  to  be,  that  there  is  a 
progressive  subdivision  of  the  bronchial  canals  until  their  ulti- 
mate ramifications  terminate  in  culs  de  sac,  which  we  call  the 
air  cells.  Thus,  the  tubes  continually  subdivide,  but  never 
anastomose.  % 

*  De  Fabrica  Pulmonum,  a  Reg.  Acad.  Scient.  praam,  ornat.     Berolini,  1822. 

|  Memoires  de  l'Academie  Royale  de  Medecine,  torn.  iv.  1835. 

%  As  the  work  of  Reissessen  is  but  little  studied  in  this  country,  I  shall  give  his 


118  BRONCHITIS. 

Although  I  have  not'  made  any  observations  on  the  normal 
structure  of  the  lung,  which  could  confirm  or  shake  this  doc- 
trine, yet  I  have  been  convinced,  from  the  examination  of 
morbid  parts,   that  the  views  of  Malpighi  and  Reissessen  are 


conclusions  on  this  subject  in  his  own  words.     After  detailing  the  experiments  on 
which  his  opinions  are  founded,  he  adds  : — 

1.  "  Fistula  igitur  spiritalis  in  ramos  dividitur  certa  constantissimaque  ratione  et 
diametro  decrescentes  et  numero  augescentes,  usque  dum  coecis  terminetur  finibus 
iisdemque  rotunde  clausis. 

2.  "  Nee  ideo  in  telarn  cellulosani  abit  hujusve  naturam  recipit,  sed  propriam  ipsius 
fabricam  ad  extremos  usque  fines  servat,  quibus  ut  dixi  clausis,  cellulas  refert,  sive 
vesiculas  aeriferas. 

3.  "  Cartilagenia  tantum  persistit,  quoadusque  fabricse  subtilitas  cartilaginem  fert, 
deinde  membranacea  excurrit."     Op.  Cit.  p.  xi. 

I  shall  also  subjoin  the  observations  of  M.  Reynaud. 

"  I  have  repeatedly  examined  the  lungs  of  the  foetus  that  had  not  respired,  and  on 
passing  mercury  into  the  tubes,  if  I  found  very  fine  lobules  at  the  edge  of  the  inferior 
lobe.  I  could  distinctly  see  a  fine  air  tube  entering  them,  dividing  necessarily  into 
many  branches,  each  of  which  again  subdivided  in  the  same  manner,  and  so  on  re- 
peatedly. These  divisions,  shortening  and  diminishing  in  diameter,  terminated  by 
becoming  pitted,  as  if  a  vast  number  of  little  culs  de  sac,  or  depressions  arose  from 
their  sides,  and  their  extremities  were  rounded  and  closed.  Beyond  this  point  the 
mercury  could  not  penetrate.  It  presented  a  perfectly  regular  arborescent  form,  whose 
terminal  ramifications  had  no  lateral  connexion,  as  proved  by  the  fact  that  even  when 
these  ramifications  were  pressed  close  to  one  another  no  admixture  of  the  mercury 
took  place.  When  the  quicksilver  was  pressed  into  one  of  the  minute  tubes,  the  fine 
bronchial  tree  could  be  seen  forming  before  the  eye.  And  what  proved  that  these 
canals,  through  which  the  mercury  had  penetrated,  really  pre-existed  was,  that  on 
removing  the  pressure  the  mercury  retired,  again  to  return  to  its  previous  position- 
But  on  its  reaching  its  final  termination  it  could  be  forced  no  farther,  nor  did  the 
pressure  employed  cause  any  of  the  minute  terminal  globules  to  be  confounded. 

"  In  many  other  instances,  even  where  I  employed  no  injection,  or  any  other  prepara- 
tion whatever,  I  have  seen  the  same  disposition  in  the  adult  lung  of  animals  and  man, 
whose  bronchial  terminations  are  much  larger  than  in  the  foetus.  In  a  portion  of  the 
lung  of  an  ape,  which  I  removed  from  the  anterior  edge  of  the  organ,  and  dried  upon 
glass,  so  that  the  air  was  continued  in  its  last  bronchial  ramifications,  the  disposition 
above  described  could  be  most  plainly  seen. 

"  What  prevents  us  observing  so  easily  this  mode  of  termination  of  the  bronchial 
tubes  in  the  recent  human  lung  is,  that  the  last  ramifications  terminate  perpendicularly 
to  the  pleura,  from  which  we  can  only  see  their  terminal  culs  de  sac,  and  the  trunks 
from  which  these  have  been  derived.  In  a  considerable  number  of  lungs,  however, 
I  have  observed  that  in  certain  points  of  their  surface  there  existed  a  curious  disposi- 
tion which  allowed  me  to  observe  the  trajet  of  several  bronchial  ramifications  through 
the  pleura.  From  some  cause,  which  I  cannot  explain,  a  certain  number  of  tubes, 
longer  than  the  others,  had  not  the  pleura  for  their  limit,  but  having  arrived  at  that 
membrane,  in  place  of  terminating  perpendicularly  to  it,  they  turned  and  ran  parallel 
to  it  for  a  distance  varying  from  two  to  five  lines,  or  upwards.  Under  these  circum- 
stances, the  air  contained  in  them,  like  the  meicury,  as  above  stated,  formed  a  perfectly 
regular  tree,  the  arborescent  form  of  which  was  continued  to  a  point,  beyond  which 
pressure  could  no  longer  force  it,  and  which  obviously  shewed  the  termination  of  the 
tree." — Memoivts  de  V  Acad.  Royale  de  Medecine,  torn.  iv.  Fas.  11.  The  same  author 
adds  a  confirmatory  dissection,  which  it  is  unnecessary  to  insert  here. 


BRONCHITIS.  119 

correct.  To  this  point  we  shall  just  now  return,  when  1  shall 
describe  a  singular  variety  of  pneumonia,  since  noticed  by 
Keynaud,  which  gives  a  beautiful  demonstration  of  the  pul- 
monary structure,  and  the  relation  of  the  air  cells  to  the 
tubes. 


NARROWING  AND  OBLITERATION  OF  THE  BRONCHIAL  TUBES. 

Hitherto  the  diminution  in  capacity,  and  obliteration  of  the 
bronchial  tubes,  have  been  merely  noticed  as  curious  points  of 
pathological  anatomy,  and  it  was  reserved  for  M.  Reynaud  to 
call  the  attention  of  pathologists  more  especially  to  this  most 
important  lesion.  Yet  even  this  distinguished  physician  goes 
little  farther  than  to  describe  the  various  species  of  obliteration, 
declaring  that  as  yet  he  is  ignorant  of  its  symptoms,  and  even  in 
doubt  as  to  its  causes.  To  me  it  appears  that  there  can  be  little 
question  as  to  its  cause  in  the  great  majority  of  instances,  and 
that  to  its  existence  we  are  to  attribute  many  hitherto  unex- 
plained auscultatory  phenomena,  of  importance,  not  only  in  the 
diagnosis  of  bronchitis,  but  more  especially  in  that  of  the  early 
stages  of  pulmonary  consumption. 

It  is  obvious  that  when  inflammatory  action  seizes  on  a 
bronchial  tube,  its  effect,  considered  anatomically,  will  vary 
according  to  the  diameter  of  the  canal.  In  the  larger  tubes, 
whose  parietes  are  guarded  with  strong  cartilaginous  plates, 
nothing  but  a  great  local  hypertrophy  of  the  mucous  membrane 
could  cause  an  obliteration,  while  in  the  minuter  tubes,  whose 
perviousness  is  not  so  provided  for,  the  same  process  would 
much  sooner  produce  obliteration. 

Indeed,  in  the  diseases  of  what  may  be  called  tubular  or- 
gans, experience  shews,  that  when  we  can  compare  canals  of 
different  diameters,  as,  for  instance,  in  the  circulating  system, 
the  liability  to  obliteration  is  directly  as  the  smallness  of  the 
tube.  We  accordingly  find  that  in  the  lung  it  is  the  minuter 
tubes  which  are  commonly  the  seat  of  the  obliterating  process, 
and  when  we  reflect  on  the  frequency  of  pulmonary  irritations, 
and  the  extreme  minuteness  of  the  ultimate  ramifications  of  the 
tubes,  it  seems  strange  indeed,  that  the  lesion  does  not  more 
often  occur.  It  is  obvious,  however,  that  in  the  respiratory 
motions,  both  of  inspiration  and  expiration,  but  particularly  the 


120  BRONCHITIS. 

first,  there  is  an  important  provision  against  the  obliteration 
of  the  air  passages  while  in  a  state  of  disease. 

But  the  subject  must  be  considered  in  another  point  of  view, 
namely,  as  connected  with  original  structural  differences  in  the 
lining  membrane  of  the  large  tubes  and  smaller  ramifications. 
It  seems  now  established,  that  in  following  the  bronchial  rami- 
fications, from  their  origin  to  the  pleura,  we  may  observe,  if  not 
a  complete  transformation  from  mucous  to  serous  membrane,  at 
least  a  decided  tendency  to  it,  which  increases  as  we  approach 
their  terminations.  In  the  larger  tubes  we  find  a  vascular 
mucous  membrane,  endowed  with  villosities  and  glands,  but  as 
we  advance  into  the  substance  of  the  lung,  this  tissue  gradually 
loses  its  original  characters,  until  at  its  ultimate  point,  if  it  be 
not  completely  serous  membrane,  it  closely  approaches  to  it  in 
appearance  and  function.  If  we  now  add  these  considerations 
to  the  preceding,  we  get  at  once  a  sufficient  explanation  of  the 
point  in  question.  As  M.  Reynaud  remarks,  we  may  expect  the 
plastic  inflammation,  the  more  the  affected  tissue  approaches  to 
white  structure,  and  hence  another  cause  of  the  greater  liability 
of  the  minute  tubes  to  obliteration. 

A  diminution  of  the  calibre  of  the  air  passages  may  arise 
from  various  causes  ;  among  which  the  following  are  recognized 
by  pathologists  : 

First.  A  thickening  of  the  mucous  membrane.  This  may 
result  from  inflammatory  turgescence,  congestion,  or  oedema,  or 
be  caused  by  a  permanent  organic  change,  in  which  there  is 
actual  hypertrophy  of  the  membrane.  These  changes  are  most 
evident  in  the  affections  of  the  larger  tubes. 

Second.  We  observe  this  change  as  a  result  of  the  se- 
cretions of  the  tube.  This  is  seen  either  in  cases  of  croup,  or 
of  that  form  of  bronchitis  in  which  casts  of  the  tubes  are  ex- 
pelled. In  the  latter  instance  very  large  tubes  may  be  affected, 
so  that  we  can  hardly  agree  with  Andral  in  his  opinion,  that 
unless  when  the  larynx  in  children,  or  the  minute  bronchi  in 
them  and  the  adult  are  engaged,  this  cause  hardly  affects  the 
capacity  of  the  tube. 

TJiird.   The  compression  of  the  tubes  by  external  tumours. 

Fourth.  The  existence  of  foreign  bodies  within  the  tube. 

Such  are  the  causes  enumerated  by  Andral ;  but  it  is  with 
the  two  first  classes  that  we  have  at  present  to  do.     It  is  plain, 


BRONCHITIS.  121 

that  if  any  of  these  causes  be  carried  to  a  certain  point,  oblite- 
ration of  the  tube  must  ensue  ;  but  we  find  that  this  termination 
is  much  more  often  a  result  of  disease  of  the  interior  than  of 
the  exterior  of  the  tube. 

Obliteration  of  the  Bronchi. — In  considering  the  relation 
of  this  disease  to  inflammatory  action,  we  shall  first  advert  to 
some  important  points  established  by  M.  Reynaud. 

If  we  commence  at  the  termination  of  the  tube  or  the  air 
cell,  and  proceed  towards  the  trachea,  it  is  found  that  oblite- 
ration may  take  place  at  almost  all  points  of  the  bronchial  tree. 
I  have  already  alluded  to  a  case  by  Andral,  where  the  ob- 
struction, which  was  owing  to  a  local  hypertrophy  of  the  mucous 
membrane,  took  place  only  a  few  lines  from  the  origin  of  the 
principal  bronchus  of  the  upper  lobe.  I  do  not  know  of  any 
case  of  obliteration,  or  even  great  internal  obstruction  of  the 
primary  divisions  of  the  trachea,  but  with  this  exception,  the 
disease  has  been  met  with  in  the  remaining  portions  of  the 
tree. 

In  all  cases,  except  where  the  tube  was  extremely  minute, 
it  was  found,  that  just  at  the  commencement  of  the  obliteration 
a  cul  de  sac  existed,  beyond  which  the  tube  was  converted 
into  a  solid  fibrous  cord,  furnishing  also  ramifications  which 
answered  to  the  originally  pervious  tubes. 

In  some  cases  these  culs  de  sac  formed  dilatations  of  the 
tube,  a  fact  principally  observed  when  the  larger  canals  were 
engaged ;  while  in  others,  the  tube  terminated  more  or  less 
abruptly,  without  any  perceptible  dilatation,  and  was  replaced 
by  a  solid  fibrous  cord,  which  when  it  sprung  from  a  large 
tube,  could  be  seen  to  be  conical,  gradually  diminishing  in 
volume,  and  traceable  near  to  the  surface  of  the  lung,  or  even 
under  the  pleura.  In  other  respects  the  disposition  of  these 
cords  was  very  variable  ;  in  some  instances  their  subdivisions 
were  as  regular  as  those  of  the  bronchial  tubes  themselves,  and 
terminated  near  the  pleura  by  a  vast  number  of  minute  fila- 
ments ;  while  in  others,  a  single  cord  passed  onwards  to  the 
pleura,  from  the  sides  of  which  secondary  filaments  were  seen 
to  emanate. 

These  observations,  it  must  be  borne  in  mind,  apply  chiefly 
to  that  form  of  obliteration  in  which  the  sides  of  the  tube  ad- 
here, without  the  presence  of  any  foreign  matter  in  their  cavity. 


122  BRONCHITIS. 

The  condition  of  the  mucous  membrane,  in  the  vicinity  of  the 
obliteration,  was  various  ;  in  some  cases  being  healthy,  in  others 
inflamed. 

One  of  the  most  interesting  points  connected  with  these  re- 
searches, was  the  state  of  the  pulmonary  tissue  and  bronchial 
tubes  in  the  vicinity  of  the  obliteration.  In  the  effects  pro- 
duced on  these  structures  we  may  see  some  analogy  to  the  re- 
sults of  obstruction  of  the  arterial  system,  namely,  atrophy,  and 
a  collateral  circulation.  Thus,  although  proceeding  from  causes 
widely  different  from  those  alluded  to,  we  find  a  dilatation  of 
the  neighbouring  tube  and  an  atrophy  of  the  pulmonary  tissue 
in  these  cases  of  obliteration.  But  it  is  plain  that  when  we 
recollect  the  structure  of  the  lung,  we  at  once  see  that  this 
dilatation  of  the  neighbouring  tubes  has  no  analogy  to  the 
collateral  circulation  in  arterial  obstruction. 

It  is  found  that  in  the  vascular  system  the  circulation  can 
be  continued  collaterally,  or  even  into  the  original  trunk  below 
the  point  of  obliteration.  But  as  Reynaud  well  remarks,  this 
can  never  occur  in  the  case  of  the  bronchial  tube,  there  being 
no  collateral  communication  between  its  branches.  Hence 
there  is  a  diminution  in  the  extent  of  respiratory  surface  equi- 
valent to  the  impermeable  portion  of  the  organ.  But  as  the 
inspiratory  effort  is  undiminished,  its  effect  must  be  to  dilate 
the  tubes  in  the  vicinity  of  the  obliteration.  According  to  this 
view,  the  dilatation  is  a  purely  mechanical  process,  how  far 
we  are  to  consider  it  as  such  in  all  cases,  must  be  hereafter 
examined. 

As  might  be  expected,  those  parts  of  the  lung  to  which  the 
obliterated  tubes  extend,  have  been  found  to  present  a  sunken 
appearance,  so  as  to  cause  depression  of  various  depths  on  the 
pleural  surface.  The  mechanism  of  this  change  is  obvious. 
In  the  neighbourhood  of  the  obliterated  canals,  however,  the 
air  cells  were  frequently  found  dilated,  while  in  other  instances, 
the  tissue  was  dense  and  impermeable. 

It  would  appear  that  we  may  consider  this  obliteration  of 
the  bronchial  tubes  in  two  points  of  view :  first,  as  commencing 
in  the  finer,  and  proceeding  by  continuity  of  disease  to  the 
larger  tubes ;  and  secondly,  as  the  result  of  obstruction  of  a 
large  trunk,  and  the  consequent  obliteration  of  the  tubes  to 
which  it  gave  birth,  by  a  process  similar  to  that  observed  in 


BRONCHITIS.  123 

arteries  after  ligature.  Of  these  species  the  first  is  the  most 
frequent  and  important ;  and  I  cannot  help  thinking  that  its  in- 
vestigation will  not  only  go  far  to  clear  up  the  long  controverted 
point  as  to  the  nature  and  origin  of  tubercles,  but  also  throw 
light  on  other  subjects  of  thoracic  pathology. 

M.  Keynaud  draws  a  distinction  between  the  cases  in  which 
the  obliteration  has  taken  place  by  simple  adhesion  of  the  pa- 
rietes,  and  those  where  it  is  produced  by  a  substance  formed 
and  accumulated  in  their  interior.  But  this  distinction  seems 
unnecessary  ;  for  if,  as  I  apprehend  we  shall  find  to  be  the  case, 
there  is  an  analogy  between  these  obliterations  and  those  of 
serous  membranes,  there  seems  to  be  no  more  reason  for  this 
distinction  in  the  former  than  in  the  latter  case.  In  inflam- 
mations of  the  pleura  or  pericardium,  &c,  we  may  have  the 
cavity  destroyed  either  by  simple  adhesion,  or  with  an  inter- 
vening layer  of  the  products  of  the  inflammation ;  yet,  in  either 
instance,  the  nature  of  the  disease  does  not  seem  different.  Of 
course  I  do  not  mean  to  deny,  that  in  certain  cases  a  foreign 
matter,  not  the  result  of  the  disease  of  the  affected  tube,  but 
proceeding  from  other  sources,  might,  in  its  trajet,  obstruct  and 
obliterate  the  canal. 

This  disease  has  been  met  with  as  a  chronic,  or  an  acute 
affection.  As  a  chronic  disease  it  will  be  frequently  found  in 
connexion  with  tubercle.  It  is  an  interesting  fact,  that  it  occurs 
much  more  frequently  in  the  upper  than  the  inferior  portions 
of  the  lung,  and  its  connexion  with  the  development  and  phe- 
nomena of  tubercle  is  too  obvious  to  be  overlooked.  When 
discussing  the  question,  as  to  how  far  we  can  distinguish  be- 
tween bronchitis  and  phthisis,  we  shall  return  to  this  point,  and 
here  only  remark,  that  the  advance  of  medicine  is  strongly  tending 
to  shew  how  artificial  many  of  our  distinctions  have  been. 

As  yet  but  very  few  cases  of  the  disease,  in  its  acute  form, 
have  been  described.  But  there  can  be  no  question,  that  this 
has  arisen  from  the  careless  mode  in  which  dissections  of  the 
lung  are  commonly  made.  I  have  little  doubt,  that  oblite- 
ration of  the  minute  tubes  occurs  in  many  cases  of  pulmonary 
disease ;  and  that  thus  the  pent  up  secretions  of  the  air  cells 
represent,  in  some  cases,  the  acute  granular  tubercle,  and  in 
others,  where  the  affection  is  more  general,  the  suppurative 
pneumonia. 


124  BRONCHITIS. 

Thus,  in  a  patient  of  Louis',  who  died  of  pneumothorax, 
after  small-pox,  numerous  tubercles  were  found  throughout  the 
perforated  lung.  On  dissecting  the  small  bronchial  tubes  which 
led  to  them,  these  canals  were  found  very  red,  and  lined  with 
a  firm  layer,  which  filling  their  cavities,  continued  to  their 
terminations,  thus  giving  them  a  granular  appearance.  Along 
their  course  the  blood  vessels  were  black,  and  the  pulmonary 
tissue  of  a  deep  reddish  brown  colour.  There  was  no  har- 
dening of  the  lung,  nor  the  semi-transparent  infiltration,  but 
the  entire  lung  was  filled  with  small  cavities  containing  pus. 
One  of  these  cavities  was  lined  with  a  whitish  membrane,  which 
was  prolonged  into  the  mouth  of  the  bronchus  that  opened  into 
the  cavity.  "  This  plastic  material,"  says  the  author,  "  pre- 
sented the  same  characters  as  that  contained  in  the  small  bronchi, 
which  by  their  reunion  formed  those  apparently  tuberculous 
masses  which  we  have  spoken  of  above." 

With  respect  to  that  form  of  disease,  in  which  it  represents 
the  suppurative  pneumonia,  I  have  to  remark,  that  in  the  third 
volume  of  the  Dublin  Medical  Journal,*  four  years  before  M. 
Reynaud's  memoir  appeared,  I  described  a  form  of  pneumonia, 
at  that  time  unknown,  but  which  since  has  been  noticed  by 
M.  Reynaud.  Of  the  nature  of  this  affection  I  was  ignorant, 
but  I  now  feel  no  doubt,  that  it  was  an  example  of  this 
"plastic  croup'"  of  the  air  cells  and  minute  bronchial  tubes, 
and  quite  analogous  to  the  case  described  by  the  above  author. + 

A  young  man  entered  the  Meath  Hospital  on  the  13th  of 
April,  1832,  labouring  under  the  usual  symptoms  of  acute 
pneumonia,  which  were  of  three  days'  standing ;  the  disease  was 
found  to  occupy  the  lower  lobe  of  the  left  lung,  which  had 
passed  into  the  stage  of  hepatization.  We  employed  general 
and  local  bleeding,  and  put  him  on  the  use  of  free  doses  of 
calomel  and  opium.  The  blood  drawn  did  not  present  any  in- 
flammatory appearance,  and  although  his  general  symptoms 
seemed  alleviated,  yet  the  stethoscope  did  not  shew  any  im- 
provement in  the  condition  of  the  lung.  In  the  course  of  the 
third  day  of  his  treatment,  a  violent  exacerbation  took  place, 
subsequently  to  which  a  moist  crepitus  was  heard  mixed  with 

*  Contributions  to   Thoracic  Pathology.     Notice  of  an   hitherto  unci  escribed  ter- 
mination of  pneumenia.     Op.  cit.  p.  50. 
•)■  Mernoires  de  l'Acad.  Royale.  &c. 


BRONCHITIS-.  125 

the  bronchial  respiration  over  the  dull  portion,  and  the  right 
lung  became  affected  with  a  general  bronchitis.  These  circum- 
stances, combined  with  the  fact  that  no  ptyalism  whatever  had 
occurred,  induced  rue  after  two  days  to  make  the  diagnosis  of  the 
third  stage  of  pneumonia.  About  this  time  a  remarkable  change 
took  place  in  the  stethoscopic  phenomena.  A  large  rale  was 
heard  about  the  root  of  the  lung,  and  the  bronchial  respi- 
ration here  became  so  peculiarly  modified,  that  even  after 
repeated  examinations  I  declared  to  the  class,  that  I  could  not 
satisfy  myself  of  its  exact  nature,  and,  therefore,  could  not  say 
whether  or  not  an  abscess  had  formed  ;  the  dulness  continued. 
On  the  seventh  day  copious  sweatings,  preceded  by  rigors, 
supervened ;  these  continued  till  the  twelfth  day  from  his 
admission,  when  he  sunk. 

On  dissection,  we  found  the  bronchial  mucous  membrane 
universally  inflamed,  and  recent  adhesions  of  the  pleura,  parti- 
cularly the  left.  On  removing  the  left  lung,  its  upper  lobe  was 
found  crepitating,  though  engorged,  but  the  lower,  when  viewed 
externally,  represented  a  bag  of  matter,  the  yellow  colour  of 
which  was  seen  plainly  through  the  pulmonary  pleura.  This 
being  opened,  displayed  the  substance  of  the  lower  lobe  com- 
pletely dissected  from  its  pleura,  by  the  suppurative  inflam- 
mation of  the  sub-serous  cellular  membrane.  This  process  also 
was  found  to  have  invaded  extensively  the  inter-lobular  and  in- 
ter-vesicular cellular  tissue,  so  as  to  cause  this  part  of  the  lung 
to  represent  nearly  the  structure  of  a  bunch  of  grapes.  All 
these  nearly  isolated  lobules  were  surrounded  by  puriform  mat- 
ter, in  which  they  hung  from  their  bronchial  pedicles.  There 
was  no  air  in  the  cavity  thus  formed  within  the  pleura,  yet  ex- 
ternal to  the  lung,  nor  could  I  find  any  evidence  of  any  bronchial 
communication  with  it. 

At  the  period  of  this  dissection  I  was  not  able  to  find  any 
description  of  this  termination  of  pneumonia,  and  merely  re- 
marked that  the  case  was  one  which  might  be  appealed  to  by 
those  who  hold  that  the  original  seat  of  pneumonia  is  in  the 
inter-lobular  and  inter-vesicular  cellular  tissue,  and  that  the  air 
cells  are  secondarily  affected.  Here  we  found  the  sub-serous 
and  inter-vesicular  tissue  extensively  suppurated,  so  as  to  pre- 
sent a  beautiful  dissection  of  the  lung,  while  the  pulmonary 
vesicles  were  comparatively  intact,  but  remained,  as  represented 


126  BRONCHITIS. 

by  the  bunch  of  granules,  immersed  in  the  surrounding  puriform 
matter. 

I  shall  now  give  an   abstract  of  M.  Reynaud's  case  of  the 
same  form  of  disease. 

"  A  patient,   aged  35,   died  after  a  rapid  acute    pneumonia. 
The  left  lung  was  entirely  hepatized,  the  top  of  the  organ  alone 
being  free  from  alterations.     On  cutting  into  the  lung  its  tis- 
sue was   red,  interspersed  with  yellow  and  black  patches.     In 
some  portions  the  colour  was  uniformly  grey,  or  like  that  of  pus. 
The   organ,   covered  by  a   recent   yellow    false  membrane,   did 
not    collapse  on  opening    the    chest  ;    its    density  and    specific 
gravity  might  be  compared  to  that  of  the  liver  ;    it  was  com- 
pletely deprived  of  air,   and  broke  under  the  finger.     By  these 
characters  it  was  easy  to  recognize  the  second  stage  of  pneu- 
monia   and    its    passage    into    the    third    or    suppurative  stage. 
So  far  the  lung  presented   nothing  that  could  make  it   distin- 
guishable from  other  lungs  in  the  stage  of  red  or  grey  hepati- 
zation ;    but    closer    attention    discovered    consistent    cylinders 
projecting  from  the  interior  of  the  bronchi  of  the  second  and 
third  order,  as  is  often  seen  to  occur  with  respect  to  the  dis- 
coloured coagula  observed  in  blood-vessels,  and  for  which  at  first 
sight  these  were  mistaken.     As  this  matter  formed  in  the  inte- 
rior of  the  bronchi   solid  cylinders  which  penetrated   all  their 
divisions,  it  could  be  taken  out  in  a  very  arborescent  form,  the 
perfect  cast  of  the   bronchial   ramification  itself.       At  a  short 
distance    from    the   periphery  of  the   organ    these   branches  of 
plastic  matter  still    presented  the  arborescent   appearance,  and 
by  careful  dissection  might  be  followed  to  the  terminal  vesicles 
within    half   an    inch    of   the  pleura,   where  there  appeared  on 
them  small  lateral  swellings,  round,   regular,   at  first  isolated, 
afterwards  more  numerous,  so  that  they  appeared  festooned  on 
their  borders.     Some  of  these  projections  occurred  at  only  one 
side,  and  in   this  particular  instance   they  gave  off  other  and 
more  numerous  bulbs,  presenting  the  appearance  of  bunches  of 
grapes.     A  very  slight  pulling  on  the  principal  cord  from  which 
they  sprung  sufficed  to  remove  them  without  any  dissection  of 
the  cavities  which  contained  them. 

"  According  as  we  approached  closer  to  the  pleura,  the  little 
cylinders,  of  which  we  have  spoken,  became  divided  into 
branches,    shorter,    more    numerous,   and    swollen   at  their  ex- 


BRONCHITIS.  127 

tremity,  so  as  to  appear  knotty  ;  and  immediately  under  the 
pleura  they  appeared  in  form  and  colour  similar  to  those  gra- 
nules that  are  observed  in  some  of  the  forms  of  hepatiza- 
tion of  the  lung,  which  this  patient  exhibited  in  the  highest 
degree. 

"  This  appearance  was  not  only  observable  on  the  surface  of 
the  lung,  but  internally  and  on  all  the  points  of  the  incised 
surface.  All  the  bronchi  that  were  examined  were  in  the  same 
state  as  those  I  have  described.  The  smaller  the  bronchi  were 
the  more  full  were  they ;  thus  in  the  branches  the  plastic 
matter  did  not  occupy  two-thirds  of  their  calibre,  while  their 
terminations  were  accurately  filled  in  their  whole  diameter. 

"  In  its  external  characters  the  contained  substance  resem- 
bled fibrine  ;  it  was  of  a  slightly  yellowish  white  colour,  resist- 
ing, elastic,  and  capable  of  being  separated  into  filaments.  It 
appeared  under  the  microscope  to  be  composed  of  a  multitude 
of  uncoloured  and  perfectly  round  globules,  like  those  of  the 
blood,  excepting  that  in  the  terminations  of  the  tubes,  where  it 
was  grey  or  of  a  dirty  black  colour.  This  matter  differed  in 
appearance  in  those  parts  of  the  lung  affected  with  the  second 
and  with  the  third  stage  of  pneumonia.  In  the  latter  the  fila- 
ments were  much  more  moist,  less  resisting,  and  thinner,  and 
filled  less  exactly  the  cavities  of  the  tubes. 

"  The  bronchial  parietes  offered  nothing  remarkable  either  in 
colour  or  thickness ;  some  tore  with  more  facility  than  would  be 
expected  in  the  healthy  state  ;  towards  their  terminations  their 
colour  was  similar  to  the  contained  matter." 

To  dwell  on  the  close  similarity  of  these  cases  would  be 
superfluous  ;  but  we  might  inquire  whether  this  form  of  disease 
is  not  more  common  than  would  at  first  appear.  I  cannot  help 
thinking  that  it  is  to  be  met  with  in  many,  if  not  all  cases  of 
the  interstitial  suppurative  pneumonia  (Laennec's  third  state), 
and  that  adventitious  circumstances  prevent  our  seeing  the 
peculiar  appearance  of  the  bunches  of  granules.  Indeed,  Andral 
explains  the  granular  structure  of  the  lung  when  thus  affected, 
by  an  enlargement  and  thickening  of  the  cells  ;  and  I  have  little 
doubt,  that  by  a  process  similar  to  that  by  which  we  demon- 
strate the  cellular  membrane  of  the  brain,  the  structure  of  the 
lung  could  also  be  shewn.  I  think  it  will  be  found  if  a 
drop  of  water  be  let  fall  continually  on  a  lung  in  an  advanced 


128  BRONCHITIS. 

stage  of  pneumonia,  that  the  purulent  matter  between  the 
minute  bronchi  and  air  cells  will  be  washed  away,  and  the  above 
appearance  produced. 

When  Ave  consider  the  structure  and  functions  of  the  lung, 
it  seems  probable  that  its  minute  bronchial  tubes,  or  excretory 
ducts,  might  be  plugged  up  by  secretions  of  the  cells,  independent 
of  inflammation  in  the  parietes  either  of  the  tubes  or  cells.  Yet 
we  cannot  help  looking  on  the  obliteration  as  principally  con- 
nected with  inflammation.  In  fact,  the  preponderance  of  the 
latter  process,  in  the  vast  majority  of  internal  diseases,  gives 
alone  a  great  probability  that  the  lesion  in  question  is  one  of  its 
results.  But  when  we  find  it  occurring  in  an  organ  and  tissue, 
of  all  others  the  most  liable  to  this  action  ;  when  we  recollect 
that  the  adhesive  process  is  always  preceded  by  increased  action ; 
when  we  see  this  most  evident  in  that  part  of  the  tube  in  which 
the  white  tissues  are  predominant,  and  perfectly  analogous  to  the 
same  process  in  serous  inflammations ;  when  we  observe  so  close 
a  resemblance  between  this  disease  and  the  inflammations  of 
other  tubular  organs,  such  as  arteries,  veins,  and  lymphatics  ; 
when  we  find  it  in  most  cases  occurring  with  other  signs  of 
chronic  irritation  of  the  lung,  as  in  phthisis,  or  as  a  distinct 
result  of  acute  inflammation,  we  cannot  avoid  coming  to  the 
conclusion,  that  it  is  a  frequent  and  most  important  result  of 
bronchitis  ;  and  that  before  we  can  consider  the  diagnosis 
and  pathology  of  this  disease  as  established,  its  phenomena 
must  be  studied  with  reference  to  the  obliteration  of  the  minute 
tubes. 

I  need  hardly  say,  that  the  diagnosis  of  this  lesion  is  still  to 
be  investigated.  But  although  not  possessing  any  particular 
observations  on  the  point,  we  may,  to  a  certain  degree,  anticipate 
its  signs.  They  will  of  course  depend  on  various  circumstances, 
such  as  the  number  of  tubes  affected,  the  state  of  the  air  cells, 
and  so  on.  If  but  a  few  tubes  are  affected,  it  is  probable 
that  no  perceptible  physical  sign  would  be  produced  ;  but  if  the 
contrary,  then  we  would  have  a  proportional  feebleness  of 
respiration.  Under  these  circumstances,  if  the  air  cells  con- 
tinued unaffected,  or  but  little  engaged,  the  sound  on  percussion 
would  be  clear,  and  thus  would  be  produced  a  combination  of 
phenomena,  commonly  found  in  the  earlier  stages  of  phthisis. 

On  the  other  hand,  if  a  great  number  of  the  terminal  ramifica- 


BRONCHITIS.  129 

tions,  or  cells,  became  plugged  up  by  their  own  secretions,  the 
combination  of  feebleness  of  respiration  with  a  degree  of  dulness 
would  be  produced  ;  and  this  combination,  as  every  one  knows, 
is  the  most  common  sign  of  incipient  phthisis;  and  the  similarity 
is  completed  when  Ave  recollect  that  the  seat  of  tubercle  and 
obliterated  bronchi  is  most  often  the  upper  lobes  of  the  lung. 
Indeed  there  can  be  little  doubt,  that  we  have  been  long  observing 
the  physical  signs  of  phthisis  under  a  false  idea  of  their  nature, 
and  that  many  of  them,  at  least,  are  to  be  attributed  to  this 
lesion.  When  I  come  to  the  subjects  of  pneumonia  and  phthisis, 
this  point  shall  be  again  brought  before  the  reader ;  and  I  shall 
examine  whether  the  lines  of  distinction,  which  have  been  drawn 
between  these  affections,  are  in  all  cases  so  well  denned  as  some 
pathologists  have  supposed. 

DILATATION    OF    THE    BRONCHIAL    TUBES. 

I  have  already,  when  speaking  of  obliteration  of  the  tubes, 
alluded  to  the  analogy  between  that  disease  and  affections  of  the 
circulating  system.  Thus,  in  the  obliteration  by  adhesion,  in 
the  plugging  up  by  the  results  of  morbid  secretion,  in  the 
atrophy  of  the  parts  of  the  tube  beyond  the  obstruction,  and  in 
its  reduction  to  a  solid  fibrous  cord,  we  see  circumstances  com- 
mon to  disease  both  of  the  bronchial  tubes,  and  the  arteries  in 
general.  We  might  also  extend  this  analogy  to  the  case  of 
dilatation  of  these  canals,  and  trace  a  resemblance  between  the 
bronchial  and  arterial  diseases.  In  both  we  may  see  dilatation, 
either  partial  or  more  general;  in  both  there  is  a  loss  of  elasticity, 
produced  in  most  instances  by  chronic  inflammation,  and  allow- 
ing of  enlargement  of  the  canal  by  the  action  of  the  fluid  which 
passes  through  it.  Further,  we  see  in  either  case  obliteration  of 
the  smaller  trunks  in  the  vicinity  of  the  diseased  tube,  while  in 
other  instances  they  are  pervious  even  when  springing  from  the 
dilated  portion  ;  and  we  observe  compression  and  atrophy  of  the 
surrounding  parts.  In  these  observations  I  only  allude  to  the 
true  aneurism  ;  although  I  think  it  not  improbable  that  the  false 
aneurism  of  the  bronchial  tubes  may  yet  be  discovered. 

Authors  have  described  various  forms  of  this  disease,  which 
in  general  terms  are  reducible  to  three  varieties  :  first,  that  in 
which  the  tube  is  continuously  dilated,  so  as  to  be  nearly  the 

K 


130  BRONCHITIS. 

same  diameter  at  its  termination  as  its  commencement.  When 
this  disease  is  general,  and  that  we  lay  open  the  bronchial  sys- 
tem, the  tubes  present  the  appearance  of  the  fingers  of  a  glove. 
In  the  next  variety,  we  may  have  a  series  of  dilatations  in  the 
course  of  a  single  tube,  an  appearance  which  has  been  well 
compared  by  Laennec  to  the  common  bladder-wrack  (fucus 
vesiculosus.)  And  lastly,  a  bronchial  tube  may  be  dilated  into 
one  large  cavity,  which  gives  the  signs  of,  and  is  often  with 
difficulty  distinguished  from,  a  phthisical  abscess.  As  yet 
but  little  is  known  of  the  causes  which  determine  these  different 
forms. 

But  a  more  important  division  is  that  which  is  based  on  the 
existence  or  absence  of  inflammatory  action  in  the  tissue  itself. 
In  some  cases  decided  marks  of  chronic  inflammation  are  found, 
such  as  thickening,  ulceration,  opacity,  puriform  secretion,  and 
so  on;  while  in  others,  the  tubes  are  found  thinned,  so  as  to 
become  almost  transparent.  It  is  not  improbable,  but  that  in 
the  first  of  these  cases  the  dilatation  is  owing  to  a  long-continued 
morbid  action  in  the  affected  portion  of  the  tube  itself,  which, 
while  it  has  hypertrophied  the  tunics,  has  destroyed  their  tonicity, 
while  that  in  the  other  case,  the  dilatation  will  be  found  to  be 
passive,  and  produced  not  so  much  by  disease  of  the  tube  itself, 
as  by  the  obliteration  of  other  canals,  which,  as  Eeynaud  has 
shewn,  in  consequence  of  the  respiratory  effort  continuing  the 
same,  is  a  powerful  cause  of  dilatation  of  the  unaffected  tubes. 
At  the  same  time  we  must  admit,  that  a  process,  similar  to  that 
of  the  softening  and  thinning  of  the  stomach  might  also  occur  in 
the  bronchial  tubes,  and  thus  produce  a  dilatation  independent 
of  increased  nutrition  or  vascular  action. 

The  explanations  that  have  been  given  as  to  the  cause  of  this 
disease  are,  to  a  certain  degree,  various ;  Laennec  held,  that  the 
dilatation  was  produced  by  the  stasis  of  a  large  sputum  in  the 
tube,  which,  from  its  frequent  repetition,  ultimately  produced 
enlargement.  But  this  explanation  has  been  considered  too 
mechanical  by  subsequent  authors.  Thus  Andral*  declares,  that 
it  must  be  referred  to  some  vital  action  of  the  parts,  andKochef 
and  Williams:}:   to   inflammation,  which,   by  diminishing  the 

*  Clinique  Medicale,  torn.  ii. 

f  JDictionnaire  de  Medicine  et  de  Chirurgie,  Art.  Bronchite. 

X  Cyclopaedia  of  Practical  Medicine. 


BRONCHITIS.  131 

cohesion  of  the  tissues,  causes  them  to  yield  to  the  impressions 
of  respiration  and  cough.* 

In  examining  this  question,  we  should  begin  with  recollecting 
the  tissues  which  form  the  bronchial  tubes.  These  are  mucous 
membrane,  cellular  tissue,  cartilaginous  plates,  and  the  two 
orders  of  fibres,  first  accurately  investigated  by  Reissessen,  the 
one  longitudinal,  and  the  other  circular.  Now,  if  the  views  of 
this  author,  as  to  the  muscularity  of  the  lung,  be  correct,  and 
that  they  are  so  seems  admitted,  we  may  divide  the  bronchial 
structures  into  the  non-muscular,  and  the  muscular  layers. 
Among  the  first  are  to  be  enumerated  the  cartilaginous  plates, 
and  also  those  longitudinal  fibres,  which  he  has  shewn  to  be 
analogous  to  the  elastic  coat  of  arteries  ;  and  in  the  second,  we 
have  the  circular  fibres,  which  are  to  be  considered  as  muscular. 
If  we  now  study  the  effects  of  irritation  on  each  of  these  classes 
of  tissues,  we  find  that  on  the  non-muscular  it  produces  loss  of 
elasticity,  as  is  observed  in  the  case  of  arteries,  causing  their 
aneurismal  dilatation ;  and  in  this  way  we  can  understand  the 
enlargement  of  the  bronchial  tubes,  by  the  repeated  impulsion  of 
respiration  and  cough. 

But  another  cause  may  exist,  and  it  is  one  as  yet  not  alluded 
to  by  any  author,  I  mean  a  paralysis  of  the  muscular  structure 
itself,  the  result  of  the  inflammatory  action  ;  and  which,  like  the 
paralysis  of  the  intestine  in  enteritis,  or  ileus,  is  followed  by  a 
dilatation  of  the  tube.  Dr.  Abercrombie  has  shewn,  that  ileus 
may  occur  without  mechanical  obstruction ;  that  the  dilatation 
of  the  tube  may  be  referred  to  a  lesion  of  the  muscular  apparatus 
itself ;  f  and  further,  that  the  collapsed  parts  are  almost  inva- 
riably found  healthy  at  all  periods  of  the  disease,  the  morbid 
appearances  being  confined  to  the  distended  portions. 

There  can  be  no  doubt  of  the  fact,  no  matter  how  we  explain 
it,  that  where  muscular  structures  are  in  close  connexion  with 
other  tissues  which  are  inflamed,  their  functions  suffer,  and  we 
observe,  first,  an  increase  of  innervation,  as  shewn  by  pains  and 
spasms,  and  next  a  paralysis,  more  or  less  complete.     When  we 

*  Dr.  Gairdner  considers  that  "  almost  all  the  so-called  bronchial  dilatations  and  all 
those  of  the  abrupt  sacculated  character  are  in  fact  the  result  of  ulcerative  excavations 
of  the  lung  communicating  with  tbe  bronchi,"  and  becoming  lined  with  a  membrane 
"  not  exactly  resembling  the  mucous  membrane  of  a  bronchus."  See  Monthly  Jour, 
of  Med.  Science,  vol.  xiii.  p.  248.     (Ed.) 

t  Diseases  of  the  Stomach  and  Abdominal  Viscera,  p.  185. 

k2 


132  BRONCHITIS. 

come  to  speak  of  empyema,  diaphragmitis,  and  inflammation  of 
the  heart,  we  shall  see  of  what  importance  these  considerations 
are.  At  present  it  appears  that  we  may  hope  to  elucidate  some 
points  in  the  symptoms  and  treatment  of  bronchitis  by  having 
recourse  to  this  view.  May  not  this  paralysis  explain  the  diffi- 
culty of  expectoration  in  certain  cases  ;  the  stasis  of  matters  in 
the  tubes,  and  the  liability  to  asphyxia  in  bad  catarrhal  fevers  ? 
And  we  might  further  inquire,  how  far  its  existence  should  lead 
us  to  modify  our  treatment,  and  seek  for  some  agent  which 
would  stimulate  the  bronchial  muscles  to  contract.  Abercrombie 
relates  a  case  of  distention  of  the  bowels,  in  which  galvanism 
had  the  best  effect ;  and  I  have  already  alluded  to  the  use  of  the 
same  agent  in  pulmonary  disease  by  Drs.  Philip  and  Forbes. 
Now,  as  the  lung  derives  a  large  portion  of  its  nervous  supply 
from  the  cerebro-spinal  system,  Ave  might  hope,  by  the  exhibition 
of  such  remedies  as  strychnine,  to  act  beneficially  upon  it  when 
its  innervation  was  injured. 

There  remains  for  examination  another  interesting  point  con- 
nected with  this  subject.  It  has  been  shewn  by  Purkinje  and 
Valentin,*  that  the  vibratory  motions  produced  by  cilia  on  the 
surfaces  of  many  of  the  invertebrated  animals  and  reptiles,  is  a 
phenomenon  common  to  the  respiratory  and  generative  mucous 
membranes  of  the  warm-blooded  animals.  These  motions  were 
first  observed  by  Steinbuchf  in  the  larvae  of  the  Batrachian  rep- 
tiles more  than  thirty  years  ago,  and  since,  it  may  be  said, 
re-discovered  by  Dr.  Sharpey  of  Edinburgh,  who,  in  a  paper 
published  in  1830,  t  pointed  out  the  existence  of  the  motion  in 
question  in  the  larva  of  the  frog  and  salamander,  in  most  of  the 
tribes  of  mollusca,  and  in  the  annelida  and  actinia.  He  endea- 
vours to  prove  that  it  was  a  provision  extensively  present  among 
aquatic  animals,  serving  chiefly  to  maintain  a  flow  of  water  along 
the  surface  of  their  respiratory  organs,  but  in  some  cases  also  to 
convey  food  to  the  animal,  discharge  the  ova,  or  assist  in  loco- 
motion. According  to  this  physiologist,  the  characters  of  the 
motion  were,  first,  that  the  fluid  was  moved  along  the  surface  of 
the  parts  in  a  determinate  direction  ;  second,  that  the  impelling 

"  Midler's  Archiv.  fur  Anatomie,  No.  V.,  3  834.  See  also  Dublin  Medical  and 
Chemical  Journal,  May,  1835. 

f  Analecten  neuer  Beobachtungen  und  Untersuchungen  f Ur  die  Naturkunde.  Fiirth, 
1802. 

J  Edin.  Med.  and  Surg.  Journal,  vol.  xxxiv. 


BRONCHITIS.  133 

power  resided  in  the  surface  over  which  the  fluid  was  conveyed, 
which  in  all  instances,  as  subsequent  observations  proved,  is 
covered  with  moving  cilia ;  and,  lastly,  that  it  continued  for 
some  time  in  detached  portions  of  the  tissue,  the  impulsion  of 
the  fluid  taking  place  in  the  same  direction  as  before  the  separa- 
tion of  the  parts. 

In  a  subsequent  paper  *  Dr.  Sharpey  has  published  some 
additional  observations  on  this  subject,  and  states  several  facts, 
in  which  he  had  been  anticipated  by  previous  observers ;  thus 
illustrating  what  has  been  the  case  in  many  instances,  that  our 
most  useful  discoveries  have  resulted  from  the  observations  of 
more  than  one  individual,  and  may  be  justly  termed  progressive. 
It  would  be  improper,  in  a  work  like  this,  to  enter  into  any 
lengthened  details ;  let  it  suffice  to  state,  that  according  to 
the  experiments  of  Purkinje  and  Valentin,  this  vibratory  motion 
occurs  only  in  two  systems  of  organs,  namely  those  of  respiration 
and  generation ;  and  that,  in  the  latter  case,  it  has  been  ob- 
served only  in  the  female.  All  parts  of  the  internal  surface  of 
these  organs  in  mammalia,  birds,  and  reptiles  present  this 
action,  which  as  yet  has  not  been  found  in  any  part  of  the 
intestinal  canal  of  vertebrated  animals.  It  has  been  demon- 
strated on  the  mucous  membrane  of  the  respiratory  passages, 
from  its  commencement  to  its  termination, — over  the  whole 
lining  membrane  of  the  windpipe  and  its  branches,  even  to  the 
smallest  divisions  which  admit  of  investigation.  It  is  also  con- 
spicuous in  the  nose,  but  no  trace  of  it  can  be  discovered  in  the 
lining  membrane  of  the  mouth,  pharynx,  glottis,  or  its  ligaments. 
These  observations  have  been  lately  confirmed  by  Dr.  Sharpey, 
who  has  not  only  demonstrated  the  existence  of  the  ciliary  motion 
in  mammalia,  birds,  and  perfect  reptiles,  but  has  shewn  in  cer- 
tain cases,  the  direction  in  which  matters  are  impelled  along  the 
surface,  in  consequence  of  these  vibrations. t 

It  is  probable  that  we  have  not  as  yet  learned  all  the  uses  of 
these  ciliary  vibrations,  but  that  they  possess  a  power  of  impell- 
ing matters  along  their  surface,  seems  established.  "  Although," 
say  MM.  Purkinje  and  Valentin,  "the  vibratory  motion  is  to  be 
regarded  more  as  a  general  morphological  phenomenon,  yet  we 

*  Edinburgh  New  Philosophical  Journal,  July,  1835. 

f  Account  of  the  Discovery  by  Purkinje  and  Valentin  of  the  Ciliary  Motions,  A*c, 
by  Wm.  Sharpey,  M.D.    Ibid. 


134  BRONCHITIS. 

cannot  entirely  overlook  its  particular  uses.  For  by  its  means 
the  secretions  of  those  mucous  membranes  on  which  it  occurs, 
maybe  conveyed  onwards,  and  many  singular  phenomena  maybe 
accounted  for  in  this  way.  Thus,  for  instance,  when  the  bronchial 
mucus  accumulates  during  a  long  uninterrupted  sleep,  and  is 
afterwards  discharged,  we  do  not  bring  it  up  from  the  interior 
of  the  lungs,  but  only  from  the  larynx,  or  top  of  the  windpipe ; 
but  we  refrain  from  pointing  out  further  applications,  that  we  may 
avoid  the  field  of  mere  hypothesis,  which  is  here  so  tempting." 

Without  entering  farther  into  this  subject,  we  may  remark, 
that  the  pathology  of  bronchitis  and  of  pulmonary  disease  in 
general,  must  be  studied  with  reference  to  these  motions.  We 
can  understand,  as  connected  with  the  subject  of  dilatation  of 
the  tube,  how,  by  allowing  of  the  stasis  of  secretion,  a  paralysis 
of  the  circular  muscles  may  be  followed  by  the  disease  ;  and  if 
this  be  true,  may  not  the  same  occur  with  respect  to  these 
vibratory  cilia  ?  May  not  their  action  be  at  first  increased,  and 
afterwards  destroyed  by  inflammation,  or  may  they  not,  under 
certain  circumstances,  acquire  an  undue  development  ?  Eeynaud 
has  described  a  condition  of  the  bronchial  membrane  in  a  patient 
who  had  long  laboured  under  catarrh,  where  it  presented 
numerous  villosities  standing  out  from  its  surface,  so  as  to  give 
the  idea,  that  aliments  would  have  been  digested  had  they  been 
laid  on  its  surface. 

We  have  now  taken  a  view  of  the  possible  causes  of  the  lesion, 
and  have  seen  that  it  depends  in  most  cases  on  a  morbid  action, 
generally  inflammatory,  which,  while  it  hypertrophies  the  tissues, 
permits  them  to  yield  to  forces,  against  which,  in  their  healthy 
state,  they  have  various  natural  provisions.  In  others,  it  may 
be  the  result  of  atrophy  ;  and  in  a  third  order  perhaps,  it  pro- 
ceeds from  causes,  which,  as  far  as  the  dilated  tube  is  concerned, 
are  purely  mechanical,  such  as  the  obliteration  of  other  tubes, 
or  violent  cough  from  an  irritation,  existing  elsewhere. 

In  examining  into  the  history  of  the  disease,  we  find  that  it 
may  occur  at  all  ages,  from  two  months  upwards.  Guersent  is 
of  opinion  that  it  is  occasionally  congenital,  and  a  predisposing 
cause  of  pulmonary  disease.*  With  respect  to  the  important 
inquiry  as  to  duration  of  disease,  we  may  divide  the  cases 
into  three  classes.     In  the  first,  we  find  that  dilatation  may 

*  Diet,  de  Medicine,  Art.  Coqueluche,  tome  vi. 


BKONCHITIS.  135 

occur  to  a  great  extent  in  a  comparatively  short  time.  This 
has  been  principally  observed  in  young  children  affected  with 
hooping  cough,  in  whom  the  period  of  two  or  three  months  is 
sufficient  to  produce  the  fullest  development  of  the  disease. 
On  considering  the  circumstances  of  these  cases  it  is  plain,  that 
everything  is  combined  which  could  bring  about  such  a  result. 
There  is  a  bronchial  irritation,  accompanied  by  violent  cough, 
and  this  occurring  at  a  period  of  life  when  the  tissues  are  still 
imperfect,  and  the  muscular  apparatus  not  yet  fully  developed, 
is  so  powerful  a  cause,  that  it  seems  only  wonderful  that  the 
lesion  does  not  more  often  occur. 

In  the  next  class,  we  may  place  those  cases  in  Avhich  a 
bronchial  irritation  has  continued  for  many  years,  in  certain 
cases,  indeed  for  the  greater  part  of  the  life  of  the  individual. 
Thus,  in  three  cases  of  this  description,  given  by  Laennec,  the 
duration  of  the  disease  was  fifty,  forty-one,  and  twenty  years. 
In  a  case  which  I  observed  it  had  lasted  forty  years.  Andral 
relates  cases  of  four,  five,  and  six  years'  duration,  and  other 
authors  detail  similar  instances. 

Lastly,  we  have  this  lesion  as  a  common  accompaniment  of  the 
tuberculous  disease  of  the  lung.  Here  the  period  of  duration 
is  of  course  various.  Whether  the  dilatation  proceeds  from  the 
obliteration  of  other  tubes,  as  noticed  by  Reynaud,  or  is  a  result 
of  the  accompanying  bronchitis  of  phthisis,  and  assisted  by  the 
passage  of  the  secretions  and  cavities,  remains  to  be  determined, 
but  most  probably  it  will  be  found  that  all  these  causes  act.  It 
would  be  an  interesting  point  of  inquiry  to  ascertain  how  far 
the  emaciation  of  viscera,  which  we  see  so  commonly  in  phthisis, 
may  predispose  to  this  lesion.  May  there  not  be  a  condition 
of  the  tubes  and  their  muscular  fibres,  analogous  to  that  of  the 
heart  and  stomach ;  a  state  of  atrophy,  highly  favourable  for  the 
occurrence  of  passive  dilatation  ? 

We  may  next  consider  the  nature  and  amount  of  the  expectora- 
tion. It  need  scarcely  be  stated,  that  in  a  disease  occurring 
under  such  different  circumstances,  there  is  no  characteristic 
expectoration,  and  accordingly  the  various  forms  of  mucous, 
muco-serous,  muco-purulent,  and  purulent  secretions,  have  been 
met  with.  The  sputa  may  be  foetid  and  nummular,  and  he- 
moptysis may  occur,  even  in  cases  without  tubercle. 

A  more  important  inquiry  is  that  relating  to  the  quantity  of 


13G  BKONCHITIS. 

the  secretion,  the  more  especially  as  Laermec  has  dwelt  strongly 
on  this  point  in  speaking  of  the  causes  of  the  disease.  Now 
without  denying  the  influence  of  a  superabundant  secretion  in 
producing  this  disease,  yet  we  must  admit  it  as  a  cause  which 
is  not  constant,  and  even  by  itself  incompetent  for  the  effect. 
Dilatation  has  been  met  with  where  the  secretion  has  been 
scanty,  or  even  wanting,  and  an  abundant  expectoration  may 
occur  without  the  lesion  in  question.  "We  must  then  seek  for 
other  causes  which  may  assist  in  the  production  of  the  disease. 
To  some  of  these  I  have  already  alluded,  and  future  investi- 
gations must  determine  how  far  in  addition  to  the  chronicity, 
violent  cough,  and  abundant  expectoration,  described  by  Laennec, 
the  organic  changes  resulting  from  hypertrophy  or  inflammation 
of  Andral,  or  the  mechanical  dilatation  consequent  on  the 
obliteration  of  other  tubes,  which  Eeynaud  has  shown  to  be 
perhaps  the  most  common  cause,  other  circumstances  may  act. 
And  it  seems  highly  probable  that  among  these  we  shall  yet 
reckon  the  loss  of  tonicity  of  the  longitudinal  fibres,  and  the 
paralysis  of  the  circular  muscles  of  Reissessen,  and  even  of  the 
cilia  of  Purkinje  and  Valentin. 

This  disease  is  met  with  uncomplicated  or  combined  with 
other  affections,  particularly  tubercle  :  we  have  the  authority  of 
Laennec  for  stating  that  its  most  ordinary  seat  is  in  the  upper 
lobe  of  the  lung,  although  it  may  exist  in  every  portion  of  the 
organ,  a  fact  strongly  bearing  on  its  connexion  both  with  obli- 
teration of  the  minute  tubes  and  tubercle.  Indeed  in  most  of 
the  cases  where  it  has  occurred  in  the  inferior  portions,  its  first 
seat  seems  to  have  been  above,  as  shewn  by  the  greater  amount 
of  the  lesion.  Andral,  however,  details  one  case,  in  which  the 
dilatation  existed  in  the  middle  lobe  of  the  right  lung ;  but  even 
here  a  calculous  concretion  was  found  in  the  upper  portion. 
With  this  latter  affection  it  is  commonly  combined ;  indeed  I 
do  not  remember  a  single  instance  where  I  have  found  pulmo- 
nary calculi  without  a  corresponding  bronchial  dilatation.  We 
shall  see  hereafter  how  stronglv  this  bears  on  the  subject  of 
tuberculous  disease. 

But  there  is  another  combination  which  has  not  been  suffi- 
ciently noticed,  namely,  that  with  dilatation  of  the  air  cells,  the 
vesicular  emphysema  of  Laennec,  of  which  the  following  is  a 
remarkable  example.     A  man,   aged  40,  was  admitted  into  the 


BRONCHITIS.  137 

Meath  Hospital,  labouring  under  the  symptoms  of  chronic 
bronchitis,  with  paroxysms  of  orthopnoea,  and  with  copious  ex- 
pectoration of  masses  of  a  yellow  colour,  flowing  together  like 
the  white  of  eggs.  He  stated  that  he  had  been  subject  to  an 
asthmatic  cough  since  boyhood.  It  was  observed  that  he  con- 
stantly lay  on  the  left  side,  which  presented  nothing  remarkable 
in  form,  but  the  right  was  singularly  convex,  particularly  on  its 
anterior  portion,  where  a  remarkable  prominence  existed,  ex- 
tending from  the  middle  of  the  third  to  that  of  the  seventh  rib. 
On  percussion,  the  right  side  sounded  morbidly  clear,  but  the 
respiratory  murmur  was  generally  feeble,  and  over  the  whole 
thorax  nearly  replaced  by  a  sibilous  rale  ;  the  heart's  impulse 
was  strong,  and  felt  over  the  anterior  portion  of  the  right  side, 
and  with  violent  pulsation  at  the  ensiform  cartilage. 

This  case,  which  was  sent  in  as  an  example  of  hydrothorax, 
we  considered  to  be  one  of  Laennec's  emphysema,  with  severe 
bronchitis  and  hypertrophy  of  the  heart.  After  he  had  remained 
in  hospital  some  time  we  observed  that  the  postero-inferior 
portion  of  the  left  side  was  dull,  and  that  over  this  side 
considerable  resonance  of  the  voice,  though  not  amounting 
to  pectoriloquism,  could  be  heard.  Soon  after  this  the  patient 
sunk. 

On  dissection  the  lungs  did  not  collapse,  but  appeared  firmly 
bound  down  by  adhesions  so  universal,  that  the  cavities  of  the 
pleurse  were  completely  obliterated.  In  both  lungs  the  lobes 
were  united,  but  this  union  must  have  been  the  consequence  of 
recent  inflammation,  as  the  coagulable  lymph  thrown  out  was 
soft,  and  the  interlobular  pleura  beautifully  injected  with  red 
vessels.  The  adhesions  between  the  pulmonary  and  costal 
pleura?,  on  the  contrary,  appeared  to  be  the  consequence  of  a 
former  affection,  as  they  were  exceedingly  strong,  and  on  the 
antero-superior  part  of  the  right  lung  the  membranes  were 
converted  into  a  thick,  white,  and  cartilaginous  substance.  The 
whole  of  the  right  lung  was  in  a  state  of  emphysema,  all  the  air 
cells  appearing  dilated,  and  the  pleura  raised  in  many  places 
into  vesicles  the  size  of  a  walnut ;  when  cut  into,  these  vesicles 
were  found  divided  by  membranous  septa,  perpendicular  to  the 
surface  of  the  lung.  The  volume  of  this  lung  was  double  that 
of  the  left,  its  bronchial  tubes  filled  with  muco-purulent  fluid, 
and  their  lining  membrane  of  a  bright  red  colour.      The   left 


138  BKONCHITIS. 

lung  was  much  diminished  in  size ;  the  upper  part  covered 
with  large  vesicles,  the  lower  of  a  pale  colour  and  flabby  con- 
sistence, but  still  presenting  the  dilated  air  cells.  Upon  cutting 
into  this  portion  of  the  lung,  we  thought  the  knife  had  entered 
an  abscess,  as  a  large  quantity  of  a  viscid  and  yellowish  fluid 
flowed  out,  and  displayed  a  cavity  in  the  pulmonary  tissue, 
capable  of  containing  a  moderately  sized  apple ;  but  on  closer 
examination  this  cavity  proved  to  be  an  enormously  dilated 
bronchial  tube,  as  it  was  lined  by  a  delicate  mucous  membrane 
continuous  with  that  of  the  bronchial  tubes,  and  beneath  which 
traces  of  the  cartilaginous  rings,  peculiar  to  these  canals,  could 
be  observed.  All  the  bronchial  tubes  on  this  side  were  more  or 
less  affected,  so  that  the  lung  appeared  to  contain  many  small 
abscesses.  Posteriorly  the  pulmonary  tissue  was  of  a  dark  grey 
colour  and  cartilaginous  hardness,  evidently  the  product  of 
former  inflammation.  In  the  immediate  neighbourhood  of  the 
dilated  tubes,  however,  it  was  solid,  but  of  a  red  colour  and 
soft  consistence,  the  consequence  of  more  recent  inflammation  ; 
the  heart  was  more  than  twice  its  natural  size,  the  right  ventricle 
greatly  enlarged  and  thickened,  the  left  thickened  without 
alteration  of  its  capacity.  Dilatation  of  the  auricles ;  no 
disease  of  the  valves  ;  aorta  healthy. 

I  have  inserted  this  case  as  it  illustrates  some  interesting 
points  in  the  history  of  the  disease.  It  shows  that  in  the  same 
subject  a  chronic  bronchitis  may  produce  very  different  effects 
upon  each  lung ;  thus  in  the  right  lung  the  lesion  was  essen- 
tially a  dilatation  of  the  air  cells,  the  bronchial  tubes  being 
scarcely,  if  at  all,  affected,  while  in  the  left  the  very  reverse  had 
occurred;  and  the  bronchial  tubes  were  so  dilated  as  to  repre- 
sent pulmonary  abscesses.  It  is  difficult  indeed  to  conjecture 
as  to  the  progress  of  disease  in  this  patient.  It  seems  pro- 
bable, from  the  occurrence  of  the  sub-pleural  vesicles,  that  a 
degree  of  dilatation  of  the  air  cells  in  the  left  lung  had  once 
existed  ;  in  other  words,  that  the  state  of  the  air  cells  in  both 
lungs  was,  at  one  time,  similar,  but  that  from  some  cause  the 
bronchial  tubes  in  the  left  entered  into  a  separate  pathological 
condition,  and  by  their  gradual  but  extreme  dilatation  pro- 
duced a  real  atrophy  of  the  lung.  That  the  bang  was  actually 
atrophied  was  shown  by  the  fact,  that  its  absolute  size  was 
diminished,    a   diminution    which    appeared    more    remarkable 


BRONCHITIS.  139 

when  the  organ  was  contrasted  with  the  right  lung,  and  fully 
explained  the  remarkable  difference  of  size  of  either  side  of  the 
chest,  observed  during  the  life  of  the  patient. 

In  discussing  the  diagnosis  of  this  affection  it  must  be 
admitted,  that  it  is  surrounded  with  difficulties,  inasmuch  as 
there  is  no  point  of  absolute  difference  between  its  symptoms 
and  physical  signs,  and  those  of  other  diseases,  in  which  cavities 
are  formed  in  the  lung.  We  see  it  occurring  at  all  ages,  with  a 
great  variety  of  symptoms,  whether  we  consider  the  constitu- 
tional suffering  or  the  secretions  of  the  lung,  and  produc- 
ing changes  whose  physical  signs  are  commonly  identical  with 
those  of  ulcerous  cavities  communicating  with  the  bronchial 
tubes.  Further,  it  is  to  be  recollected,  that  more  or  less  of 
the  lesion  is  to  be  met  with  in  many  of  the  chronic  diseases 
of  the  lung,  so  that  it  is  only  when  it  becomes  excessive  and 
prominent  that  its  separate  diagnosis  will  be  called  for.  Now 
as  the  symptoms  and  signs  consist  of  cough,  expectoration,  and 
indications  of  cavities,  it  is  plain  that  in  most  cases  the  question 
will  be  between  this  disease  and  phthisis. 

Before  entering  further  into  the  diagnosis,  let  us  recollect  the 
changes  produced  in  this  disease.  These  are,  first,  a  continuous 
dilatation,  next,  a  succession  of  local  dilatations,  and,  thirdly,  a 
great  enlargement  of  a  tube,  so  as  to  represent  a  pulmonary 
abscess.  Now  it  is  plain,  that  these  lesions  must  give  different 
physical  signs ;  with  those  of  the  first  we  are,  as  yet,  not  suffi- 
ciently acquainted.  In  all  probability  they  will  be  found  to 
consist  in  an  extensive  bronchial  respiration  without  the  dulness 
of  solidification,  and  a  strong  but  diffused  resonance  of  the  voice. 
This  form  of  the  lesion  will  not  present  the  signs  of  excavations 
containing  fluid,  and  communicating  with  the  bronchi,  and  hence 
will  be  less  likely  to  be  confounded  with  phthisis. 

In  considering  the  diagnosis  of  the  latter  varieties,  it  cannot 
be  denied  that  it  is  one  of  great  difficulty  ;  yet  the  subject  is 
full  of  interest,  as  we  here  first  meet  with  an  illustration  of  one 
of  these  fundamental  principles  of  physical  diagnosis  to  which 
I  have  briefly  alluded  in  the  first  section  of  this  work,  I  mean 
that  of  successive  observation.  But  previous  to  our  entering  on 
the  physical  signs,  let  us  inquire  whether  the  constitutional 
symptoms  can  guide  us  in  distinguishing  the  disease  from 
phthisis. 


140  BRONCHITIS. 

To  him  who  has  only  studied  the  subject  of  phthisis  in 
books,  or  whose  actual  experience  is  limited,  it  would  appear 
an  easy  matter  to  draw  the  line.  But  in  truth,  the  tuberculous 
disease  is  so  protean  an  affection,  that  comparatively  little  value 
is  to  be  placed  in  the  absence  of  an}r  of  its  more  charac- 
teristic symptoms.  The  advance  of  medicine  has  shewn  that 
this  diagnosis  is  not  so  easy  as  Laennec  conceived  it  to  be  ; 
and  that  cases  will  occur  in  which,  in  the  present  state  of  our 
knowledge,  it  is  difficult,  if  not  impossible,  to  avoid  error. 
The  absence  of  the  constitutional  symptoms  of  phthisis,  and 
the  long  duration  of  the  affection,  are  the  points  principally 
relied  on  ;  but  we  find  that  any  of  these  symptoms  may  be 
absent  in  true  phthisis ;  that  this  affection  may  last  for  many 
years  ;  and  that  cases,  which  seem  to  have  been  nothing  but 
bronchitis  for  years  together,  terminate  by  tuberculization  and 
ulceration  of  the  lung.  On  the  other  hand,  there  is  no  symptom 
of  phthisis  which  may  not  occur  in  dilatation  of  the  tubes  ;  pain, 
haemoptysis,  cough,  all  varieties  of  expectoration,  fever,  emacia- 
tion, atrophy  of  the  lung,  &c. 

I  do  not  mean  to  say,  that  these  symptoms  are  of  as  common 
occurrence  in  dilatation  of  the  tubes  as  in  phthisis  ;  such  a 
statement  would  be  far  from  the  truth,  but  that  they  may  occur 
is  certain  ;  and  hence,  the  absence  of  the  usual  symptoms  of 
phthisis  will  not  assist  us  in  all  cases.  The  same  remark 
applies  to  the  duration  of  the  disease,  though  not  so  strongly ; 
for  although  dilated  tubes  may  occur  in  a  few  months,  and 
phthisis  last  for  many  years,  yet  it  cannot  be  denied,  that  these 
are  the  exceptions  rather  than  the  rule.  And  it  is  to  be  borne 
in  mind,  that  the  cases  of  acute  dilatation  are  principally  met 
with  in  children. 

As  illustrative  of  the  occasional  similarity  of  symptoms 
between  this  disease  and  phthisis,  I  shall  abstract  a  case  by 
M.  Andral,  which  was  considered  by  M.  Lerminier  to  be  one 
of  chronic  phthisis.  In  this  patient,  a  disposition  to  contract 
bronchitis  had  existed  for  several  years,  and  during  the  year 
1821,  he  complained  of  a  slight  oppression.  In  December  he 
had  haemoptysis  for  the  first  time,  and  in  the  course  of  two 
months  his  expectoration  became  abundant,  puriform  and  foetid, 
these  symptoms  were  succeeded  by  pain  of  the  left  side. 
During  the  month  of  April  following,  the  expectoration  lost  its 


BRONCHITIS.  141 

nummular  character,  but  became  extremely  abundant  and  foetid  ; 
prostration  and  emaciation  continued,  and  the  patient  was 
attacked  by  shiverings  in  the  evening,  followed  by  burning 
heat  during  the  night,  but  it  was  observed  that  he  never 
sweated,  a  circumstance  which  excited  some  surprise,  as  it  was 
considered  that  he  laboured  under  pulmonary  phthisis  :  diar- 
rhoea succeeded,  and  the  patient  sunk  in  the  month  of  June 
following.  Here,  with  the  exception  of  the  absence  of  sweat- 
ing, all  the  other  symptoms,  both  in  their  character  and  mode 
of  succession,  were  very  similar  indeed  to  those  of  suppurative 
phthisis.  Nor  did  the  study  of  the  physical  signs  throw  more 
light  on  the  subject ;  the  respiration  was  feeble  on  the  left  and 
loud  on  the  right  side  ;  the  voice  resounded  strongly  over  the 
whole  left  side,  and  in  the  mammary  region  and  at  the  inferior 
angle  of  the  scapula,  there  was  evident  pectoriloquism.  Yet 
on  dissection  no  tubercles  were  found,  but  the  disease  was  shewn 
to  be  an  example  of  extreme  dilatation  of  the  bronchial  tubes  of 
the  left  lung  with  the  same  disease,  though  in  a  less  degree,  in 
the  right. 

I  apprehend  that  in  the  present  state  of  diagnosis  the  true 
nature  of  such  a  case  could  not  be  determined  by  the  most  ex- 
perienced observer  ;  the  disease  wanted  the  extreme  chronicity 
which  we  are  taught  is  necessary  for  the   production   of  great 
dilatation  of  the  bronchial  tubes.     There  was  hgeruoptysis  in  its 
early  periods,   purulent  expectoration,   emaciation,  hectic  fever, 
and  diarrhoea,  and  the  physical  examination  shewed  feebleness 
of  respiration,  with  the  signs  of  cavities  in  one  of  the  lungs.     It 
is  true,   that  the  foetor   of   the    expectoration,   the    absence  of 
sweating,  and  the  situation  of  the  cavities,  were  circumstances 
somewhat  differing  from  those  of  ordinary  phthisis.     But  there  is 
not  one  of  them  which  might  not  occur  in  phthisis  ;  and  when  the 
other  signs  and  symptoms  existed,  it  is  plain  tbat  from  these 
alone  no  physician  could  have  determined  that  the  case  was  one 
of  dilated  tubes,  and  not  of  phthisical  or  other  ulcerous  cavities. 
This  case  shews  the  difficulty  that  may  attend  the  question  as 
to  the  symptoms  merely.     In  the  same  way  were  we  to  base  our 
diagnosis  on  the  duration  of  the  case,  we  might  also  fall  into 
error;   for  as  I  have  before  stated,  we  may  have  true  phthisis 
advancing  for  many  years,   and  when  occurring  in   the  adult, 
often  without  its   usual  constitutional    symptoms.     Bronchitis, 


142  BRONCHITIS. 

on  the  other  hand,  may,  after  a  period  of  several  years,  pass  im- 
perceptibly into  tuberculous  disease  of  the  lung ;  and  although 
it  might  be  urged,  that  if  the  patient  was  of  a  tuberculous 
diathesis,  that  disease  would  have  shewn  itself  before  a  period  of 
several  years  had  elapsed ;  yet  I  have  now  seen  so  many  cases  of 
bronchitis,  which  continued  for  years  as  such,  and  ultimately 
terminated  in  tuberculous  ulceration  of  the  lung,  that  I  place 
but  little  confidence  in  such  an  argument. 

Thus,  if  we  suppose  a  case  presenting  symptoms  of  cough, 
wasting,  and  puriform  expectoration,  and  in  which  we  detect  a 
cavity  or  cavities,  it  appears  to  me,  that  in  determining  the 
nature  of  these  cavities  we  shall  be  but  little  assisted  by  the 
knowledge  that  the  patient  has  had  cough  for  four,  eight,  or  ten 
years,  for  he  may  have  had  a  bronchitis  passing  into  phthisis,  or 
primary  tuberculous  disease  of  the  lung ;  and  the  cavities  which 
we  discover  may  have  been  but  recently  formed,  and,  for  all  we 
know,  advancing  by  ulceration. 

But  is  the  question  of  time  of  no  importance  in  determining 
this  point  ?  I  would  answer,  that  taken  alone,  or  even  in  com- 
bination with  a  solitary  observation  of  the  case,  it  has  but  little 
value.  Here  we  see  an  instance  of  the  necessity  of  successive 
observations,  and  the  difficulty  which  often  attends  diagnosis 
when  we  see  a  patient  for  the  first  time.  But  if  we  had  made 
several  successive  observations,  if  we  had  ascertained  that  the 
signs  of  cavities  had  existed  for  years  with  but  little  change, 
and  without  the  usual  symptoms  of  phthisis,  or  the  signs  of 
tubercular  extension,  then  indeed  the  question  of  time  is  of  great 
importance,  and  of  course  the  greater  the  period  of  duration  the 
more  certain  the  diagnosis. 

Physical  Signs  of  Dilatation  of  the  Tubes. — It  is  obvious 
that  the  signs  of  this  disease  must  vary,  not  only  according  to 
the  extent  of  the  lesion,  but  also  with  its  nature.  Thus  the 
signs  of  the  simple  continuous  dilatation  of  many  tubes  will  differ 
from  that  in  which  local  distentions  are  produced,  so  large  as  to 
represent  pulmonary  abscesses.  In  addition  to  the  signs  result- 
ing from  these  forms  of  dilatation,  we  have  further  those  from 
the  compression  of  the  pulmonary  tissue,  so  that  the  sources  of 
the  signs  are,  first,  simple  enlargement  of  the  bronchial  tubes, 
next,  the  existence  of  cavities,  and  thirdly,  the  compression  and 
atrophy  of  the  lung. 


BEONCHITIS.  143 

It  would  appear,  that  when  the  disease  is  confined  to  a  single 
bronchial  tube  it  may  escape  detection  ;  thus,  in  one  of  Andral's 
cases,  the  patient  had  suffered  for  five  or  six  years  from  bronchitis. 
During  the  two  last  years  an  organic  disease  of  the  stomach 
supervened,  which  ultimately  proved  fatal,  but  during  his  stay  in 
hospital  no  physical  sign  of  dilatation  was  detected  ;  the  chest 
sounding  clear,  and  the  respiration  being  heard  on  both  sides, 
mixed  with  the  usual  bronchial  rales.  On  dissection,  a  cal- 
careous concretion  was  found  in  the  upper  portion  of  the  right 
lung,  and  the  mucous  membrane  of  the  bronchi  presented 
numerous  red  patches,  the  tubes  being  filled  with  mucus.  In 
the  middle  lobe  of  the  right  lung  a  bronchial  tube  was  found 
dilated  to  nearly  three  times  the  diameter  of  that  from  which  it 
arose.  The  lesion  was  confined  to  this  particular  tube,  and  was 
not  pointed  out  by  any  physical  sign.  The  same  author  details 
another  case,  in  which  an  obstinate  cough,  with  abundant  puri- 
form  expectoration,  had  existed  for  a  length  of  time.  In  this 
patient  a  marked  mucous  rattle  existed  on  the  left  side,  being 
heard  in  the  subspinous  fossa  and  the  mammary  region :  here 
the  sound  on  percussion  was  clear,  and  there  was  no  morbid 
resonance  of  the  voice.  It  was  found  on  dissection  that  the 
bronchial  tubes  of  the  inferior  lobe  were  inflamed,  filled  with 
puriform  mucus,  and  in  many  places  presenting  small  dilatations. 
Here,  as  Andral  remarks,  the  seat  and  extent  of  the  bronchitis 
was  pointed  out  by  auscultation,  but  there  was  no  sign  which 
could  lead  to  the  suspicion  of  bronchial  dilatation. 

I  have  already  stated,  that  we  are  not  yet  sufficiently  informed 
as  to  the  physical  signs  of  the  extensive  but  continuous  dilatation 
of  the  bronchi.  In  a  case  of  this  kind,  however,  recorded  by 
the  author  from  whom  I  have  just  quoted,  the  physical  signs 
were  a  resonance  of  the  voice,  not  amounting  to  true  pecto- 
riloquism.  In  the  same  situation  he  states  that  a  species  of 
bronchial  respiration  occurred,  as  if  the  individual  was  blowing 
strongly  at  the  extremity  of  the  cylinder,  while  everywhere  else 
the  respiratory  murmur  was  heard  as  usual.  On  dissection, 
in  the  situation  corresponding  to  this  phenomenon,  namely,  the 
upper  lobe  of  the  right  lung,  all  the  tubes  were  found  dilated. 
To  those  who  are  familiar  with  stethoscopic  investigations  the 
relation  between  the  signs  and  organic  changes  must  appear 
sufficiently  obvious.     In  some  cases,  as  Laennec  has  described, 


144  BKONCHITIS. 

this  puffing  or  blowing  respiration  gets  that  character  which  he 
denominates  veiled,  by  which  is  meant  a  modification,  giving  the 
idea  of  a  thin  veil,  or  septum,  interposed  between  the  observer 
and  the  seat  of  the  sign,  and  moving  at  each  act  of  respiration. 

In  the  third  variety,  cavities  of  different  sizes  are  produced, 
which  contain  a  fluid,  and  communicate  freely,  not  only  with 
the  original  trunk,  but  with  minor  branches,  and  consequently 
their  physical  signs  are  identical  with  those  of  ulcerous  cavities 
of  the  lung.  They  present  cavernous  respiration,  gurgling,  and 
pectoriloquism ;  and  if  anything  was  wanting  to  add  to  the 
resemblance  between  this  disease  and  phthisical  cavities,  it  is, 
that  the  seat  of  both  lesions  is  most  commonly  in  the  upper 
lobes  of  the  lung. 

It  is  obvious  that  all  these  physical  signs  are  common  to  other 
diseases  of  the  lung,  and  hence  it  is  only  by  their  existence  in  a 
case  in  which  the  duration  and  nature  of  the  symptoms  are 
opposed  to  the  idea  of  ulcerous  caverns,  that  we  can  arrive  at 
the  probable  diagnosis  of  dilated  tubes.  But,  on  the  other 
hand,  where  the  symptoms,  both  local  and  constitutional,  re- 
semble phthisis,  as  closely  as  in  the  cases  described  by  Andral 
and  Louis,  it  seems  impossible  to  arrive  at  a  certain  diagnosis, 
at  least  on  a  first  examination  ;  and  the  probabilities  as  to 
frequency  being  always  in  favour  of  phthisis,  we  must,  unless 
some  more  certain  sign  be  discovered,  always  incline  to  the 
opinion  that  the  case  is  one  of  softened  tubercle. 

But  the  facility  of  arriving  at  a  diagnosis  in  any  case  turns  on 
other  circumstances  than  the  mere  observation  of  signs  and 
symptoms,  with  which  we  have  become  acquainted  for  the  first 
time.  Much  depends  on  the  observation  of  the  progress  of 
the  case,  and  the  modification  of  signs,  which  has  occurred  in 
any  given  space  of  time.  For  example,  we  are  called  to  a  patient 
who  presents  the  signs  of  a  cavity,  but  from  some  peculiarity  in 
the  symptoms  it  becomes  a  question  whether  this  is  a  phthisical 
ulcer  or  a  dilated  tube.  Now  this  can  be  often  determined  by 
successive  observations  of  the  case,  by  which,  if  we  discover  an 
extension  of  the  cavity  too  rapid  to  be  explained  upon  the 
hypothesis  of  dilated  tubes,  we  may  at  once  arrive  at  the  diag- 
nosis of  phthisis.  I  have  frequently  had  recourse  to  this  mode, 
and  always  with  success.  It  is  obvious  that  the  cavity  may 
remain  stationary,  or  may  extend,  and  that  it  is  only  in  the 


BRONCHITIS.  145 

latter  case  that  this  diagnosis  can  be  made  available,  but  when 
we  can  employ  it,  is  almost  always  pathognomonic,  and  forms  an 
excellent  illustration  of  the  value  and  certainty  of  physical  signs. 

Another  source  of  diagnosis  of  a  similar  character  may  be 
drawn  from  the  observation  by  percussion.  In  a  considerable 
number  of  cases  of  phthisical  abscess,  the  signs  of  the  cavity  are 
often  preceded  by  absolute,  and  in  all  by  comparative  dulness. 
This  we  can  understand,  when  we  recollect  that  the  phthisical 
abscess  is  formed  by  the  suppuration  of  turberculous  masses 
and  of  solidified  lung.  But  these  conditions  do  not  precede  the 
dilatation  of  the  bronchial  tubes,  for  which  solidity  of  the  pul- 
monary tissue  is  by  no  means  a  necessary  antecedent.  On  the 
contrary,  if  dulness  should  occur,  it  would  be  in  the  advanced 
stages  of  the  disease,  when  the  intervening  pulmonary  tissue 
had  become  compressed  and  carnified.  Hence  we  say,  in  general 
terms,  that  in  phthisis  we  have  first  dulness,  and  then  cavity, 
ivhile  in  dilated  tubes  we  have  first  cavity,  and  then  dulness. 

But  the  bronchial  tubes  may  be  sufficiently  dilated  to  give 
pectoriloquism  and  bronchophonia  without  any  dulness.  Of 
this  the  following  case,  taken  from  the  work  of  Louis,*  is  a 
striking  example. 

A  patient,  aged  55,  who  had  been  subject  to  dyspnoea  from 
infancy,  had  laboured  under  a  chronic  bronchitis  for  several 
years.  This  affection  was  always  worse  in  winter,  and  at  that 
period  he  emaciated  considerably.  During  the  last  month  he 
had  lost  his  appetite,  and  the  cough  had  become  more  trouble- 
some ;  the  debility  had  increased,  but  there  had  been  neither 
pain  of  the  chest  nor  haemoptysis. 

On  admission  he  presented  the  following  symptoms  :  he  was 
pale  ;  the  lower  extremities  slightly  cedematous ;  the  belly  large, 
and  obscurely  fluctuating :  pulse  but  little  accelerated :  cough 
moderate :  sputa  opaque  and  greenish  :  tongue  of  a  dirty  white 
in  the  centre,  with  thirst,  and  complete  anorexia.  During  the 
last  fifteen  days  he  laboured  under  diarrhoea  and  night  sweats. 

On  percussion  the  chest  was  everywhere  sonorous,  yet  the 
respiration  was  almost  perfectly  tracheal.  In  the  upper  portion 
of  the  right  lung,  both  anteriorly  and  posteriorly,  there  existed 
a  large  crepitus  ;  and  in  these  situations  the  resonance  of  the 
voice  amounted  to  imperfect  pectoriloquism. 

*  Recherchea  Anatomico-Pathologiques  euv  la  Phthisie,  Obs.  11. 

L 


146  BRONCHITIS. 

Until  the  period  of  his  death,  which  took  place  on  the  19th 
of  December,  his  debility  was  progressive,  the  dyspnoea  became 
every  day  worse,  and  during  the  last  week  his  sputa  resembled  a 
greenish  pus.  The  physical  signs  on  the  right  side  underwent 
no  change,  but  after  he  had  been  a  week  in  hospital,  the  left 
sub-clavicular  region  presented  a  mucous  rale,  mixed  with 
gurgling.  Posteriorly  the  sound  of  respiration  was  strong,  and 
the  resonance  of  the  voice  considerable. 

On  dissection  the  upper  portion  of  the  right  lung  seemed  to 
be  converted  into  a  great  number  of  cysts,  varying  in  size  from 
that  of  a  pea  to  that  of  a  large  nut.  These  proved  to  be  nothing 
but  dilated  tubes,  containing  a  reddish  mucus,  mixed  with  a 
yellow  opaque  fluid.  They  were  in  opposition,  and  were  formed 
of  a  very  thin  mucous  membrane,  which  was  red,  firm,  and 
continuous  with  that  of  the  bronchial  tubes,  which  were  other- 
wise perfectly  healthy.  The  same  lesion  existed  on  the  upper 
portion  of  the  left  lung,  and  extended  about  an  inch  and  a  half 
from  the  summit ;  the  dilatation  here  was  less  decided  than  in 
the  right  lung ;  no  tubercles  nor  tuberculous  matter  could  be 
anywhere  discovered. 

This  patient  was  considered  by  M.  Louis  to  labour  under  an 
-organic  disease  of  the  abdomen,  and  a  chronic  and  circumscribed 
phthisis.     He  states,  that  the   perfect   sonoreity  of  the   upper 
portion  of  the  chest  made  him  at  first  doubtful,  but  the  results 
of   auscultation    were    greatly   in   favour   of  the    existence   of 
tuberculous  caverns.     Thus  the  tracheal  respiration,  the  rnuco- 
crepitating  rale,   and  the  imperfect  pectoriloquism,  and  above 
all,  the  situation  of  these  signs,  seemed  to  point  out  an  an- 
fractuous tuberculous  cavity.     He  candidly  admits  his  error,  and 
remarks,  that  if  the  affection  was  tuberculous,  and  that  it  had 
lasted  so  long  as  ten  years,  it  should  by  that  time  at  least  have 
produced  an  induration  of  the  lung  sufficient  to  give  a  dull  sound 
on  percussion.     He  further  remarks  in  a  note,  that  he  is  not 
ignorant  of  the  fact,  that  a  tuberculous  cavity,  with  indurated 
parietes,  may  exist  with  clearness  of  sound  on  percussion,  but 
that  in  such  cases  the  cavity  must  be  of  great  size.     That  the 
last  observation  is  true  I  feel  fully  satisfied ;  I  have  never  seen 
a  tuberculous  cavity  which  gave  a  clear  sound  on  percussion, 
unless  where  the  cavity  was  very  large  and  well  defined,  and 
even  here  the  sound  on  percussion,  though  clear,  is  not  similar 


BRONCHITIS.  147 

to  that  of  the  pulmonary  cells,  but  lias  a  somewhat  tympanitic 
character.  On  the  other  hand,  anfractuous  phthisical  cavities, 
such  as  would  produce  the  phenomena  detailed  in  this  case,  are, 
as  far  as  my  experience  goes,  always  accompanied  by  dulness  of 
sound  on  percussion ;  so  that  if  this  rule  be  general,  it  would 
follow,  that  the  occurrence  of  the  signs  of  anfractuosities  with 
clearness  of  sound  on  percussion,  will  be  diagnostic  of  dilated 
tubes :  of  course  such  a  diagnosis  should  be  corrected  by  the 
history  of  the  case  and  the  actually  existing  symptoms.  I  may 
observe  further,  that  in  this  case  a  combination  of  certain  signs 
occurred,  which  I  have  never  found  in  any  case  of  phthisis,  nor 
can  I  conceive  its  existence  possible  in  that  disease.  I  allude  to 
the  combination  of  extensive  tracheal  respiration  with  clearness 
of  sound  on  percussion.  In  phthisis  the  existeuce  of  the  first 
of  these  signs  is  accompanied  by  decided  dulness  in  almost 
every  case.  To  this  I  shall  return  when  describing  the  signs  of 
pulmonary  tubercle. 

As  the  treatment  of  this  affection  does  not  in  any  shape  differ 
from  that  of  chronic  mucous  catarrh,  I  shall  not  further  allude 
to  it  here,  but  at  once  proceed  to  sum  up  the  state  of  our 
knowledge  of  its  diagnosis.     It  may  be  stated  : 

1st.  That  the  cases  of  this  disease  which  have  been  described 
by  authors,  may  be  divided  into  three  classes. 

(a)  Cases  in  which  symptoms  of  chronic  catarrh,  with  copious 
expectoration,  have  existed  for  a  number  of  years,  varying  from 
ten  to  fifty,  or  even  more,  and  without  the  constitutional 
symptoms  of  phthisis. 

(b)  Cases  presenting  the  symptoms  of  phthisis,  in  which  the 
constitution  suffers  severely ;  the  disease  may  last  from  five 
months  to  five  or  even  ten  years.  This  last  case  has  been 
principally  observed  in  adults. 

(c)  Cases  which  may  be  termed  acute.  These  are  to  be  ob- 
served in  children  after  hooping  cough,  and  the  disease  has 
occurred  in  the  space  of  three  months. 

2nd.  That  we  meet  with  this  affection  as  an  uncomplicated 
disease,  or  in  conjunction  with  other  lesions,  of  which  obliteration 
of  the  bronchi  and  tubercle  are  the  most  common. 

3rd.  That  dilatation  of  the  bronchial  tubes  may  be  accom- 
panied by  an  atrophy  of  the  air  cells,  and  thus  the  affected  side 
of  the  chest  be  diminished  in  volume. 

l2 


148  BRONCHITIS. 

4th.  That  in  the  same  case  we  may  observe  a  predominance 
of  dilatation  in  the  bronchial  tabes  of  one  lung,  and  of  the  air 
cells  in  the  other. 

5th.  That  the  continuous  dilatation  may  affect  a  single  tube 
without  presenting  any  marked  physical  signs. 

6th.  That  we  may  even  have  numerous  small  dilatations 
without  other  phenomena  than  those  of  ordinary  bronchitis. 

7th.  That  when  the  continuous  dilatation  is  decided  and 
extensive,  the  phenomena  which  have  been  observed  are  the 
blowing  respiration  and  extended  resonance  of  the  voice.  In 
some  cases  too  the  veiled  puff  has  been  observed  by  Laennec. 

8th.  That  when  the  local  dilatations  are  decided,  the  phe- 
nomena are  those  of  suppurating  cavities  communicating  with 
the  tubes. 

9th.  That  although  it  is  extremely  difficult,  on  account  of 
the  similarity  of  the  physical  signs,  and  in  some  cases  of 
symptoms,  to  distinguish  this  disease  from  phthisis  with  sup- 
purating cavities,  yet  by  observing  the  mode  of  combination 
and  the  succession  of  the  signs,  the  rate  of  increase  of  the 
cavities,  and  the  connexion  of  these  with  the  history  of  the 
case,  we  may,  in  some  cases  at  least,  arrive  at  a  diagnosis  which 
shall  be  correct. 

10th.  That  where  a  number  of  tubes  are  dilated  in  one  lobe, 
the  case  may  be  distinguished  from  tuberculous  anfractuosities 
by  the  clearness  of  sound  on  percussion. 

11th.  That  in  cases  where  we  have  had  an  opportunity  of 
examining  the  patient  from  an  early  period,  the  fact  of  dulness 
not  having  preceded  the  signs  of  a  cavity  may  enable  us  to  dis- 
tinguish the  disease  from  phthisis. 

12th.  That  in  the  same  manner  the  combination  of  extensive 
tracheal  respiration  with  clearness  of  sound,*  seems  to  be  diag- 
nostic of  dilated  tubes. 

*  From  the  very  improper  mode  of  examining  the  post  mortem  appearances  in  the 
lungs,  which  is  commonly  adopted  in  this  country,  a  difference  of  opinion  as  to  the 
actual  nature  of  the  cavities  may  occur ;  and  I  have  seen  instances  in  which,  after 
this  irregular  dissection,  it  was  not  easy  to  determine  the  question.  I  have  been 
in  the  habit  of  directing  the  attention  of  my  pupils  to  the  following  points,  which 
enable  us  to  set  the  matter  at  rest.  The  lung  should  be  dissected  by  means  of  a 
fine  pair  of  scissors,  in  which  the  end  of  one  blade  is  blunt,  and  turned  upwards. 
This  instrument  may  be  called  a  bronchotome.  The  operator,  beginning  at  the  bifur- 
cation of  the  trachea,  should  follow  the  tubes  to  the  surface  of  the  lung,  and  lay 
as  many  of  them  open  as  possible.  For  the  finer  tabes  he  may  use  a  slender 
grooved  director  and  a  Daviel's  scissors.    Now  if  the  case  be  one  of  simple  dilated 


BRONCHITIS.  149 


ULCERATION  OF  THE  BRONCHIAL  TUBES. 

I  shall  not  occupy  many  pages  on  this  subject,  which  is  one 
of  more  interest  to .  the  pathological  anatomist  than  to  the 
student  of  diagnosis.  As  yet,  indeed,  we  are  ignorant  of  any 
symptom  or  sign  which  may  be  considered  pathognomonic  of 
the  lesion  in  its  simple  form,  where  the  ulcerative  process 
has  commenced  in,  and  is  confined  to,  the  mucous  surface  of 
the  tube.  And  even  in  these  more  complicated  cases  of  ulce- 
ration and  perforation  of  the  lung,  we  recognize  the  occurrence 
of  bronchial  ulceration,  less  by  any  signs  proper  to  it  as  by 
phenomena  resulting  from  other  mechanical  conditions,  which 
have  resulted  from  the  primary  disease.  Thus  in  phthisical 
abscesses,  and  in  pneumothorax  by  perforation,  the  signs  of 
gurgling  and  metallic  tinkling  point  out  a  communication  with 
the  bronchial  system ;  but  while  the  process  which  produced 
that  communication  was  going  on,  there  were  no  characteristic 
or  proper  symptoms  or  signs. 

"When  we  compare  the  frequency  of  ulceration  in  the  respira- 
tory and  gastro-intestinal  mucous  membranes,  we  are  struck  with 
the  great  preponderance  of  the  latter.  This  is  particularly 
observed  in  the  acute  diseases,  in  which  we  find  that  the  in- 
testinal surface  so  often  runs  into  extensive  ulceration,  a  character 
very  different  from  that  of  the  lung,  in  which  acute  bronchitis 
commonly  destroys  life  without  a  perceptible  ulceration  of  the 
surface.  Indeed  the  great  majority  of  bronchial  ulcerations  are 
the  result  of  a  chronic  disease. 

The  greater  liability  of  the  digestive  mucous  membrane  to 
ulcerate  may  be  understood,  when  we  reflect  on  the  much  more 
extensive  development  of  the  mucous  glands  in  that  system, 
the  greater  necessity  for  their  activity  in  the  normal  state, 
their  being  open  to  the  action  of  a  great  variety  of  heterogeneous 
matters,  and  the  varied  sympathetic  actions  which  the  numerous 
abdominal  viscera  exercise  upon  them. 


tubes,  he  will  observe,  that  all  the  cavities  are  in  the  direction  of  the  tubes,  that  no 
transverse  division  of  the-e  can  be  observed  at  their  junction  with  the  cavity,  and 
that  the  mucous  lining  of  the  tube  is  perfectly  continuous  with  that  of  the  cavity, 
which  may  also  present  the  cartilages,  and  the  longitudinal  and  circular  fibres  in  a 
state  of  hypertrophy.  These  cavities  also  differ  remarkably  from  phthis  cal  excava- 
tions in  never  presenting  the  transverse  bands ;  and  should  tubercles  be  absent  in 
other  portions  of  the  lung,  the  point  will  be  set  completely  at  rest. 


150  BRONCHITIS. 

Andral  states,  that  these  ulcerations  are  more  frequent  in  the 
larynx  than  in  the  bronchial  tubes,  and  more  common  in  the 
latter  than  in  the  trachea.  This  statement  seems  certainly  true 
with  respect  to  primary  ulceration  ;  but  if  we  take  in  the  cases 
of  tuberculous  phthisis,  we  shall  find  a  great  preponderance  in 
favour  of  the  bronchial  tubes  over  even  the  larynx.  The  same 
author  has  divided  the  cases  of  bronchial  ulceration  into  two 
classes,  according  to  the  point  as  to  whether  the  tube  has  been 
destroyed  from  within  outwards,  or  the  reverse.  I  shall  not 
enter  further  into  this  discussion,  and  shall  conclude  this  short 
notice  by  enumerating  some  of  the  principal  instances  of 
bronchial  fistulae. 

(a)  Suppurated  tubercle,  and  other  ulcerous  cavities  of  the 
lung. 

(b)  Empyema  opening  into  the  lung. 

(c)  Evacuation  of  an  hepatic  abscess  through  the  bronchial 
tubes. 

(d)  Communication  between  an  aneurism  of  the  aorta  and  the 
lung. 

(e)  Communication  between  the  oesophagus  and  trachea. 
(/)  Fistulae  of  the  tubes  opening  into  the  bronchial  glands.* 
(f/)  Communication  between  the  thyroid  gland  and  trachea. 
(h)  Perforation  of  the  pulmonary  artery.! 

Other  cases  have  been  met  with,  but  in  the  above  list  we  have 
the  most  frequent  and  best  attested  examples  of  the  lesion.  It 
may  be  observed  finally,  that  the  communications  thus  formed, 
in  most  instances  at  least,  result  from  ulceration,  commencing 
either  within  the  bronchus,  and  perforating  outwards,  or  external 
to  the  tube,  and  taking  the  reverse  direction. 


DILATATION     OF     THE    AIR    CELLS. — EMPHYSEMA    OF    THE    LUNG     OF 

LAENNEC. 

It  seems  to  me  that  in  adopting  the  name  of  dilatation  of  the 
air  cells  for  this  disease,  we  avoid  much  error  and  confusion. 
The  term  emphysema  of  the  lung,  given  to  it  by  Laennec,  is 
improper,  inasmuch  as  emphysema  is  not  the  principal  character- 
istic of  the  disease,  and  though  a  frequent,  yet  still  by  no  means 

*  Les  Maladies  tuberculeuses  des  Glandes  Bronchiques,  par  J.  M.  Berton. 
f  Berton,  op.  cit. 


BRONCHITIS.  151 

a  constant  complication.  Indeed  it  seems  certain,  that  even  if 
we  admit  the  existence  of  the  pleural  vesicles  of  Laennec  to  have 
heen  produced  by  rupture  of  the  cells,  yet  that  this  may  exist 
without  true  general  emphysema  of  the  lung.  And  it  is 
difficult  to  conceive  how  emphysema  could  exist  in  the  lung 
without  becoming  diffused  over  the  body. 

That  these  vesicles  under  the  pleura  are  often  formed  by  the 
distention  or  by  the  coalescence  of  many  distinct  air  cells,  rather 
than  by  the  effusion  of  air  into  the  subserous  cellular  membrane, 
is,  I  am  sure,  true  in  a  considerable  number  of  cases.  For 
although  we  may,  in  some  cases,  succeed  by  pressure  in  changing 
the  position  of  the  vesicle,  yet  we  shall  often  fail,  shewing  that 
the  air  is  confined,  and  in  no  respect  under  the  same  conditions 
as  in  the  true  emphysema  of  cellular  membrane. 

We  may  consider  this  affection  under  three  heads. 

First.  Simple  dilatation  of  the  cells  without  rupture. 

Second.  Dilatation  of  the  cells,  with  rupture  of  their  parietes  ; 
so  that  several  shall  coalesce,  and  form  a  cavity  of  some  extent. 

Third.  The  combination  of  the  second  condition  with  a  true 
emphysema  of  the  inter-lobular  cellular  texture,  but  which  is 
generally  very  slight.     To  this  subject  I  may  hereafter  return. 

This  disease  consists  essentially  in  a  dilatation  of  the  air  cells. 
The  lung  becomes  enlarged,  and  the  whole  quantity  of  air  within 
the  thorax  is  increased.  Like  the  preceding  affection  it  is  most 
commonly  the  result  of  a  chronic  irritation  of  the  mucous  mem- 
brane of  the  lung ;  but  it  differs  from  it  in  these  particulars, 
that  while  in  the  former  disease  the  irritation  engaged  the 
larger  tubes,  and  was  generally  accompanied  by  copious  secretion, 
in  the  latter  we  find  that  the  most  minute  tubes,  and  even  the 
air  cells  are  the  cavities  affected,  and  the  secretions  more  often 
scanty,  viscid,  and  unelaborated. 

Various  explanations  have  been  given  of  the  formation  of  this 
disease.*  It  has  been  conceived  that  the  long  continued  and 
violent  coughing  acts  in  distending  the  air  cells  beyond  their 
ordinary  dimensions,  and  from  this  frequently  repeated  and  long 
continued  dilatation  they  at  last  become  permanently  enlarged. 
In  addition  to  this,  it  is  held,  that  the  viscid  secretion  that  exists 
in  the  minute  bronchial  tubes  acts  in  blocking  these  up  during 
expiration,  the  force  of  which  is  not  so  great  as  that  of  inspi- 

*  See  Appendix,  Note  A , 


152  BEONCHITIS. 

ration,  and  hence  assists  in  producing  dilatation  of  the  air  cells 
by  keeping  them  in  a  permanently  distended  state.  There 
can  be  little  doubt  that  both  these  causes  act,  and  their 
combination  seems  sufficient  to  explain  the  lesion.  The 
existence  of  an  additional  cause  has  been  suggested  by  M. 
Meriadec  Laennec,  namely  the  expansion  of  the  inspired  air 
in  consequence  of  the  temperature  of  the  body.  Under  this 
supposition  the  air  entering  the  cell  at  a  lower  temperature 
of  course  soon  assumes  that  of  the  lung,  but  as  its  exit  is 
prevented  or  impeded  by  the  inspissated  mucus  lining  the 
minute  tubes,  its  rarefaction  must  act  in  dilating  the  air  cell. 
That  this  cause  may  have  some  effect  I  do  not  deny,  but  it 
seems  probable,  that  the  period  of  its  action  must  be  very 
limited  ;  and  when  we  recollect  the  number  of  passages,  through 
the  most  vascular  organ  of  the  body,  that  the  inspired  air  has 
to  traverse  before  reaching  the  cell,  it  seems  hardly  possible 
that  any  rarefaction,  which  it  may  undergo  there,  would  be  at 
all  sufficient  to  dilate  its  cavity.  It  appears  to  me  that  there 
is  an  additional  cause  not  sufficiently  dwelt  on,  and  which 
is  connected  with  the  common  complication  with  spasmodic 
symptoms.  Under  these  circumstances  the  circular  fibres  of  the 
bronchi  become  increased  in  strength  and  in  irritability,  and 
their  irregular  action,  it  is  obvious,  must  interfere  with  res- 
piration, and  tend  to  preserve  a  dilated  state  of  the  chest.* 

To  the  practical  physician,  however,  the  great  point  of 
consideration  is,  that  this  disease  of  the  lung  is  the  result  of 
bronchitis  ;  and  that  for  its  prevention,  alleviation,  or  cure,  if 
that  were  possible,  the  treatment  must  be  conducted  upon  this 
principle.  These  patients  labour  under  a  persistent  bronchitis, 
but  are  liable  to  repeated  exacerbations,  which  are  often 
erroneously  supposed  to  be  spasmodic,  and  hence  constantly 
maltreated,  but  which  are  in  all  cases  the  result  of,  or  accom- 
panied by,  an  increase  of  the  bronchial  irritation  ;  the  spasmodic 
symptoms  being  the  necessary  result. 

The  facility  with  which  we  can  recognize  this  disease  depends 
generally  on  its  degree  of  development.     In  its   slighter  forms 

*  It  is  to  be  observed  that  emphysema  is  usually  the  result  of  a  special  form  of 
bronchitis — capillary — the  dry  catarrh  of  Laennec.  This  result  is  also  favoured  in  cases 
of  hereditary  emphysema  by  a  disturbance  of  nutrition,  which  as  Hertz  has  pointed 
out  explains  its  occurrence  in  children  without  previous  bronchitis  and  its  increased 
frequency  with  the  advance  of  age. — Ziemssen's  Cyclopedia,  vol.  v.  p.  357.     (Ed.) 


BRONCHITIS.  153 

it  may  often  escape  detection,  but  when  it  becomes  advanced  or 
extensive  its  diagnosis  is  easy.  But  there  is  another  condition 
of  great  importance  to  be  considered,  namely,  the  amount  of 
yielding  of  the  thoracic  walls ;  and  I  think  I  shall  be  able  to 
prove,  that  in  some  important  respects  the  stethoscopic,  and 
even  other  signs,  depend  greatly  on  this  circumstance. 

Patients  labouring  under  this  disease  are  affected  with  an 
habitual  dyspnoea,  which,  in  the  earlier  periods,  is  often 
mitigated  in  summer,  to  return  with  violence  during  the 
winter;  they  are  also  liable  to  repeated  attacks  of  what  might 
be  termed  a  congestive  bronchitis,  during  which  the  difficulty 
of  breathing  becomes  extreme. 

The  physiognomy  of  these  individuals  is  almost  characteristic. 
The  complexion  is  generally  of  a   dusky  hue,  and  the  counte- 
nance, though  with  an  anxious  and  melancholy  expression,  has 
in  several  cases  a  degree  of  fulness  which  contrasts  remarkably 
with  the  condition  of  the  rest  of  the  body.     It  is  probable  that 
this  results   from  hypertrophy    of    the  cellular  membrane  and 
respiratory  muscles  of  the  face  ;  the  first  produced  by  repetitions 
of  venous  obstruction,  and  the  second  by  the  violent  exertion 
of  the  whole  system  of  inspiratory  muscles.     The  nostrils  are 
dilated,   thickened,  and  vascular.     The   lower  lip  is  enlarged, 
and  its  mucous  membrane  everted  and  livid,  giving  a  peculiar 
expression  of  anxiety,  melancholy,  and  disease  to  the  counte- 
nance.    The   shoulders  are  elevated  and  brought  forward,  and 
the  patient  stoops  habitually,  a  habit  contracted  in  his  various 
fits  of  orthopncea  and  cough,  and  the  relief  which  is  experienced 
from  inclining  the  body  forwards.     Thus,  even  in  bed,  we  often 
find  these  patients  sitting  up  with  their  arms  folded  and  resting 
on  their  knees,  and  the  head  bent  forwards,  the  object  of  which 
seems  to  be  to  relax  the   abdominal  muscles,  and  to  substitute 
the  mechanical  support  of  the  arms  for  that  of  muscles  which 
would  interfere  with  inspiration.     To  such  a  degree  does  this 
habit  of  stooping  alter  the  conformation  of  the  chest,  that  I  have 
seen  several  cases  in  which  the  acromial,  inter- scapular,  supra 
and  sub-spinous  surfaces  had  become  nearly  horizontal.     Under 
these  circumstances  the  apices   of  the  scapula?  are  remarkably 
projected ;    anteriorly   we    observe    the    clavicles    arched    and 
prominent,  and  the  triangular  spaces  which  answer  to  the  inser- 
tion of  the   sterno-mastoid,  and  scaleni  muscles  are  singularly 


154  BRONCHITIS. 

deep.  The  cellular  membrane  and  adipose  tissue  of  the  neck 
seem  to  be  absorbed,  but  the  muscles  of  inspiration,  and  par- 
ticularly the  sterno-mastoid  and  scaleni  are  hypertrophied,  and 
the  thyroid  cartilage  is  generally  prominent  and  hard,  so  as  to 
feel  as  if  ossified.  When  we  examine  the  chest  we  discover 
other  and  remarkable  changes  ;  the  sternum  has  lost  its  flatness, 
or  its  relative  concavity,  but  is  thrown  forward  and  arched  both 
in  a  longitudinal  and  transverse  direction  ;  the  intercostal  spaces 
are  widened,  but  not  dilated  as  in  empyema :  on  the  supero- 
anterior  portion,  indeed,  the  chest  seems  smooth  and  convex, 
but  this  is  owing  to  the  hypertrophied  state  of  the  pectoral 
muscles,  a  condition  induced  by  the  long-continued  difficulty  of 
respiration.  When  we  examine  the  side,  however,  we  see  the 
intercostal  spaces  deeply  marked,  and  presenting  no  indication 
of  protrusion  ;  so  that  if  we  compare  the  disease  of  dilatation 
of  the  cells  and  empyema,  with  respect  to  the  external 
conformation  of  the  chest,  we  find  that  in  the  first,  the  appear- 
ance of  smoothness  and  dilatation  is  most  evident  superiorly, 
while  in  the  latter  the  reverse  occurs.  The  lateral  portions  of 
the  chest  are  remarkably  deep,  and  their  convexity  not  at  all 
proportioned  to  that  of  the  anterior  or  posterior  portions  of  the 
thorax.  On  applying  the  hand  to  the  inferior  sternal  region  we 
generally  find  that  the  heart  is  pulsating  with  a  violence  which 
we  would  not  expect  from  the  examination  of  the  pulse  at  the 
wrist,  which  is  often  small  and  feeble,  while  the  impulses  of  the 
right  ventricle  are  given  with  great  strength.  These  phenomena 
are  generally  owing  to  an  hypertrophied  state  of  the  right 
cavities  of  the  heart,  which  so  commonly  attends  this  disease, 
an  affection,  frequently  attended  with  a  violent  impulse  and 
feeble  pulse.  But  I  have  observed  two  other  causes  for  the  pro- 
duction of  this  symptom  or  sign,  the  knowledge  of  which  is  of 
importance,  inasmuch  as  that  they  may  produce  the  phenome- 
non in  question  without  disease  of  the  heart  actually  existing. 
The  first  of  these  is  the  displacement  of  the  heart  by  the  dilated 
lung,  which  pushes  it  downwards,  so  that  its  impulses  become 
manifest  in  the  epigastric  region,  not  from  disease,  but  from 
displacement.  This  should  be  observed  more  remarkably  when 
the  pulmonary  disease  predominates  in  the  left  side  ;  in  the 
cases  which  I  have  seen,  the  disease  affected  both  lungs  equally. 
The  other  cause  for  this  symptom  is  a  congested  and  enlarged 


BRONCHITIS.  155 

state    of    the   liver,    which    not   unfrequently  accompanies   the 
disease,  from  causes  sufficiently  ohvious. 

On  examining  the  epigastrium,  and  indeed  the  whole  of  the 
supero-anterior  portion  of  the  abdominal  cavity,  we  commonly  find 
it  full  and  resisting,  although  without  any  perceptible  or  distinctly 
localized  tumour.  On  percussion  the  right  hypochondrium  and 
the  epigastrium  sound  dull,  and  in  certain  cases  we  are  able  to 
trace  the  margin  of  the  liver  below  the  false  ribs.  This  may 
depend  on  two  causes,  either  an  enlargement  of  the  organ,  or  its 
displacement  by  the  flattening  of  the  diaphragm.  To  the  latter 
condition  of  this  muscle  I  shall  presently  direct  the  attention  of 
the  reader. 

Physical  Signs  of  Dilatation  of  the  Cells. — The  physical 
signs  of  this  disease  are  few,  but  in  most  cases,  where  the  disease 
is  established,  are  so  well  marked,  and  so  obvious,  that  there 
is  hardly  a  disease  to  which  physical  diagnosis  is  more  easily 
applicable.  The  following  are  the  sources  of  the  physical  signs 
in  this  affection : 

1st.  The  increased  quantity  of  air  within  the  thorax. 

2nd.  The  increased  volume  of  the  lung,*  and  the  resistance 
of  the  thoracic  parietes. 

3rd.  The  displacement  of  the  heart  and  abdominal  viscera. 

4th.  Bronchitis  of  the  minute  tubes. 

5th.  Congestion  of  the  lung. 

6th.  The  existence  of  the  sub-pleural  vesicles  of  Laennec. 

On  percussing  the  chest,  in  a  case  where  the  disease  is  decided, 
we  observe  that  the  sound  is  morbidly  clear.  It  is  not,  however, 
tympanitic,  as  in  pneumothorax,  but  may  be  described  as  the 
maximum  of  the  true  pulmonary  sound. f  In  a  case  of  extensive 
disease  this  clearness  is  general,  but  it  may  be  partial,  and  merely 
correspond  to  the  most  affected  portion  of  the  lung.  It  is  but 
little,  if  at  all,  increased  on  a  deep  inspiration,  in  which  it  differs 
remarkably  from  the  sound  of  the  healthy  lung,  but  agrees  with 
that  of  its  solidified  state.  In  fact,  this  character,  though  oc- 
curring in  states  of  the  lung  so  opposite  as  its  rarefaction  and 
solidification,  is  yet  owing  to  the  same  cause  in  both,  namely, 

*  Although  this  and  the  preceding  condition  may  be  said  to  imply  the  same  state  of 
things,  yet  it  is  necessary  to  separate  them,  as  the  first  is  the  source  of  the  passive,  and 
the  second  an  important  modifier  of  the  active  auscultatory  phenomena. 

f  The  percussion  sound  is  tersely  described  by  Dr.  Walshe  as  "mass  of  tone 
increased;  pitch  lowered,  quality  exaggerated."    4th  edition.     (Ed.) 


156  BKONCHITIS. 

the   greatly   diminished  volume   of  air  which  can  enter  at  an 
inspiration. 

We  may  further  observe,  that  the  sound  on  percussion  is  often 
clear  down  to  the  lowest  portion  of  the  thorax.  The  natural 
hepatic  dulness  of  the  postero-inferior  portion  of  the  right  side 
disappears,  and  unless  where  the  heart  is  much  enlarged,  the 
sound  of  the  cardiac  region  is  remarkably  clear.  This  will  be 
particularly  the  case  if  the  lung  overlaps  the  pericardium  to  any 
extent,  of  which  we  can  easily  satisfy  ourselves  by  means  of  the 
stethoscope. 

But  in  almost  all  cases  of  such  extensive  disease,  we  find  a 
complication  with  enlargement  of  the  heart,  the  result  of  the  long- 
continued  and  increasing  obstruction  to  the  pulmonary  circulation, 
and  this  will  give  an  increase  of  dulness  over  the  organ, 
particularly  at  its  right  side.  We  then  find  that  there  is  dulness 
from  the  situation  of  the  apex  of  the  left  ventricle  as  far  as  the 
right  side  of  the  sternum  ;  and  as  Piorry  has  remarked,  the  extent 
of  this  dulness  may  be  found  to  vary  according  to  the  degree  of 
pulmonaiy  obstruction.  This  is  the  most  common  case ;  but  in 
a  few  instances,  even  though  the  enlargement  of  the  heart  be 
considerable,  we  find  in  these  regions  a  clear  sound  on  percussion, 
or,  at  all  events,  a  want  of  dulness  commensurate  with  the  heart 
disease,  a  circumstance  explicable  by  the  increased  volume  of  the 
lung,  which,  by  throwing  the  parietes  forwards,  buries  the  heart 
in  the  thoracic  cavity.  In  such  cases  the  impulse  of  the  organ 
ceases  to  be  a  measure  of  its  disease,  and  we  are  surprised  at 
finding  an  hypertrophied  heart,  although,  during  life,  the  impulse 
at  the  side  and  lower  sternal  regions  had  been  slight.  As  a 
general  rule  we  may  state,  that  where  this  complication  exists 
with  a  distinct  impulse,  the  sound,  on  percussion  of  the  cardiac 
region,  will  be  dull. 

But  the  morbid  clearness  of  the  chest  is  not  met  with  in  all 
stages  of  the  disease ;  it  is  only  observed  when  the  affection  has 
arrived  to  an  advanced  degree,  and  may  be  altogether  wanting  in 
the  earlier  periods.  A  patient  may  have  a  degree  of  dilatation  of 
the  air  cells  sufficient  to  give  decided  feebleness  of  respiration, 
without  any  perceptible  increase  in  the  clearness  of  sound.  Of  this 
I  saw  a  remarkable  instance  in  a  patient  who  was  admitted  into  my 
wards,  and  who  presented  a  group  of  symptoms  and  signs  which 
led  me  to  suspect  the  existence  of  an  aneurism  of  the  aorta  ;  his 


BRONCHITIS.  157 

complaints  had  been  of  about  five  months'  standing,  up  to  which 
time  he  had  enjoyed  good  health  ;  he  then  contracted  cough, 
followed  by  severe  dyspnoea  on  exercise,  and  some  pain  in  the  back 
and  upper  portion  of  the  chest.  We  found  that  both  sides 
sounded  equally  upon  percussion,  nor  was  the  sound  at  all 
morbidly  clear.  The  respiration  in  the  right  lung  was  puerile, 
while  in  the  upper  portion  of  the  left  it  was  exceedingly  feeble. 
The  impulse  and  sound  of  the  heart,  as  observed  below  the 
mamma,  seemed  natural,  but  a  double  pulsation  could  be  heard 
at  the  upper  portion  of  the  left  side  ;  there  was  no  bruit  de 
souffiet,  dysphagia,  or  laryngeal  breathing. 

Here  was  a  group  of  symptoms  and  signs,  which  I  thought 
might  possibly  depend  upon  a  small  aneurismal  tumour,  com- 
pressing the  left  bronchus.  But  I  made  no  positive  diagnosis  in 
the  case.  The  patient  some  time  afterwards  died  with  effusion 
into  the  chest ;  and  on  dissection  it  was  found  that  there  was  no 
aneurism,  but  that  partial  dilatation  of  the  air  cells  existed, 
affecting  only  the  upper  portion  of  the  left  lung,  and  that  the 
right  cavities  of  the  heart  were  dilated  and  somewhat  hyper- 
trophied.  The  feebleness  of  respiration  was  clearly  attributable 
to  the  dilatation  of  the  air  cells;  and  the  case  shews,  that 
this  lesion  may  exist  to  such  a  degree  as  to  give  distinct 
stethoscopic  signs,  although  the  sound  on  percussion  be  not 
perceptibly  increased.  In  other  cases  too  I  have  found  on 
dissection,  dilatation  of  the  air  cells  to  some  extent,  although 
during  life  percussion  gave  no  unusual  results. 

I  now  proceed  to  consider  the  remaining  sources  of  physical 
signs  in  this  disease,  or  those  which  are  the  principal  causes  of 
the  active  auscultatory  phenomena.  I  shall,  in  the  first  place, 
dwell  on  the  increased  volume  of  the  lung,  and  consider  it  first  in 
relation  to  the  stethoscopic  signs,  and  next,  as  causing  displace- 
ment of  adjacent  parts.  And  we  shall  inquire  how  far  the  degree 
of  resistance  afforded  by  the  thoracic  parietes  tends  to  influence 
both  the  auscultatory  signs,  and  those  more  obvious  ones,  which 
proceed  from  the  displacement  of  surrounding  organs. 

The  modifications  of  the  sounds  of  respiration  in  this  disease 
depend  on  the  following  causes  : 

1st.  The  increased  volume  of  the  lung. 

2nd.  The  existence  of  bronchitis,  principally  affecting  the 
minute  tubes,  and  often  complicated  with  congestion  of  the  lung. 


158  BRONCHITIS. 

3rd.  The  formation  of  the  sub-pleural  vesicles.* 
The  first  of  these  sources  of  modification  of  the  respiratory 
phenomena  being  the  most  important  in  the  diagnosis,  I  shall 
dwell  particularly  upon  it. 

One  of  the  first  circumstances  which  strikes  the  observer  in  this 
affection,  is  the  want  of  accordance  between  the  inspiratory 
efforts,  and  the  sound  of  pulmonary  expansion ;  the  first  being 
evidently  excessive,  and  the  latter  extremely  feeble.  When  he 
employs  percussion  he  will  at  once  discover  that  the  cause  of  this 
feebleness  cannot  be  any  solidification  of  the  lung,  as  the  sound 
is  either  natural,  or  clearer  than  natural,  and  under  these  circum- 
stances he  must  seek  for  some  other  cause  to  explain  the  pheno- 
menon. It  appears  to  me,  that  in  the  increased  volume  of  the 
lung,  he  will  find  the  cause  of  this  important  sign  :  for  the  organ 
being  in  a  permanent  state  of  enlargement,  the  dilatation  of 
the  chest  can  be  hut  little  added  to  by  the  inspiratory  effort,  and 
hence  the  sound  of  respiration  becomes  proportionally  feeble. 
Hence  this  feebleness  of  respiration,  coinciding  with  clearness  of 
the  chest  and  increase  of  the  inspiratory  efforts,  becomes  the 
most  important  physical  sign  of  the  disease  in  question.  Other 
causes,  however,  have  been  enumerated,  particularly  the  thicken- 
ing of  the  mucous  membrane,  the  result  of  that  chronic  bron- 
chitis which  so  constantly  attends  this  affection.  Thus  Laennec 
has  stated,  that  in  the  dry  catarrh,  which  so  commonly  produces 
this  disease,  the  mucous  membrane  of  the  minuter  tubes  is  often 
extremely  thickened,  which,  to  a  certain  degree,  explains  the 
feebleness  of  respiration,  and  also  the  fact  that  when  we  compress 
the  lungs  taken  from  an  emphysematous  patient,  we  find  greater 
difficulty  in  reducing  them  to  their  state  of  flaccidity  than  if  they 
were  in  their  ordinary  condition.  In  fact,  cceteris  paribus,  the 
sound  of  respiration  is  directly  as  the  facility  of  the  entrance 
of  the  air,  and  any  mechanical  obstruction,  whether  in  the 
trachea,  the  larger  or  the  more  minute  bronchial  tubes, 
will  cause  a  corresponding  feebleness  of  the  respiratory  murmur. 
This  has  been  long  known ;  I  remember  seeing  an  interesting 
example  of  this  in  a  patient  whose  chest  I  was  requested  to 
examine  previous  to  the  performance  of  tracheotomy.  The  his- 
tory of  the  case  was  such  as  might  warrant  the  supposition  of  the 

*  This  source  of  signs  is  given  on  the  authority  of  Laennec,  and  it  is  to  be  recol- 
lected, that  these  vesicles  are  not  necessarily  attendant  on  the  disease. 


BKONCHITIS.  159 

existence  of  a  pulmonary  emphysema.  On  percussion  the  chest 
sounded  everywhere  extremely  clear,  but  the  vesicular  murmur 
was  feeble,  notwithstanding  the  violent  efforts  of  the  patient ;  yet 
on  the  trachea  being  opened,  it  became  at  once  loud,  even  to 
puerility,  and  continued  with  this  character  for  some  time  after 
the  operation.*  But  without  denying  that  this  thickening  has  an 
effect,  I  cannot  help  thinking,  that  we  must  also  attribute  much 
to  the  increased  volume  of  the  lung  for  the  following  reasons  : 

First.  In  cases  of  ordinary  bronchitis,  even  when  the  minute 
tubes  are  engaged,  this  remarkable  disproportion  between  the 
inspiratory  efforts  and  sound  of  expansion  is  either  not  observed, 
or  occurs  in  a  much  smaller  degree.  In  these  cases  we  hear  either 
a  mixture  of  the  vesicular  murmur  with  various  rales,  or  observe 
that  the  murmur  is  almost  masked  by  the  rales ;  but  in  both 
cases  the  phenomena  indicate  full  expansion  and  contraction  of 
the  lung,  and  their  intensity  can  be  remarkably  modified  by  the 
efforts  of  the  patient.  Yet  in  cases  of  dilatation  of  the  cells  this 
is  not  observed,  and  the  phenomena  are  but  little  modified 
whether  the  patient  breathes  in  his  ordinary  manner,  or  makes 
an  increased  effort  at  inspiration.  In  the  former  case  the  air  cells 
may  be  considered  as  unaffected,  and  on  the  obstruction  which 
results  from  the  thickening  of  the  bronchial  membrane,  or  the 
presence  of  secretion  in  the  tubes  being  overcome,  the  lung 
expands,  and  this  expansion  is  evident  to  the  auscultator. 

Secondly.  I  have  observed  that  in  confirmed  dilatation  of  the 
air  cells,  the  sign  of  feebleness  of  respiration  is  but  little  affected 
by  the  increase  or  diminution  of  the  bronchitis,  at  least  as  far  as 
we  can  judge  of  the  latter  by  the  physical  signs  and  constitu- 
tional symptoms.  Thus,  it  not  unfrequently  happens,  that  such 
patients  are  attacked  with  exacerbations  of  the  bronchial  irritation, 
which  may  subside  under  treatment,  but  during  their  continu- 
ance the  physical  signs  are  less  an  increase  of  the  feebleness  of 
respiration  than  of  the  various  rales  ;  and  on  the  other  hand, 
when  they  subside,  that  feebleness  is  scarcely,  if  at  all,  dimi- 
nished ;  in  fact,  the  sign  of  feebleness  is  but  little  affected  by  the 
increase  or  diminution  of  the  bronchitis,  a  circumstance  quite  in 
accordance  with  my  view  of  its  cause,  namely,  the  diminished 
quantity  of  air  that  enters  the  affected  portion  of  the  lung. 

I  have  already  stated,  that  the  feebleness  of  respiration  in  this 
*  See  Beau,  Archives  Generates,  1835. 


160  BRONCHITIS. 

affection  is  owing  to  the  increased  volume  of  the  lung,  by  which 
the  amount  of  the  inspiration  is  diminished ;  for  if  the  lung  be 
thus  hypertrophied,  so  as  to  press  strongly  on  the  chest,  and 
preserve  that  cavity  distended,  even  after  expiration,  it  is  obvious, 
that  on  the  next  inspiration  the  volume  of  air  entering  will  be 
minus  the  expanding  of  the  lung  from  its  own  distending 
force. 

Let  us  suppose  that  the  area  of  the  healthy  chest,  after  expi- 
ration, to  be  equal  to  10,  and  the  maximum  of  its  expansion  to  be 
equal  to  15,  it  is  plain,  that  if  from  the  disease  the  lung  acquires 
a  volume  in  rest  equal  to  12^,  the  inspiration  would  be  diminished 
by  one-half;  hence  a  cause  of  feebleness  of  respiration,  as  part 
of  the  inspiratory  effort,  is  supplied  by  the  expansion  of  the  lung, 
which  results  from  its  being  kept  compressed  in  the  state  of  rest. 

It  is  obvious,  however,  that  the  physical  signs  of  the  pulmonary 
compression  must  vary  according  to  the  rigidity  of  the  thoracic 
walls.  If  we  take  two  cases  of  Laennec's  emphysema,  and  suppose 
that  in  one  the  chest  yields  pari  passu  with  the  enlargement  of 
the  lung,  while  in  another  it  is  rigid  and  unyielding,  it  is  plain 
that  the  physical  condition  of  the  lung,  and  of  course  the  physical 
signs  of  its  actions,  must  be  different.  If  the  feebleness  of 
respiration  depend  upon  the  compression  of  the  lung,  it  should 
follow,  that  if  in  any  case  the  chest  yielded  easily  and  fully  to  the 
pulmonary  enlargement,  we  might  have  great  and  extensive 
dilatation  of  the  cells,  without  the  sign  which  is  supposed  to  be 
characteristic,  so  that  the  feebleness  of  respiration  would  seem 
more  a  measure  of  compression  of  the  lung  than  a  direct  sign  of 
dilatation  of  the  cells.  Of  these  views  the  following  case  is 
strongly  illustrative,  and  I  place  the  more  value  on  it  as  the 
patient  has  been  at  different  periods  under  my  observation. 

A  young  man,  of  feeble  muscular  development,  and  considerably 
below  the  middle  size,  entered  the  Meath  Hospital,  labouring 
under  the  usual  symptoms  of  Laennec's  emphysema ;  the  chest 
was  enormously  enlarged  on  both  sides,  but  the  principal  yielding- 
seemed  to  have  taken  place  in  the  upper  and  anterior  portions ; 
the  circumference  at  the  mammary  regions  being  three  feet  and  an 
inch,  an  increase  of  at  least  seven  inches  above  its  natural 
development.  The  sternum  and  clavicles  were  arched,  the 
scapular  regions  nearly  horizontal,  and  the  development  of  both 
sides  equal.     Yet,  in  this  case,  the  characteristic  signs  existed 


BRONCHITIS.  161 

only  in  the  supero-anterior  portion  of  the  right  side,  while  over 
the  rest  of  the  thorax  the  respiration  could  be  heard  loudly,  and 
after  the  individual  had  been  treated  for  bronchitis  it  was  pure. 
In  this  case  the  symptoms  had  lasted  for  upwards  of  five  years, 
and  after  the  second  year  the  enlargement  of  the  chest  became  so 
manifest  as  to  excite  the  attention  of  all  the  patient's  friends. 

Here  there  was  a  case  in  which  the  yielding  of  the  chest  was 
more  remarkable  than  any  we  had  ever  witnessed,  and  yet  over 
the  greater  portion  of  the  thorax  the  respiration  was  anything 
but  feeble ;  and  it  is  a  most  curious  and  interesting  fact,  that 
with  the  absence  of  the  signs,  there  was  also  absence  of  the 
symptoms  of  compression.  There  was  no  evidence  of  disease  of 
the  heart ;  there  had  never  been  cedema ;  the  jugular  veins  were 
not  distended  ;  the  liver  was  not  depressed ;  and  the  patient,  so 
far  from  being  embarrassed  by  exercise,  was  always  better  after 
walking  a  considerable  number  of  miles.  A  short  time  before 
entering  the  hospital  he  performed  a  journey  of  forty  miles  on 
foot  in  the  course  of  a  single  day.  His  only  inconvenience  was 
the  recurrence  of  bronchitic  attacks,  but  when  these  were  absent 
his  general  health  was  excellent. 

It  might  here  be  inquired,  what  was  then  the  cause  of  the 
feebleness  of  respiration  in  the  anterior  portion  of  the  right  lung  ? 
I  think  that  in  all  probability  there  was  here  rupture  of  the  air 
cells,  and  that  in  this  condition  we  have  a  cause,  in  addition  to 
that  of  compression  of  the  lung,  for  the  ordinary  feebleness  of 
respiration. 

We  shall  now  consider  some  of  the  other  physical  signs,  which 
result  from  the  enlargement  of  the  lung,  and  which,  like  the 
preceding,  vary  with  the  amount  of  resistance  of  the  thoracic 
walls. 

Signs  connected  with  the  Intercostal  Muscles  and  Dia- 
phragm.— The  next  result  of  the  increased  volume  of  the  lung, 
which  we  now  consider,  is  its  effect  in  displacing  the  more 
yielding  parts  of  the  thorax.  These  may  be  considered  to  be  the 
mediastinum,  the  intercostal  muscles,  and  the  diaphragm ;  and 
we  shall  find,  that  although  the  mediastinum  yields  in  cases  of 
the  disease  occurring  in  a  single  lung,  yet  that  the  muscular 
expansions  exhibit  a  great  power  of  resistance,  and  in  many 
cases  do  not  yield,  even  after  the  chest  has  been  much  enlarged. 
In  this  respect  we  observe  a  remarkable  difference  between  this 

M 


162  BKONCHITIS. 

disease  and  empyema,  in  which  the  yielding  of  the  muscular 
expansions  forms  one  of  the  most  important  signs. 

When  we  examine  the  intercostal  spaces  in  this  affection, 
even  after  great  dilatation  of  the  chest  has  occurred,  we  see  them, 
so  far  from  being  obliterated,  deeply  marked,  and  the  muscular 
fibres  acting  powerfully,  so  as  to  elevate  the  ribs,  and  assist  in 
the  imperfect  inspiration.  I  have  never  seen  an  exception  to 
this,  and  the  rule  applies  to  every  intercostal  space ;  and  as  a 
point  of  difference  between  the  two  diseases  of  accumulation, 
empyema,  and  Laennec's  emphysema,  it  is  of  the  greatest 
interest.  When  I  come  to  consider  empyema  I  shall  point  out 
the  causes  of  this  difference,  which  have  not  been  hitherto 
understood.* 

But  the  same  remarks  cannot  be  made  with  respect  to  the 
diaphragm,  which,  in  certain  cases,  yields  before  the  enlarged 
lung,  so  as  greatly  to  increase  the  cavity  of  the  chest  down- 
wards. This  circumstance  may  be  taken  as  a  most  important 
distinguishing  mark  in  cases  of  this  disease,  which  may  be 
divided  into  those  with,  and  those  without,  diaphragmatic  dis- 
placement. 

From  the  position  of  the  muscle,  and  its  inferior  mechanical 
support,  we  should  expect,  a  priori,  that  it  should  yield  more  to 
mechanical  pressure  than  the  intercostals.  And  such  I  have 
ascertained  to  be  the  fact,  as  while  I  have  often  seen  dis- 
placement of  the  diaphragm,  in  no  case  did  I  find  that  the 
intercostals  were  similarly  affected. 

Between  the  two  cases  of  Laennec's  emphysema,  with  and 
without  this  displacement,  I  have  observed  some  striking  dif- 
ferences as  to  symptoms  and  signs.  Of  those  in  which  the 
diaphragm  is  not  affected,  we  have  an  excellent  example "  in  the 
case  which  I  have  described  of  great  yielding  of  the  thoracic 
walls.  Here  the  signs  of  pressure  on  the  lung  were  much  less 
distinct,  and  there  existed  no  indication  of  hepatic  displacement, 
the  epigastrium,  so  far  from  being  tumid,  being  actually  col- 
lapsed. But  in  the  case  with  displacement  of  the  diaphragm  we 
observe  that  there  is  much  more  distress  in  breathing ;  that  the 

*  "  It  must  be  confessed,"  says  Dr.  Walshe,  "  that  the  published  experience  of 
physicians  generally  does  not  accord  with  that  of  Dr.  Stokes  in  respect  of  the 
bulging  of  emphysema  ;  both  Louis  and  Woillez  are  wholly  opposed  to  Dr.  Stokes  on 
this  point."— Page  326.    4th  edition.     (Ed.) 


BRONCHITIS.  163 

epigastrium  is  full  and  resisting,  and  that  the  heart  is  pushed 
down  sometimes  so  far  as  to  be  on  a  level  with  the  ninth,  or 
even  tenth  intercostal  space. 

Under  these  circumstances  the  postero -inferior  portion  of  the 
chest,  and  the  regions  of  the  liver  and  heart  anteriorly,  give  a 
perfectly  clear  sound,  which  is  explicable  by  the  displacement  of 
these  viscera,  and  also  by  the  condition  of  the  lung. 

When  these  patients  are  stripped,  and  lying  on  the  back,  a 
remarkable  character  of  respiration  may  be  observed.  We  see 
the  thorax  powerfully  elevated  upwards,  and  the  abdomen  as 
powerfully  protruded  downwards ;  but  there  is  this  remarkable 
difference  from  forced  respiration  in  the  healthy  state,  that  the 
abdominal  protrusion  does  not  begin  so  high,  and  while  the 
umbilical  and  hypogastric  regions  move  upwards  and  forwards, 
the  epigastrium  and  upper  portions  of  both  hypochondria  remain 
comparatively  motionless,  while  the  corresponding  ribs  are 
drawn  in.  This  is  explicable  by  the  new  position  of  the  dia- 
phragm; it  has  descended,  and  carried  the  abdominal  viscera 
before  it ;  and  its  contraction  takes  effect  at  a  point  lower  in 
proportion  to  its  displacement. 

That  this  displacement  is  a  purely  mechanical  result,  and  not 
analogous  to  that  in  empyema,  shall  be  shewn  hereafter.  It 
varies  so  remarkably  with  the  volume  of  the  lung,  that  I  have 
seen  the  heart,  after  the  subsidence  of  a  bronchitic  attack, 
mount  from  the  tenth  to  the  eighth  intercostal  space. 

On  the  subject  in  general,  we  want  some  accurate  dissections. 
I  regret  that  my  experience  is  but  limited,  but  I  shall  state  it. 
It  would  appear  that  much  will  depend  on  whether  the  disease 
predominates  in  the  upper  or  lower  lobes ;  if  in  the  latter,  the 
shape  of  the  lung  is  altered,  and  I  have  found  in  this  way,  that 
from  the  great  enlargement  of  the  cells,  and  the  formation  of 
sub-pleural  vesicles,  the  lower  surface,  from  being  concave,  had 
become  flattened,  or  even  convex.  Under  these  circumstances 
the  diaphragm  must  of  course  yield. 

In  a  patient  who  died  in  the  Meath  Hospital,  the  following 
appearances  were  found  :  the  liver  was  in  its  natural  situation, 
but  the  left  ala  of  the  diaphragm  was  pushed  far  down,  so  as  to 
become  convex  towards  the  abdomen.*     But  a  source  of  fallacy 

*  For  this  dissection  I  have  the  authority  of  my  friend,  Dr.  Hudson,  who  then 
acted  as  clinical  clerk  in  the  medical  department  of  the  institution. 

M   2 


164  BRONCHITIS. 

exists  in  this  case,  and  in  all  dissections  made  to  clear  up  this 
point,  it  must  be  borne  in  mind  that  the  diaphragm  may  have 
yielded  post  mortem,  merely  from  the  pressure  which,  during  life, 
it  had  been  able  to  resist.* 

Signs  from  the  Displacement  of  the  Mediastinum. — In 
considering  these  signs  we  find,  that  although  they  may  exist  so 
as  to  be  demonstrable  during  life,  yet  that  they  are  less  remark- 
able than  those  in  empyema.  In  certain  cases  where  the  disease 
is  confined  to  one  lung,  the  morbid  signs  extend  across  the  mesian 
line  to  a  distance  proportioned  to  the  extent  of  the  disease ;  and 
as  in  empyema  we  have  dulness  and  absence  of  respiration  ex- 
tending across  the  mesian  line  from  disease  of  one  pleura,  so 
in  the  dilatation  of  the  air  cells  we  have  the  morbid  clearness 
and  characteristic  respiration,  under  the  same  circumstances ; 
and  if  anything  was  wanting  to  complete  the  analogy,  it  is, 
that  the  displacement  of  the  mediastinum  can  be  observed  to 
vary  with  the  state  of  disease  in  either  case. 

Thus,  when  the  dilatation  of  the  cells  is  confined  altogether,  or 
nearly  so,  to  one  lung,  percussion  gives  a  peculiarly  clear  sound 
over  the  affected  side  ;  and  if  the  disease  has  displaced  the  medi- 
astinum this  clearness  will  be  found  across  the  whole  sternum, 
and  it  may  be  for  an  inch  or  so  beyond  it.  This  line,  which  is 
well  defined,  having  been  passed,  we  then  observe  the  natural 
pulmonary  sound,  which  an  experienced  ear  will  have  no  difficulty 
in  distinguishing  from  that  of  the  diseased  lung.  If  the  observer 
now  applies  the  stethoscope  over  the  affected  side,  and  carries 
the  instrument  across  the  chest,  he  will  find  that  the  peculiar 
phenomena  of  respiration  do  not  disappear  until  he  passes  the 
sternocostal  articulations  of  the  opposite  side,  where,  like  the 
clearness  on  percussion,  they  suddenly  cease,  and  are  replaced 
by  the  natural  respiratory  murmur. 

I  must  state  here,  that  although  we  should  expect  a  priori 
that  these  signs  always  exist  in  the  advanced  stages  of  the  disease, 
when  confined  to  one  lung,  yet  that  I  have  only  verified  them  in 
a  single  instance,  and  that  additional  observations  will  be  neces- 

*  "  There  are  some  cases,"  says  Dr.  "Waters,  "  in  which  the  floor  of  the  chest  yields 
greatly  to  the  expanding  lungs,  the  diaphragm  being  pushed  down,  &c." — Diseases  of 
the  Lungs,  p.  148.  "  Whenever,"  says  Hertz,  "  the  elasticity  of  the  lung  is 
diminished  or  altogether  lost,  and  the  lung  remains  in  a  permanent  inspiratory 
position,  the  air  being  forced  out  of  it  in  very  inconsiderable  quantity,  the  diaphragm 
cannot  rise  and  resume  its  expiratory  position," — Ziemssen'e  Cyclopaedia,  vol.  v.    (Ed.) 


BRONCHITIS.  165 

sary  to  ascertain  their  exact  value  or  constancy.  I  have  little 
doubt,  however,  from  the  analogy  of  the  disease  in  question  with 
empyema,  that  they  will  be  found  to  occur  in  all  cases  of  con- 
firmed dilatation  of  the  cells,  when  the  disease  occupies  but  a 
single  lung. 

But  although  in  both  instances  the  mediastinum  be  displaced, 
yet  in  the  disease  before  us  the  change  is  seldom  seen  in  so  strik- 
ing a  manner  as  in  empyema.  One  reason  for  this  may  be  the 
fact,  that  in  most  cases  of  decided  dilatation  of  the  cells,  the 
disease  exists  in  both  lungs,  while  double  empyema  is  one  of 
the  rarest  of  diseases.  Another  will  be  admitted  when  we 
recollect  that  the  inflammatory  action  of  pleuritis,  by  softening 
the  serous  membranes,  will  render  them  more  likely  to  yield  in 
that  disease  than  in  Laennec's  emphysema,  where  no  such  action 
exists. 

The  heart,  of  course,  will  follow  the  displaced  mediastinum, 
and  its  position  vary  with  the  affected  lung  and  the  amount  of 
disease.  My  experience,  however,  leads  to  the  conclusion,  that 
in  this  affection  lateral  displacement  of  the  heart  is  rarely  seen  to 
any  remarkable  degree,  another  circumstance  of  difference  be- 
tween this  affection  and  empyema,  and  to  be  explained  by  the 
preceding  considerations.  This  remark,  however,  does  not  apply 
so  much  to  the  displacement  downwards,  which,  as  I  have 
shewn,  may  occur  to  a  very  great  degree.  Under  these  circum- 
stances the  precordial  region  is  clear  on  percussion,  and  the 
impulse  of  the  heart  may  be  altogether  wanting  in  its  natural 
position,  but  occur  as  low  down  as  the  tenth  rib,  and  between 
the  costal  cartilages  and  mesian  line. 

It  is  now  admitted  that  most  of  the  patients  affected  with 
this  disease  die  with  symptoms  of  morbus  cordis  and  general 
dropsy,  and  it  is  not  difficult  to  understand  why  disease  of  the 
heart  should  be  so  common  a  complication.  The  cause  of  this 
seems  to  reside  almost  altogether  in  the  great  enlargement  of 
the  lung,  which  must  have  a  deleterious  effect  upon  the  heart 
in  the  following  respects. 

First,  as  I  have  already  shewn,  by  its  interference  with  the 
process  of  inspiration.  The  experiments  of  modern  physiologists 
have  shewn  the  great  influence  which  is  exercised  by  the  respi- 
ratory process  on  the  venous  circulation ;  but  in  the  disease 
before  us  we  find  the  chest  in  a  state  of  permanent  dilatation,  to 


I  hh  BPrtMPIITTIO 


166  BRONCHITIS. 

which  the  inspiratory  effort  can  add  but  little,  the  manifest 
consequences  of  which  must  be  an  accumulation  of  blood  at  the 
right  side  of  the  heart,  and  consequent  disease  of  its  pulmonary 
cavities.  The  vena  cava  becomes  loaded,  the  hepatic  veins 
engorged,  and  the  liver  consecutively  engaged.  Under  these 
circumstances  the  muscular  parietes  of  the  heart  become  hyper- 
trophied,  and  an  active  aneurism  of  the  auricle  and  ventricle  is 
produced. 

Secondly,  it  seems  more  than  probable  that  the  same  pressure 
which  has  distended  the  chest  and  displaced  the  diaphragm, 
must  act  directly  in  impeding  the  circulation  through  the 
pulmonary  artery  and  its  ramifications,  and  thus  we  see  an 
additional  cause  for  the  production  of  hypertrophy  of  the  right 
cavities  of  the  heart. 

Lastly,  we  must  recollect  that  the  heart  itself  is  under  the 
influence  of  anormal  pressure.  It  is  removed  from  its  natural 
situation,  and  to  a  certain  degree  deprived  of  its  natural  pro- 
tection by  the  bony  and  elastic  parietes  of  the  chest,  and  is 
compressed  between  the  distended  lung,  on  the  one  hand,  and 
the  distended  abdomen  on  the  other.  Under  these  circum- 
stances its  actions  of  dilatation  and  contraction  must  be  mate- 
rially interfered  with,  the  auricles  will  experience  a  powerful 
impediment  in  filling  the  ventricles ;  and  if  these  cavities  have 
an  active  power  of  dilatation,  this  must  also  be  materially 
impeded.  Thus,  many  circumstances  concur  to  derange  the 
pulmonary,  cardiac,  venous,  and  hepatic  circulation.  And  we 
can  only  wonder  at  the  powers  of  nature  in  prolonging  life  under 
such  a  complication  of  evils.  In  the  great  majority  of  cases 
such  patients  die  with  symptoms  of  what  is  commonly  called 
hydrothorax,  to  the  disappointment  of  the  practitioner,  who 
prescribes  according  to  the  rules  of  the  nosological  writers, 
and  a  post  mortem  examination  will  reveal  the  causes  of  his 
failure,  and  the  error  of  his  teachers.* 

Signs  from  the  Existence  of  Bronchitis. — On  the  subject 
of  the  signs  manifestly  proceeding  from  bronchial  irritation  I 
have  to  remark,  that  there  is  not  one  of  them  which  can  be 
considered  as  pathognomonic  of  the  complication  with  dilated  or 

*  To  the  above  causes  must  be  added  the  obliteration  of  numerous  small  branches 
of  the  pulmonary  artery  consequent  on  the  dilatation  and  obliteration  of  the  air 
cells.  See  Hertz  in  Ziemssen's  Cyclop.,  vol.  v.  pp.  879  and  880.  Also  Waters  on 
Emphysema.     (Ed.) 


BRONCHITIS.  167 

ruptured  air  cells,  inasmuch  as  we  may  find  them  all  in  cases 
where  no  such  affection  exists.  None  of  them  are  constant; 
and  when  they  do  occur,  scarcely  differ  from  what  is  observed  in 
simple  bronchitis :  we  may  have  all  varieties  of  the  sonorous, 
sibilous,  mucous,  and  muco-crepitating  rales  in  this  affection, 
and  the  occurrence  and  mode  of  combination  of  the  phenomena 
are  infinitely  various.  The  two  most  common  are,  the  dry 
sibilous,  and  a  diffuse  mucous  rale.  Laennec  has  stated  that 
there  is  one  form  of  rale  which  is  pathognomonic  of  the  inter- 
lobular emphysema,  although  it  may  also  occur  in  the  simple 
dilatation ;  this  he  calls  the  dry  crepitating  rale  with  large 
bubbles,  and  describes  it  as  conveying  the  impression  of  air 
entering  and  distending  lungs  which  had  been  dried,  and  of 
which  the  cells  had  been  unequally  dilated.  He  compares  it 
to  the  sound  produced  by  blowing  into  a  dry  bladder ;  and 
states  farther,  that  it  is  similar  to  that  observed  in  common 
sub-cutaneous  emphysema  when  we  press  the  stethoscope  on 
the  affected  portion.  Now,  without  at  all  calling  in  question 
the  extraordinary  tact  of  Laennec,  I  would  say,  that  this  is 
a  sign,  which,  if  it  does  exist,  must  be  so  easily  confounded 
with  other  phenomena,  such  as  those  proceeding  from  bron- 
chitis, that  an  ordinary  observer  would  not  be  safe  in  founding 
a  diagnosis  on  its  supposed  existence.  I  have  never  been  able 
to  satisfy  myself  that  I  had  recognized  it,  and  have  even  found 
the  interlobular  emphysema  in  the  lungs  of  persons,  in  whom 
during  life  I  was  not  able  to  distinguish  the  rales  from  those 
of  simple  catarrh.  He  states,  however,  that  the  phenomenon 
is  not  common,  and  when  it  exists  is  of  short  duration,  and 
observed  in  points  of  only  small  extent.  On  this  subject  further 
observations  are  necessary. 

I  shall  lastly  allude  to  the  sign  of  the  rubbing  sound,  or 
frottement,  which  has  been  described  by  Laennec  as  an  indication 
of  those  sub-pleural  air  vesicles  which  occur  in  the  interlobular 
emphysema,  and  which,  according  to  him,  when  occurring  with 
the  other  symptoms  of  dilated  cells,  may  be  looked  on  as 
diagnostic  of  the  lesion  in  question.  But  this  point  of  diag- 
nosis, like  the  last,   requires  still  further  investigation;*   and 

*  This  subject  is  fully  discussed  and  Laennec's  statement  confirmed  by  Dr.  Gairdner 
in  his  lecture  on  emphysema,  Clinical  Medicine,  p.  436.  I  have  met  with  a  similar 
case  in  which  sub-pleural  emphysema  was  found  after  death  at  the  site  of  friction 
Bound  heard  by  me  during  the  patient's  life.    (Ed.) 


168  BEONCHITIS. 

indeed  it  seems  difficult  to  understand  how  the  existence  of 
an  air  vesicle  could  give  rise  to  the  rubbing  sound.  We  know 
that  in  the  healthy  condition  of  the  internal  surfaces  of  serous 
membranes,  the  friction  of  their  opposite  faces  is  so  diminished 
by  their  smoothness,  and  their  being  lubricated  by  the  serous 
exhalation,  that  no  perceptible  sound  accompanies  their  motions. 
It  is  only  when  the  surfaces  are  rendered  dry  by  an  arrest  of 
secretion,  or  roughened  by  the  effusion  of  lymph,  that  their 
motions  produce  sounds  perceptible  to  the  ear.  Now,  even 
where  extensive  vesicles  exist,  we  commonly  find  that  the  serous 
surface,  as  far  as  smoothness  and  lubrication  are  concerned, 
continues  in  its  natural  state  ;  and  I  cannot  help  agreeing  with 
Meriadec  Laennec,  that  the  sign  of  frottement  is  to  be  looked 
on  more  as  an  indication  of  slight  pleurisy  than  of  these  sub- 
pleural  vesicles.  I  have  never  observed  this  phenomenon  unless 
in  cases  where  the  serous  surface  was  roughened ;  and  as  it  is 
admitted,  both  by  the  above  author  and  by  M.  Keynaud,*  that 
the  sound  in  pleurisy  is  undistinguishable  from  that  described 
by  Laennec  in  this  disease,  we  have,  I  think,  sufficient  reasons 
for  extreme  caution  in  the  diagnosis  of  sub -pleural  vesicles  from 
the  existence  of  the  sign  in  question. 

It  might  be  supposed  that  the  permanence  of  the  sign  and  the 
absence  of  pain  would  prove  diagnostic  marks,  but  the  truth  is, 
that  even  these  circumstances  will  not  be  sufficient.  Thus  I 
have  seen  cases  in  which  the  frottement  of  pleuritis  continued  for 
a  month  with  scarcely  any  alteration,  and  in  which,  after  the 
first  week,  the  patient  felt  no  pain,  and  only  complained  of  the 
rubbing  sensation  produced  during  respiration,  in  the  affected  part. 

Before  leaving  this  subject  I  shall  describe  another  sign  which 
promises  to  be  of  the  greatest  importance  in  diagnosis.  It  is 
founded  on  the  difficulty  of  expiration  which  occurs  in  this 
disease,  a  difficulty  by  some  attributed  to  the  obstruction  of  the 
minute  bronchial  tubes,  and  more  lately  by  Majendie  to  the 
diminished  elasticity  of  the  lung  itself. 

I  have  at  present  under  my  care,  a  patient  aged  upwards  of 
sixteen  years,  who  has  been  subject  to  cough  and  dyspnoea  from 
infancy.  The  right  side  is  enlarged,  and  very  convex  anteriorly, 
the  sternum  somewhat  arched,  and  the  clavicle  elevated.  Over 
this  side  the  sound  is  morbidly  clear  on  percussion,  and  the 

*  See  Journal  Hebdomadaire,  No.  65. 


BRONCHITIS.  169 

clearness  extends  across  the  sternum ;  yet  on  applying  the 
stethoscope  during  ordinary  respiration,  nothing  is  heard  but  a 
rnuco-crepitating  rale,  occasionally  combined  with  Laennec's 
rale  crepitant  a  grosses  bulles ;  these  signs  are  audible  during 
inspiration,  while  expiration  is  marked  by  a  dry  prolonged 
wheeze-  On  a  forced  inspiration,  however,  a  distinct  sound  of 
pure  pulmonary  expansion  follows  the  rales  above-mentioned. 

From  these  observations  I  concluded  that  the  case  was  one  of 
Laennec's  emphysema,  which  had  not  yet  arrived  at  its  most 
extreme  stage,  inasmuch  as  that  by  a  forced  inspiration  the  lung 
could  be  still  considerably  distended.  It  then  struck  me  that 
by  making  the  patient  perform  a  number  of  forced  inspirations 
rapidly,  the  lung  might  be  so  far  distended  with  air  as  to  prevent 
the  occurrence  of  any  natural  sound  of  pulmonary  expansion  for  a 
time,  and  that  thus  we  might  obtain  a  direct  proof  of  the  difficulty 
of  expiration.  This  experiment  I  put  into  effect,  and  found  that 
after  four  or  five  inspirations,  rapidly  performed,  the  respiratory 
murmur  altogether  disappeared,  nothing  being  heard  but  the 
crepitating  rales,  and  even  these  in  a  diminished  degree.  The 
patient  was  now  allowed  to  rest  and  to  breathe  naturally  for  a 
certain  number  of  times,  when  on  the  experiment  being  repeated, 
the  first  inspiration  was  distinctly  followed  by  the  murmur,  which, 
however,  diminished  at  each  successive  effort,  until  at  length  it 
became  extinct  as  before. 

The  results  of  this  experiment  are  easily  explained  by  referring 
to  the  difficulty  of  expiration,  proceeding  from  either  or  both  of 
the  causes  already  alluded  to.  In  fact,  the  repetition  of  the 
inspiratory  efforts  caused  such  an  accumulation  of  air  in  the 
diseased  portion  of  the  lung,  as  ultimately  to  nearly  prevent  its 
further  expansion,  and  thus  hinder  the  sound  of  the  respiratory 
murmur.  But  on  the  cessation  of  these  efforts  the  air  was 
gradually  evacuated,  and  the  lung  restored  to  its  original  condition. 
If  this  sign  be  found  constant,  it  will  be  a  most  valuable  addition 
to  our  means  of  detecting  the  emphysema  of  Laennec,  but  the 
frequent  repetition  of  the  experiment  must  be  avoided. 

TREATMENT    OF    DILATATION   OF   THE    CELLS. 

The  first  point  to  be  examined  into  in  discussing  this  part  of 
the   subject,   is  whether   a   cure   of  the   confirmed  disease  be 


170  BRONCHITIS. 

possible ;  the  next,  whether  we  are  in  possession  of  means 
capable  of  relieving  the  affection  to  a  certain  degree,  or  of 
preventing  its  further  extension  ;  and  the  third,  supposing  the 
disease  capable  of  modification  or  cure,  to  determine  what  are 
the  indications  and  proper  modes  of  treatment,  I  shall  examine 
these  important  questions  in  succession. 

Can   we   expect,    after  the  disease  is  established,   that   the 
dilated  air  cells  can  ever  resume  their  natural  condition  ?     Now 
we  find  that  some  patients  have  laboured  under  this  disease,  or 
its  causes,  from  infancy,  while  in  others  it  is  brought  on  by 
bronchitis  at  a  late  period  of  their  lives,  and  after  many  years  of 
previous  health.      In  the  first  case,  it  seems  scarcely  possible 
that  any  effort  of  medical  skill  can  restore  the  lung  to  its  original 
condition,  and  all  that  we  can  hope  for  is  to  palliate  the  symptoms. 
But  in  cases  of  a  comparatively  recent  origin,  to  give  up  all  hope 
of  cure  seems  scarcely  in  accordance  with  our  knowledge  of  analo- 
gous affections.     We  may  consider  the  pathological  condition  of 
the  air  cells  in  the  same  point  of  view  that  we  look  upon  chronic 
dilatations  of  other  hollow  organs,  such  as  those  of  the  stomach, 
colon,  bladder,  and  heart.     In  these  cases  we  commonly  observe 
the  two  following  circumstances  to  occur  :  first,  that  the  cause  of 
the  dilatation  is  some  mechanical  obstruction  to  the  exit  of  their 
natural  contents ;  and  next,  that  if  this  obstruction  be  long  con- 
tinued, what  was  first  a  mere  dilatation  or  distention  of  the  organ 
becomes  a  combination  of  this  with  an  organic  alteration  of  the 
parietes,  which  is  in  most  cases  an  increase  in  their  thickness 
and  strength.     Hence  the  hypertrophy  of  the  muscular  fibres  of 
the  stomach  when  the  pylorus  is  obstructed  ;  of  the  bladder  when 
the  urethra  or  prostate  are  diseased  ;  of  the  colon  in  stricture  of 
the  rectum  ;  and  of  the  right  cavities  of  the  heart  in  affections  of 
the  lung.  This  change  from  mere  dilatation  to  increase  of  growth 
seems  to  be   a  condition  very  unfavourable  for  cure,  and  the 
chances   of  its  production  may  be   stated  to  be  directly  as  the 
length  of  time  the  obstruction  is  allowed  to  continue ;  for  we 
know  that  in  the  earlier  periods  of  these  mechanical  dilatations, 
the  removal  of  the  obstruction  is  often  followed  by  the  return  of 
the  cavity  to  its  natural  dimensions.     Applying  these  considera- 
tions to  the  case  of  dilatation  of  the  air  cells,  it  seems  not  impos- 
sible that  in  the  earlier  periods  the  removal  of  the  obstruction 
would  be  followed  by  a  subsidence  of  the  disease ;  for  when  we 


BRONCHITIS.  171 

inquire  into  the  causes  of  the  affection,  we  find  these  to  be  prin- 
cipally obstructions  to  the  free  exit  of  the  contents  of  the  cavities ; 
the  viscid  mucus  and  the  turgescence  of  the  bronchial  tubes  being 
to  the  air  cells  what  pulmonary  obstruction  is  to  the  heart,  or 
urethral  to  the  bladder  ;  and  the  distention  in  these  cases  being 
perfectly  analogous. 

We  may  then  admit  that  where  actual  change  of  structure  has 
not  occurred,  a  cure,  or  a  great  alleviation  of  the  disease  is  not 
impossible.  Our  next  inquiry  is,  whether  there  is  evidence  of 
such  ever  occurring.  On  this  question  Laennec  speaks  doubt- 
ingly.  After  alluding  to  the  combination  of  extravasation  of  air 
with  dilatation  of  the  air  cells,  he  observes,  that  it  is  of  slight 
consequence  as  compared  with  the  latter  affection,  as  we  can 
hope  for  its  removal  by  absorption  as  in  other  similar  cases, 
whilst  we  cannot  well  see  in  what  manner  either  nature  or  art 
can  remedy  the  other  morbid  derangement.  "  At  the  same  time," 
he  continues,  "I  do  not  think  we  are  justified  in  considering 
this  affection  as  altogether  incurable.  In  several  instances  I 
have  fancied  that  I  discovered  the  traces  of  cicatrization  of  rup- 
tures of  the  pulmonary  tissue  of  the  kind  above  described.  In 
the  case  of  subjects  affected  with  asthma  I  have  several  times, 
during  the  fits,  detected  a  crepitous  ronchus  with  large  bubbles, 
which  ronchus  entirely  disappeared  afterwards  ;  and  it  is  quite 
intelligible,  that  if  we  can  diminish  the  intensity  of  the  cause 
which  keeps  up  the  habitual  distention  of  the  cells,  we  may  in  the 
end  hope,  that  these  will  be  actually  lessened  in  volume."*  The 
same  author,  when  describing  the  treatment  of  dry  catarrh  by 
alkalies,  states,  that  many  persons  who  had  already  emphysema 
of  the  lungs,  and  either  incessant  dyspnoea,  or  very  frequent  fits 
of  asthma,  have  been  restored  by  this  treatment  to  a  state  of 
health  so  comfortable,  that  they  hardly  exhibited  any  signs  of 
disease. 

The  question  as  to  the  curability  of  Laennec's  emphysema  has 
been  scarcely  agitated  in  medical  circles ;  and  Dr.  Osborne 
deserves  great  credit  for  bringing  this  subject  forward  in  an 
excellent  paper  on  the  pathology  and  treatment  of  dropsy,  which 
he  read  at  one  of  the  late  meetings  of  the  King  and  Queen's 
College  of  Physicians,  in  which  he  states  his  conviction,  that  this 
disease   is    at  all   events  susceptible  of  great  amelioration,  on 

*  See  Dr.  Forbes's  Translation. 


172  BRONCHITIS. 

the  ground  that  in  certain  cases  he  observed  the  feebleness  of 
respiration,  and  morbid  clearness  of  sound,  to  subside,  or  become 
greatly  diminished,  after  treatment  calculated  to  remove  the 
obstruction,  and  diminish  the  frequency  and  violence  of  cough. 
On  this  subject  I  can  only  bring  forward  the  observations  of  a 
few  cases,  but  which,  as  far  as  they  go,  are  of  great  importance 
in  elucidating  the  question.  In  the  patient,  to  whose  easel  have 
already  alluded  as  illustrative  of  the  diagnosis  from  mediastinal 
displacement,  I  found  that  after  certain  treatment,  calculated  to 
relieve  bronchial  irritation  and  diminish  cough,  that  coincident 
with  great  relief  of  symptoms,  the  following  changes  in  the  phy- 
sical signs  took  place :  first,  that  the  morbid  clearness  of  the 
affected  side,  though  not  removed,  was  diminished,  and  that  it 
terminated  at  the  mesian  line  in  place  of  extending,  as  before, 
beyond  the  opposite  side  of  the  sternum.  Secondly,  that  the 
rales  became  more  humid  and  larger,  and  the  vesicular  respira- 
tion was  manifestly  increased.  And  thirdly,  that  the  stethoscopic 
phenomena,  like  those  of  percussion,  ceased  to  be  heard  beyond 
the  mesian  line  of  the  sternum,  when  they  had  been  before  audible, 
and  that  in  this  situation  they  were  replaced  by  the  healthy 
murmur  of  the  opposite  lung.  These  alterations  in  the  signs,  so 
characteristic  of  diminution  in  the  obstruction  and  volume  of  the 
affected  lung,  were  accompanied  by  the  most  marked  improvement 
in  the  symptoms  ;  the  cough,  dyspnoea,  and  acceleration  of  breath- 
ing being  wonderfully  diminished,  and  the  condition  of  the  patient 
in  every  respect  improved. 

The  treatment  pursued  was  the  employment  of  local  bleeding 
and  counter-irritation,  with  the  exhibition  of  the  tartar  emetic  for 
several  days,  followed  by  sedative  and  demulcent  remedies. 

That  in  this  case  the  volume  of  the  affected  lung  was  reduced 
by  treatment,  there  can  be  no  doubt ;  and  when  we  connect  the 
results  of  the  case  with  those  obtained  by  Dr.  Osborne,  and  with 
the  observations  of  Laennec  on  the  treatment  of  dry  catarrh,  we 
have  decided  evidence  in  favour  of  the  possibility  of  the  diminution 
of  the  disease,  and  are  consequently  justified  in  considering  it  as 
not  altogether  incurable.  In  another  instance  I  have  seen  the 
heart,  which  was  so  much  displaced  downwards  as  to  pulsate  at 
the  cartilage  of  the  tenth  rib,  after  a  few  days  of  treatment, 
remount  towards  the  thorax,  and  correspond  to  the  eighth 
intercostal  space. 


BRONCHITIS.  173 

Some  important  questions  here  arise.  Is  the  mere  diminution 
or  even  removal  of  the  obstruction  all  that  is  necessary  for  the 
restoration  of  the  lung  to  its  natural  condition,  or  may  there  not 
be  some  other  morbid  state  to  be  overcome  before  we  can  bring 
about  so  fortunate  a  result?  Does  a  paralysis  or  atony  of  the 
circular  fibres  of  the  more  minute  tubes  exist  ?  Or,  as  Majendie 
has  suggested,  is  the  natural  elasticity  of  the  lung  destroyed  or 
injured  ?  It  seems  not  improbable  but  that  both  these  circum- 
stances may  occur,  the  muscular  structure  being  paralyzed,  as  we 
see  in  the  case  of  the  bladder  or  the  intestinal  tube,  and  the 
longitudinal  fibres  losing  their  elasticity  from  the  persistence  of 
chronic  irritation,  just  as  the  elastic  coat  of  arteries  loses  its 
property  when  chronic  disease  affects  these  vessels. 

It  is  plain  that  farther  observations  are  necessary  to  clear  up 
these  points ;  and  I  shall  merely  remark,  that  after  the  use  of 
treatment  calculated  to  remove  congestion,  inflammation,  or  other 
obstruction  of  the  minuter  tubes  ;  after  the  adoption  of  the  means 
which  Laennec  has  pointed  out  for  the  relief  of  the  dry  catarrh ; 
and  lastly,  after  using  all  means  which  could  moderate  the  cough, 
or  render  it  less  frequent,  we  might  then  have  recourse  to 
measures  calculated  to  stimulate  the  contractile  tissues  of  the  lung. 
As  yet  we  are  not  in  possession  of  means  capable  of  restoring 
elasticity  to  such  tissues  as  the  longitudinal  fibres  of  the  lung,  or 
the  middle  coat  of  the  arteries ;  but  we  do  know  of  remedies 
capable  of  stimulating  muscular  fibre  to  resume  its  vital  contrac- 
tility, at  least  of  that  portion  of  the  muscular  system  which  is 
supplied  by  the  cerebro- spinal  nerves.  It  has  been  suggested  to 
me  by  my  friend  and  pupil,  Mr.  Martin,  that  in  the  exhibition  of 
strychnine  this  object  might  be  attained.  This  practice  would 
be  well  worthy  of  trial,  for  if,  as  there  is  reason  to  believe,  the 
pulmonary  branch  of  the  vagus  is  a  nerve  of  motion  to  the  lung, 
we  might  expect  that  the  stimulation  exercised  by  the  remedy  on 
the  cerebro-spinal  centres  would  have  a  beneficial  effect  in  paralysis 
of  the  bronchial  muscles. 

I  shall  now  give  the  general  conclusions  which  may  be  drawn 
from  what  has  been  stated. 

1st.  That  the  disease  consists  essentially  in  an  enlargement 
of  the  air  cells. 

2nd.  That  the  rupture  and  coalescence  of  several  cells  is  not . 
a  constant  occurrence. 


174  BRONCHITIS. 

3rd.  That  the  disease  increases  the  volume  and  rarefaction  of 
the  lung. 

4th.  That  it  may  occur  uncomplicated  with  any  affection 
except  bronchitis,  or  exist  along  with  other  diseases  which  are 
generally  chronic. 

5th.  That  it  may  co-exist  with  great  dilatation  of  the  tubes. 

6th.  That  it  may  be  partial  or  general. 

7th.  That  percussion  gives  a  morbidly  clear  sound  when  the 
disease  has  attained  a  certain  extent. 

8th.  But  that  the  cells  may  be  so  enlarged  as  to  give  feeble- 
ness of  respiration  without  change  on  percussion. 

9th.  That  the  physical  signs  of  bronchitis  which  occur, 
though  pointing  out  the  existence  of  disease  in  the  smaller 
ramifications,  are  not  characteristic  of  the  affection. 

10th.  That  the  stethoscopic  indication  is  the  want  of  propor- 
tion between  the  sound  of  vesicular  expansion,  the  results  of 
percussion,  and  the  efforts  of  inspiration. 

11th.  That  a  most  important  source  of  physical  signs  is  to  be 
found  in  the  increased  volume  of  the  lung. 

12th.  That  this  increase  of  volume  can  be  ascertained  by 
measurement  of  the  chest,  by  the  displacement  of  the  medias- 
tinum, by  the  depression  of  the  diaphragm,  and  by  the  lateral 
displacement,  and  the  depression  of  the  heart. 

13th.  That  although  in  this  disease,  as  in  empyema,  there 
is  pressure  from  within,  yet  that  it  differs  from  the  latter  affec- 
tion in  the  absence  of  paralysis  of  the  inspiratory  muscles,  as 
shewn  in  the  comparative  states  of  the  intercostal  muscles  and 
diaphragm. 

14th.  That  the  physical  signs  from  auscultation  are  greatly 
modified  by  the  degree  of  yielding  of  the  thoracic  parietes,  the 
characteristic  feebleness  of  respiration  appearing  to  be  directly 
as  the  amount  of  resistance  to  the  increased  volume  of  the 
lung. 

15th.  That  in  the  same  way  the  signs  resulting  from  the 
displacement  of  the  mediastinum,  heart,  and  diaphragm,  will 
vary  with  the  amount  of  resistance  of  the  thoracic  parietes,  and 
be  more  obvious  the  greater  the  resistance. 

16th.  That  the  intercostal  spaces  are  not  protruded  in  this 
disease,  but  preserve  their  relative  positions  with  respect  to  the 
ribs. 


BRONCHITIS.  175 

17th.  That  the  cases  of  the  disease  may  be  divided  into  two 
classes,  viz.,  those  in  which  the  diaphragm  is  unaffected,  and 
those  in  which  it  is  depressed. 

18th.  That  in  the  first  class  the  abdomen  is  collapsed,  and 
without  tumefaction  or  dulness  of  sound  in  the  epigastric  or 
hypochondriac  regions.  In  these  cases  the  heart  is  found  in  its 
natural  position. 

19th.  That  in  the  second  class  the  reverse  occurs  ;  the  liver 
is  depressed,  and  the  heart  so  displaced,  as  that  it  has  been 
found  to  pulsate  so  low  as  the  ninth  intercostal  space.  The 
postero-inferior  portions  of  the  chest  sound  clear  even  to  the 
last  rib. 

20th.  That  under  these  circumstances  the  diaphragm  being 
flattened,  its  contraction  acts  in  diminishing  the  circumference 
of  the  trunk  in  the  region  between  the  eighth  and  tenth  ribs, 
so  that  we  observe  expansion  of  the  upper  portion  of  the  chest 
and  of  the  umbilical  region,  while  the  portion  above-mentioned 
manifestly  contracts. 

21st.  That  the  volume  of  the  lung  varies  remarkably  at 
different  periods. 

22nd.  That  when  it  is  greatest  all  the  physical  signs  are 
most  evident. 

23rd.  That  the  cause  of  its  increase  is  an  exacerbation  of 
the  bronchitis. 

24th.  That  under  treatment  calculated  to  remove  bronchial 
irritation  the  vesicular  murmur  may  return,  and  the  volume  of 
the  lung  is  diminished. 

25th.  That  these  facts  are  in  favour  of  the  opinion,  that  the 
disease  is  susceptible,  if  not  of  cure,  at  least  of  great  alle- 
viation.* 

ATROPHY   OF   THE    LUNG. 

As  yet  the  investigations  as  to  the  general  causes  of  this 
change  have  been  very  limited.  The  frequency  of  the  alteration, 
however,  has  awakened  attention,  and,    in    certain  cases,  its 

*  In  these  propositions  I  have  not  alluded  to  the  rubbing  sound  of  Laennec,  inas- 
much as  I  feel  that  this  point  of  diagnosis  is  not  as  yet  established  ;  neither  have  I 
alluded  to  the  sign  described  in  the  text  of  the  singular  feebleness  of  the  expiratory 
murmur  produced  after  forced  inspirations.  Further  observations  are  necessary  on 
both  these  subjects. 


176  BRONCHITIS. 

causes  have  been  ascertained.  We  are  here,  however,  to  inves- 
tigate its  relation  to  bronchitis,  of  which,  as  yet,  but  little  is 
known.  Atrophy  of  the  lung  has  been  recognized  in  a  variety 
of  diseases,  such  as  tubercle,  pneumonia,  cancer,  and  pleurisy ; 
but  its  direct  connexion  with  bronchitis  has  not  been  sufficiently 
examined. 

It  would  appear  on  a  general  view,  that  independent  of  that 
senile  atrophy  which  the  lung  undergoes  in  common  with  other 
organs,  the  condition  which  is  most  closely  connected  with  its 
morbid  atrophy  is  impermeability.  The  lung  indeed  is  of  all 
organs  that  in  which  we  might  expect  the  most  rapid  diminu- 
tions of  bulk  from  disease ;  for  independent  of  the  action  of  that 
law  of  atrophy,  which  operates  on  organs  after  they  cease  to 
fulfil  their  functions,  there  is  a  cause,  as  it  were,  peculiar  to 
the  lung,  and  resulting  from  its  structure.  It  is  easy  to  see 
that  when  the  air  tubes  are  obstructed,  the  cells  to  which  they 
lead,  will  diminish  in  volume.  Here  we  see  a  difference  in  this 
case  from  that  of  obstructions  of  the  circulating  system.  In  the 
air  tubes  there  are  no  anastomoses,  and  hence  no  collateral 
means  of  inflating  the  cells.  These  diminish,  and  at  last 
disappear,  and  the  volume  of  the  organ  must  proportionably 
suffer. 

Now  we  have  seen  that  obliteration  of  the  minute  tubes  is  a 
common  occurrence  in  bronchitis,  and  hence  can  understand 
how  this  disease  may  produce  atrophy  of  the  lung.  It  is  plain, 
however,  that  we  here  take  bronchitis  in  its  most  extended  sense, 
and  consider  it  as  a  disease  almost  of  the  parenchyma.  It  seems 
more  than  probable  that  in  this  way  we  can  explain  the  rapid 
atrophy  of  the  lung  in  phthisis,  the  close  connexion  of  which 
with  bronchial  obliteration  has  been  so  well  demonstrated  by 
Reynaud.  Here  it  would  seem  that  the  obliteration  of  a  number 
of  minute  tubes  was  an  early  effect  of  the  disease,  and  the 
tubercular  accumulation  and  atrophy  of  the  cells  its  direct 
consequence. 

But  in  the  ordinary  acceptation  of  the  term,  bronchitis  seems 
a  disease  but  little  likely  to  induce  this  lesion.  Indeed  one  of 
its  common  effects  is  the  very  opposite  condition,  or  hypertrophy. 
But  it  would  appear  that  obstruction  of  a  large  tube,  when 
permanent,  may  be  followed  by  atrophy,  of  which  Andral  relates 
an  example.     I  have  not  made  any  observations  on  this  subject, 


BRONCHITIS.  177 


and  shall  content  myself  with  pointing  it  out  as  a  point  for 
investigation.  To  the  consideration  of  atrophy  of  the  lung, 
however,  I  shall  return  when  describing  the  physical  signs  of 
phthisis.* 


Note  A. 


The  explanation  generally  accepted  by  the  profession  seems 
to  be  that  originally  suggested  by  Dr.  Williams  and  modified 
and  generalized  by  Dr.  Gairdner,  who  defines  emphysema  as 
"  a  secondary  mechanical  lesion  dependent  on  some  condition 
of  the  respiratory  apparatus  leading  to  partially  diminished 
bulk  of  the  pulmonary  tissue,  and  consequently  disturbing  the 
balance  of  air  in  inspiration." 

Dr.  Williams  believes  that  while  the  air  cells  communicating; 
with  plugged  bronchia  escape  distention,  those  adjoining  and 
possessed  of  free  communication  with  the  trachea  dilate  in 
consequence  of  the  extra  work  and  pressure  thrown  upon 
them.  "  This  relationship  and  this  localization,"  says  Dr. 
Walshe,  "  are  supported  by  the  position  occupied  by  emphysema 
secondary  to  adjoining  tubercle  as  originally  insisted  on  by  Dr. 
Carswell."  t 

Since  the  publication  of  the  first  edition  of  this  work,  another 
form  of  emphysema,  having  a  different  origin,  has  been  observed  ; 
namely,  rapid  and  general  dilatation  of  the  air  cells  associated 
with  embolism. 

The  first  case  of  which  I  am  aware  was  communicated  to  the 
Pathological  Society  of  Dublin  by  Dr.  Stokes  in  March,  1839. 
The  second  by  Sir  D.  Corrigan  in  December,  1841,  and  the 
third  by  Dr.  Gordon  in  December,  1855.  In  Dr.  Stokes' 
case  and  in  Dr.  Gordon's  large  and  firm  coagula  were  found  in 
the  right  ventricle,  and  extending  into  the  pulmonary  artery  and 
its  branches.  In  the  other  this  is  not  expressly  stated,  but  is 
implied.  Dr.  Gordon  alone  noticed  the  character  of  the  res- 
piration murmur,  which  he  states  was  feeble.  This  is  contrary 
to  my  own  experience,  as  in  the  cases  I  have  observed  the 
respiration  murmur  was  intensely  puerile.     A  priori  we  should 

*  See  Appendix,  Note  P. 

t  Walshe  on  Diseases  of  the  Lungs,  p.  321. 

N 


178  BKONCHITIS. 

expect  this  to  be  so,  as  we  presume  the  dilatation  of  the  air 
cells  is  caused  by  exaggerated  efforts  to  effect  the  confluence 
of  air  and  blood  which  constitutes  the  act  of  respiration. 

Note  B. 

"  It  is  difficult,"  says  Dr.  Gairdner,  "  to  conceive  anything 
more  completely  exhaustive  than  this  memoir  of  Reynaud, 
when   considered  purely  in    an    anatomical   point  of  view  and 

solely   with   reference   to   the   air   passages But    M. 

Beynaud's  researches,  though  full  of  anatomical  truths  are 
strangely  barren,  at  least  in  his  own  hands,  of  real  pathological 
interest,  which  arises  chiefly  from  his  having  too  exclusively 
pursued  the  enquiry  relative  to  the  bronchi  themselves,  and  not 
having  sought  to  connect  their  alterations  with  those  of  the 
pulmonary  tissues,  with  which  they  are  according  to  my 
experience,  as  well  as  that  of  others,  constantly  and  indis- 
solubly  associated.  Somewhat  of  the  same  objection  applies 
to  Laennec's  observations  on  dilatation  of  the  bronchi,  which 
first  gave  to  this  disease  a  place  in  pathological  anatomy. 
Accordingly  it  has  been  reserved  for  future  observers  to  discover 
that  both  the  dilatation  and  contraction  of  the  bronchi  are 
almost  always  secondary  lesions,  or  at  least  invariably  con- 
nected with  some  kind  of  disorganization  of  the  pulmonary  air 
cells." — Monthly  Journal  of  Medical  Science,  vol.  xiii. 

Of  the  observers  here  referred  to  Sir  D.  Corrigan  deserves 
especial  mention  as  the  original  propounder  of  the  theory  of 
the  relation  of  dilatation  of  the  bronchi  to  changes  of  lung 
structure  now  generally  accepted.  The  true  merit  of  Corrigan's 
observations  is  well  expressed  by  Dr.  Bastian.  "  Whilst 
Laennec  in  his  admirable  account  of  dilatation  of  the  bronchi — 
a  morbid  state  which  had  never  been  previously  described — looked 
upon  the  condensation  of  tissue  around  the  dilated  tubes  as 
being  invariably  secondary  to,  and  the  effect  of  the  dilatation, 
Corrigan,  on  the  other  hand,  maintained  that  in  a  certain 
number  of  cases,  which  he  proposed  to  range  under  the  name 
'  cirrhosis  of  the  lung,'  the  fibroid  metamorphosis  and  induration 
was  the  primary  and  essential  anatomical  lesion,  and  that  the 
dilatation  of  the  bronchi  was  only  a  secondary  effect.  Omitting 
for  the  present  the  consideration  of  the  question  as  to  whether 


BRONCHITIS.  179 

Corrigan  was  correct  in  the  explanation  he  offered  of  the  mode 
of  origin  of  the  bronchiectasis,  I  may  state  that  his  main 
position  appears  to  have  been  a  correct  one.  It  seems  to  be  un- 
doubtedly true  that,  in  a  certain  number  of  cases  in  which 
dilated  bronchi  have  been  met  with  after  death,  an  original 
fibroid  conversion  and  shrinking  of  the  lung  tissue  has  entailed 
this  as  a  consequence ;  the  bronchiectasis  has  been  secondary 
and  not  primary."* 

*  Art.  Cirrhosis,  Russell  and  Reynold's  System  of  Medicine,  vol.  iii. 


N    2 


180 


SECTION    III. 

DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

We  may  consider  this  subject  under  the  following  heads  : 
1st.  Acute  inflammation  of  the  larynx  and  trachea. 
2nd.  Chronic  inflammation. 
3rd.   Specific  irritations. 
4th.  Spasm. 

5th.  Foreign  bodies  in  the  larynx,  trachea,  and  bronchial 
tubes. 

6th.  Pressure  on  the  windpipe  by  external  tumors. 

ACUTE  INFLAMMATION  OF  THE  LARYNX  AND  TRACHEA. 

This  affection  may  arise  either  in  the  child  or  adult,  but  is 
more  frequent  in  the  former.  In  the  child  its  results  are  gene- 
rally different  from  those  in  the  adult,  as  in  the  former  the 
production  of  lymph  is  most  commonly  observed.  It  is  this 
affection  which  has  got  the  name  of  croup,  but  we  find  it  de- 
scribed under  other  denominations.  Thus,  by  some  authors  it 
is  called  the  pellicular,  by  others  the  plastic  inflammation  of 
the  larnyx,  terms  which  are  intended  to  express  the  formation  of 
an  albuminous  covering  or  cast  of  the  cavity  itself. 

We  may  meet  this  disease  under  two  essentially  different 
forms.  It  may  occur  in  the  first  place,  as  a  primary,  idiopathic, 
and  active  inflammation  of  the  respiratory  mucous  membrane,  in 
which  the  accompanying  fever  is  symptomatic.  In  the  second 
place,  we  have  it  preceded  by  fever,  and  the  formation  of  false 
membranes  in  the  pharynx  and  cavity  of  the  mouth,  which,  by 
extending  downwards  into  the  glottis  and  larynx,  produce  the 
symptoms  of  croup  in  the  advanced  stage  of  another  and  totally 
different  disease. 

The  greatest  confusion  has  arisen  in  consequence  of  authors  not 
carefully  separating  these  two  forms  of  disease  in  their  descrip- 
tions of  croup,  and  in  their  opinions  as  to  its  treatment.     For 


DISEASES    OF    THE    LARYNX    AND    TRACHEA. 


181 


the  sake  of  clearness,  I  shall  arrange  their  symptoms  in  pairs  of 
opposite  characters,  distinguishing  the  affections  by  the  names 
of  primary  and  secondary  croup. 


PRIMARY    CROUP. 

1.  The   air   passages  primarily 
engaged. 

2.  The   fever   symptomatic    of 
the  local  disease. 


3.  The  fever  inflammatory. 

4.  Necessity  for  antiphlogistic 
treatment,  and  the  frequent  suc- 
cess of  such  treatment. 

5.  The  disease  sporadic,  and 
in  certain  situations  endemic,  but 
never  contagious. 

G.  A  disease  principally  of 
childhood. 

7.  The  exudation  of  lymph 
spreading  to  the  glottis,  from 
below  upwards. 

8.  The  pharynx  healthy. 

9.  Dysphagia  either  absent  or 
very  slight. 

10.  Catarrhal  symptoms  often 
precursory  to  the  laryngeal. 

11.  Complication  with  acute 
pulmonary  inflammation  common. 

12.  Absence  of  any  character- 
istic odour  of  the  breath. 


SECONDARY    CROUP. 

1.  The  laryngeal  affection 
secondary  to  disease  of  the  pharynx 
and  mouth. 

2.  The  local  disease  arising  in 
the  course  of  another  affection, 
which  is  generally  accompanied 
by  fever. 

3.  The  fever  typhoid. 

4.  Incapability  of  bearing  an- 
tiphlogistic treatment ;  necessity 
for  the  tonic,  revulsive,  and 
stimulating  modes. 

5.  The  disease  constantly  epi- 
demic and  contagious. 

6.  Adults  commonly  affected. 

7.  The  exudation  spreading  to 
the  glottis,  from  above  down- 
wards. 

8.  The  pharynx  diseased. 

9.  Dysphagia  common  and  se- 
vere. 

10.  Laryngeal  symptoms  su- 
pervening without  the  pre-exist- 
ence  of  catarrh. 

11.  Complication  with  such 
changes  rare. 

12.  Breath  often  characteristi- 
cally foetid. 


From  the  consideration  of  these  characters  we  must  admit, 
that  independent  of  minor  differences,  there  is  a  broad  line  of 
distinction  between  these  affections  of  the  throat.  In  the  one 
the  windpipe  is  the  seat  of  an  idiopathic,  primary,  and  highly 
inflammatory  disease  ;  while  in  the  other  its  affection  is  accidental, 


182  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

inconstant,  and  secondary  to  a  diseased  state  of  the  pharynx, 
which,  in  its  turn,  is  either  symptomatic  of,  or  closely  connected 
with,  a  morbid  state  of  the  whole  system.  Yet,  as  I  said  before, 
the  want  of  an  accurate  distinction  between  these  affections  has 
led  to  the  greatest  misapprehension ;  and  wTe  see  British  physi- 
cians ridiculing  the  opinions  and  treatment  of  the  continental 
practitioners,  and  vice  versa.  The  error  all  the  while  arising 
from  the  confounding  of  two  essentially  different  affections.  In 
the  croup,  as  described  by  British  authors,  the  utility  of  an 
antiphlogistic  treatment  has  been  proved  by  experience.* 

I  shall  then  divide  the  disease  into  primary  and  secondary 
croup,  and  endeavour  to  point  out  somewhat  more  in  detail  the 
differences  in  the  signs,  symptoms,  and  treatment  of  these 
affections. 

Primary  Croup. — The  symptoms  of  this  affection  are  reducible 
to  an  irritation  of  the  respiratory  apparatus,  in  which  the  upper 
portion  of  the  tube  is  severely  and  prominently  affected.  The 
disease  has  been  described  and  generally  considered,  as  an 
affection  of  the  larynx  and  trachea  alone;  and  even  those  who 
admit  an  extension  of  disease,  yet  look  on  it  as  accidental  and 
unimportant,  and  hence  have  arisen  certain  modes  of  treatment, 
which  the  progress  of  medicine  has  shewn  to  be  erroneous.  The 
general  expression  of  the  diagnosis  of  this  disease  may  be  stated 
to  be  the  combination  of  laryngeal  cough,  succeeded  by  stridulous 
breathing,  in  a  patient  labouring  under  inflammatory  fever.  If 
these  symptoms  have  been  preceded  by  signs  of  catarrh,  and  if  the 
pharynx  presents  no  morbid  appearance,  we  make  the  diagnosis 
of  acute  inflammation  of  the  larynx,  which  may  terminate,  in 
some  cases,  by  an  effusion  of  serum  into  the  submucous  cellular 
tissue,  but  in  most  instances  is  followed  by  the  exudation  of 
lymph.  Should  the  disease  occur  in  the  child,  there  will  be  a 
strong  probability  in  favour  of  the  latter  result. 

Three  stages  of  this  affection  have  been  noticed  by  the  best 
authors;  and  although  they  are  not  always  distinctly  marked,  yet 
they  are  so  frequently  observed  that  it  is  necessary  to  notice  them 

*  Dr.  Stokes'  views  on  this  much  controverted  question  are  in  accordance  with  those 
of  Niermeyer,  who  says,  "  the  division  of  diseases  according  to  the  pathologico- 
anatomical  changes  they  induce  is  only  a  makeshift.  In  all  cases  where,  as  in  genuine 
and  diphtheritic  croup,  we  find  that  two  anatomically  similar  disturbances  of  nutrition 
depend  on  very  different  causes  we  should  consider  them  as  distinct." — Text  Book, 
vol.  ii.  p.  615. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  183 

briefly.  The  first  has  been  termed  the  catarrhal,  the  second  the 
confirmed,  and  the  third  the  suffocative  stage.  "  In  the  first,  we 
have  often  merely  the  signs  of  a  slight  bronchial  irritation,  in 
which  there  is  nothing  that  could  lead  us  to  anticipate  so 
formidable  a  termination.  In  other  cases,  however,  a  little 
hoarseness,  or  a  peculiar  resonance  of  the  cough  may  excite  alarm, 
but  there  is  no  stridulous  breathing,  or  sign  of  mechanical 
obstruction  in  the  windpipe;  nor  is  there  any  circumstance 
connected  with  this  precursory  irritation  which  can  distinguish 
it  from  the  more  ordinary  forms  of  bronchitis. 

The  duration  of  this  stage  is  exceedingly  various ;  it  may 
continue  but  for  two  or  three  hours,  or  last  as  many  days,  when 
the  second  or  confirmed  stage  sets  in,  characterized  by  a  great 
increase  of  fever,  anxiety,  and  distress,  and  by  indications  of 
mechanical  obstruction  in  the  larynx  itself.  Indeed,  one  of  the 
most  remarkable  circumstances  connected  with  the  disease,  is  the 
rapidity  with  which  this  latter  symptom  shall  occur,  a  fact 
strongly  confirmatory  of  the  opinion,  that  the  mere  effusion  of 
lymph  is  not  the  principal  cause  of  the  obstruction,  but  that  it  is 
owing  to  the  inflammatory  spasm  of  the  part ;  an  opinion  to  which 
I  have  no  hesitation  in  subscribing,  inasmuch  as  we  find  the 
symptom  of  stridulous  breathing  coming  on  suddenly,  and  at  a 
period  too  early  for  us  to  suppose  that  lymph  had  formed ;  and 
also  that  after  death  the  aperture  of  the  glottis  is  almost  never 
found  completely  obstructed.  Indeed  Dr.  Cheyne  states,  that, 
in  almost  all  cases,  three-eighths  of  the  glottis  are  found  pervious, 
'postmortem;  so  that  in  explaining  the  sudden  death,  we  must 
refer  to  a  spasm  of  the  glottis. 

The  symptoms  of  the  confirmed  croup  in  the  child  have  been 
so  accurately  detailed  by  authors,  and  in  particular  by  Cheyne 
and  Porter,  that  I  shall  not  occupy  much  space  in  describing 
them,  feeling  that  I   shall   do   more  justice  to  the   subject  by- 
referring  to  the  writings   of   these    distinguished   pathologists. 
Suffice  it  to  say,  that  all  the  phenomena  point  out  the  existence 
of  an  acute  inflammation,  with  mechanical  obstruction  to  respi- 
ration, as  shewn  by  the  fever  and  increasing  stridulous  breathing. 
As  the  disease  advances  there   is  excessive   anxiety,  slow  and 
convulsive   respiration,    loss    of  voice,    distressing    cough,    and 
scanty  expectoration ;    and   if  the   patient  is   not   relieved,   he 
sinks  in  a  collapsed  and  comatose  state. 


184  DISEASES    OF    THE    LARYNX    AND    TEACHEA. 

In  a  few  cases  casts  of  the  air  passages  have  been  expelled  by 
coughing,  with  relief  to  the  symptoms.  Such  instances,  however, 
are  exceedingly  rare. 

There  can  be  little  doubt  that  croup,  properly  so  called,  is  a 
simple  inflammatory  disease.  We  observe  it  arising  from  the 
same  cause  as  other  internal  inflammations,  accompanied  by 
inflammatory  symptoms,  frequently  complicated  with  other  in- 
flammatory diseases  of  the  respiratory  system,  and  yielding  to 
ordinary  antiphlogistic  treatment.  One  of  the  most  remarkable 
circumstances  in  its  history  is  the  fact  of  its  being  more  prevalent 
among  children  than  adults.  Indeed  it  appears  that  pure  croup 
is  rarely  met  with  after  the  age  of  puberty,  a  fact  the  more 
remarkable,  as  we  know  that  although  in  the  adult,  chronic 
irritations  of  the  larynx  are  more  frequent  than  the  acute,  yet 
that  the  latter  form  does  often  occur.  Its  results,  however,  are 
different ;  and  the  formation  of  lymph  in  idiopathic  laryngitis 
seems  peculiarly  connected  with  the  general  conditions  of  child- 
hood, or,  at  all  events,  with  that  imperfectly  developed  state  of 
the  larynx  which  precedes  the  period  of  puberty.* 

*  As  yet  no  satisfactory  explanation  of  the  greater  frequency  of  croup  in  the 
infant  has  been  given.  Yet  of  the  fact  of  this  greater  frequency  experience  does 
not  permit  us  to  doubt.  And  we  know  further,  that  the  observation  applies  to  the 
young  of  other  animals,  as  well  as  to  that  of  man.  Can  we,  by  combining  physio- 
logical with  pathological  considerations,  throw  any  additional  light  upon  this  obscure 
point? 

We  have  here  a  disease  in  a  young  animal,  in  which  there  is  an  albuminous  product, 
assuming  the  form  of  the  organ  which  has  given  birth  to  it,  and  so  far  we  may  observe 
an  analogy  with  the  reproductive  powers  of  the  invertebrated  animals,  and  the  same 
phenomenon  in  the  white  tissues  of  the  higher  organizations.  Here  I  shall  quote  from 
Dr.  Graves. 

"  The  white  structures  of  the  higher  animals  resemble  the  solids  of  white-blooded 
animals,  and  not  only  in  health,  but  disease.  Thus  the  power  of  reproduction  of  parts 
destroyed  by  accident  or  disease,  so  remarkable  in  the  lower  orders  of  animals,  is  in 
the  higher  enjoyed  only  by  white  structures,  such  as  cellular  membrane,  for  proper 
muscular  fibre  when  once  destroyed  is  not  reproduced,  condensed  cellular  membrane 
being  employed  to  repair  solutions  of  continuity,  in  this  as  well  as  all  more  highly 
organized  tissues. 

"  In  white-blooded  animals,  we  often  see  a  new  limb  appear  in  the  place  of  one 
destroyed  by  accident,  and  in  man  it  is  not  unfrequent  to  observe  a  new  white  organ 
produced  when  the  old  has  become  useless,  or  been  destroyed.  Thus  in  unreduced 
dislocations,  we  have  new  bursas  mucosas,  capsular  ligaments,  synovial  membranes,  &c, 
produced  so  as  to  form  almost  all  the  appendages  necessary  either  to  the  strength  or 
motion  of  the  new  joint.  The  same  happens  in  ununited  fractures.  Cartilage  is  thrown 
out  to  supply  the  place  of  bone  removed  by  operation  or  disease,  and  under  favourable 
circumstances,  this  cartilage  itself  becomes  ossified,  and,  as  happens  in  Necrosis,  an 
entirely  new  bone  is  sometimes  produced.  In  all  such  cases,  the  mould  of  the  bone, 
or  that  part  of  it  to  which  the  new  bone  owes  its  form  and  bulk,  is  composed  of  a 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  185 

But  croup  has  beeu  described  as  occurring  in  the  adult. 
Here  we  again  see  an  example  of  the  confusion  which  has  arisen 
from  not  carefully  separating  the  primary  and  secondary  forms 
of  the  disease ;  for,  without  denying  the  possibility  of  the 
occurrence  of  primary  croup  in  the  adult,  it  will,  I  think,  be  found, 
that  the  great  majority  of  cases  so  described  are  not  of  this  kind, 
but  are  examples  of  what  I  have  called  the  secondary  in 
contradistinction  to  the  primary  croup;  a  disease  in  which  the 
formation  of  false  membranes  seems  to  point  out  a  condition  of 
the  system,  the  very  opposite  to  that  to  which  antiphlogistic 
measures  are  applicable. 

I    shall   now   return    to    the    primary  inflammatory  croup  of 
children.     Here  one  of  the  most  important  considerations   is  the 

white  structure,  chiefly  coagulated  albumen  :  this  is  first  formed,  and  afterwards  the 
bony  particles  are  deposited  in  it  from  red  vessels. 

"  This  facility  of  reparation  forms  a  very  striking  analogy  between  the  white  parts 
in  man  and  other  red-blooded  animals,  and  the  general  structure  of  the  solids  in  white- 
blooded  animals.  In  point  of  vitality,  the  analogy  is  most  striking.  The  white  parts 
in  man,  when  not  inflamed  (then  they  for  a  time  become  red  parts,  and  have  a  corre- 
sponding increase  of  vital  energy),  enjoy  but  a  low  vitality.  They  are  scarcely,  if 
at  all,  sensible ;  do  not  possess  irritability ;  and  probably,  also,  the  circulation  of  the 
■white  blood  through  them  is  much  slower  than  that  of  the  red  blood  through  the  red 
parts ;  at  least  the  circulation  of  the  white  venous  blood  in  the  lymphatics  appears  much 
less  rapid  than  that  of  the  red  venous  blood  in  the  veins." — A  Lecture  on  the  Functions 
of  the  Lymphatic  System,  p.  19. 

From  these  facts  we  are  led  to  conclude,  that  the  chief  reproductive  power  in  the 
higher  classes  of  animals  is  enjoyed  by  the  white  tissues.  Now  the  younger  a  child 
is  the  greater  analogy  does  it  bear  to  an  animal  composed  of  white  solids  (see  Serres, 
Geoffrey  St.  Hilaire,  Andral,  &c,  &c),  and  hence  we  may  suppose  the  greater  will  be 
the  amount  of  this  local  reproductive  power.  When  we  consider  the  organization  of 
lymph  effused  upon  serous  membranes,  it  seems  not  improbable  that  the  same  might 
occur  in  the  case  of  croup,  were  such  a  process  compatible  with  life.  Again  we  have 
seen,  that  of  the  different  solids  the  white  tissues  are  those  in  which  the  reproductive 
power  is  most  commonly  seen  ;  and  it  is  a  remarkable  fact,  that  the  portion  of  the 
respiratory  apparatus  most  liable  to  croup  is  that  in  wThich  cartilage  is  most  predomi- 
nant ;  and  that  as  we  recede  from  this  point  the  plastic  inflammation  becomes  less  and 
less  developed.  How  commonly  we  observe,  in  cases  of  croup,  that  in  the  larynx 
there  exists  an  exact  cast  of  the  tube,  that  in  the  trachea  this  degenerates  into  a 
puriform  exudation,  and  that  in  the  bronchial  tubes  we  have  nothing  but  a  mucous 
secretion.  In  the  child  too  there  may  be  a  greater  relation  between  the  physiological 
and  consequently  the  pathological  states  of  the  mucous  membrane  of  the  larynx  and 
trachea,  and  their  subjacent  tissues,  than  in  the  adult;  and  the  same  condition  which 
determines  the  progressive  development  of  the  larynx  up  to  the  period  of  puberty,  may 
also  predispose  the  mucous  surface  to  the  plastic  or  formative  irritations. 

I  wish  to  be  understood  as  putting  forward  this  view  merely  as  a  subject  for  inves- 
tigation, and  am  fully  aware  of  facts,  which  seem  at  first  view,  at  least,  to  bear  against 
it ;  as,  for  instance,  the  formation  of  false  membranes  in  the  diphtheritis  of  the  adult, 
and  also  in  certain  enteric  irritations.  But  the  subject  is  one  which  deserves  a  further 
and  an  impartial  inquiry. 


186  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

complication  with  inflammation  in  the  remaining  jJortions  of  the 
respiratory  apparatus,  a  fact  of  vast  importance,  and  one  by  no 
means  sufficiently  recognized  by  medical  men.  In  a  considerable 
number  of  cases  the  laryngitis  is  preceded  by  some  inflammatory 
affection  of  the  lung,  which  continues  during  its  progress,  but 
which  is  overlooked  in  consequence  of  the  prominence  of  the 
croupy  symptoms.  I  have  little  doubt,  that  many  children  that 
die  with  symptoms  of  croup,  are  carried  off  as  much  by  disease  of 
the  lungs  as  by  that  of  the  larynx  and  trachea;  for  I  have  seen 
many  instances  in  which,  during  life,  the  stethoscope  indicated 
unequivocally  the  existence  of  intense  bronchitis  or  pneumonia, 
and  have  invariably  found  that  the  diagnosis  was  confirmed  by 
dissection.  Indeed  the  whole  respiratory  apparatus  may  be  some- 
times engaged  ;  so  that,  as  Dr.  Cheyne  observes,  we  may  find  the 
lung  filled  with  mucous  secretion,  sometimes  hepatized,  and  with 
a  fluid  effusion  into  the  cavity  of  the  pleura. 

I  have  the  notes  of  one  remarkable  case,  in  which  it  was 
proposed  to  perform  tracheotomy.  I  saw  the  patient  in  consulta- 
tion, and  satisfied  myself  of  the  existence  of  general  bronchitis, 
and  even  double  pneumonia.  The  operation  was  not  performed, 
and  the  patient  soon  afterwards  sank.  The  dissection  accurately 
verified  the  diagnosis,  for  we  found  the  bronchial  mucous  mem- 
brane universally  red,  and  the  tubes  filled  with  viscid  and  bloody 
mucus.  The  upper  lobes  were  in  the  state  of  active  congestion, 
and  the  lower  red,  solid,  and  softened,  with  a  copious  exudation 
of  albuminous  lymph  upon  the  surface  of  the  pleura. 

On  the  subject  of  this  complication  Dr.  Mackintosh  remarks, 
that  the  occasional  co-existence  of  bronchitis  must  be  always 
kept  in  view  when  considering  the  probability  of  affording  relief 
by  the  operation  of  bronchotomy.  "  I  have  seen,"  says  he,  "  the 
lungs  inflamed  in  various  degrees,  and  almost  always  considerable 
portions  are  in  a  state  of  engorgement,  owing,  perhaps,  to  the 
mechanical  impediment  to  respiration."  * 

Without  denying  that  the  mechanical  obstruction  of  the  glottis 
may  produce  an  engorgement  of  the  lung,  yet  I  cannot  help 
believing  that  this  pathological  state  is  generally  the  result  of  the 
pulmonary  inflammation,  which  often  precedes,  and  almost  always 
accompanies  the  laryngitis.  My  reasons  for  this  belief  are,  that 
in  many  cases  I  have  been  able  to  detect  this  engorgement  by 

*  Elements  of  Pathology  and  Practice  of  Physic,  vol.  i.    1831. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  187 

physical  signs  before  the  stridulous  breathing  was  fully  estab- 
lished ;  and  that  the  changes  in  the  lung  and  the  effusions  on 
the  pleura  are  quite  similar  to  those  observed  in  ordinary  cases 
of  pneumonic  inflammation. 

Physical  Signs  of  Croup. — It  is  obvious,  that  in  cases  where 
the  disease  is  confined  solely  to  the  larynx  and  trachea,  the  pas- 
sive signs  will  furnish  only  negative  information ;  for  so  long  as 
the  lung  remains  free  from  congestion  or  pneumonia,  the  sound  on 
percussion  will  continue  clear.  But  we  are  not  to  conclude  from 
this,  that  the  performance  of  percussion  is  to  be  neglected  in 
croup ;  for  whether  it  leads  to  positive  or  negative  results  the 
information  is  in  the  highest  degree  valuable  with  respect  to 
diagnosis  and  treatment.  Thus,  if  in  a  case  of  croup  we  find  the 
sound  clear,  we  may  be  tolerably  sure  that  as  yet  no  impor- 
tant amount  of  congestion  or  of  pneumonia  has  taken  place,  and 
we  may  modify  our  prognosis  and  treatment  accordingly,  while 
on  the  other  hand,  if  we  find  a  local  or  general  dulness,  we  may 
be  satisfied  that  there  is  something  more  than  laryngitis,  and 
that  the  cause  of  dulness  is  either  an  intense  congestion,  or  hepa- 
tization, or  an  effusion  into  the  pleura.  Every  practical  man 
will  see  the  importance  of  this  investigation ;  and  it  happens  for- 
tunately that  percussion  can  be  practised  with  great  facility  in  chil- 
dren, particularly  when  used  over  the  posterior,  and  consequently 
less  yielding  portions  of  the  thorax.  In  making  this  investiga- 
tion, the  operator  must  be  careful  not  to  be  misled  by  the  dulness 
of  the  lower  parts  of  the  chest,  which  may  arise  from  an  enlarged 
liver,  or  from  the  pushing  up  of  the  diaphragm  by  a  distended 
abdomen  ;  and  must  also  bear  in  mind,  that  the  precordial  region 
gives  naturally  a  dull  sound.  I  shall  only  add,  that  the  value  of 
the  clearness  of  sound,  as  a  ground  of  favourable  diagnosis,  is 
directly  as  the  period  of  duration  of  symptoms.  If  pulmonary 
or  laryngeal  irritation  have  existed  for  twenty-four  or  thirty-six 
hours,  the  chances  are,  that  if  there  was  a  pneumonic  complica- 
tion we  could  discover  some  degree  of  dulness. 

Active  Signs. — I  cannot  agree  with  Dr.  M.  Laennec  in  his 
opinion  of  the  inutility  of  stethoscopic  examination  in  the  true 
croup.*  It  is  true  that  in  the  advanced  stages  of  the  disease, 
Avhen  the  breathing  is  slow,  difficult,  and  stridulous,  it  becomes 
next  to  impossible  to  distinguish  the  vesicular  murmur,  less  from 
*  See  his  Notes  on  the  Work  of  Lrennec,  Art.  Cronp. 


f 


188  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

the  sound  produced  in  the  larynx,  than  from  the  feebleness  of  the 
pulmonary  expansion.  But  in  the  earlier  periods  of  the  case,  and 
at  the  time  too  when  such  knowledge  would  he  useful,  we 
can  easily  determine  the  condition  of  the  lung  by  the  stethoscope. 
We  may  then  hear  the  various  bronchial  rales,  and  accurately 
judge  of  their  extent  and  intensity ;  and  even  in  the  cases  with 
pneumonic  complication,  the  signs  of  the  disease,  according  to  its 
stage  or  extent,  may  be  easily  observed. 

The  active  physical  signs,  referrible  to  the  lung,  which  I 
have  had  an  opportunity  of  detecting,  have  been  as  follows  : 
First.  A  diffuse  sonorous  rale,  not  so  intense  as  to  extinguish  the 
vesicular  murmur.  Secondly.  The  same  rale,  but  with  more 
intensity,  indicative  of  disease  in  the  more  minute  tubes.  Thirdly. 
A  combination  of  the  sonorous  and  mucous  rattles,  causing  a  loud 
sound,  and  a  feeling  of  vibration  when  the  hand  is  applied  to  the 
chest.  Fourthly.  The  crepitating  rale  of  pneumonia  in  one  or 
both  lungs;  in  some  cases  with  distinct  dulness  of  sound  on  per- 
cussion. I  have  not  heard  the  bronchial  respiration  of  hepatiza- 
tion, or  the  frottement  of  pleurisy,  but  there  can  be  no  doubt, 
that  if  these  conditions  existed  before  the  laryngeal  disease  had 
attained  its  maximum,  their  signs  would  be  distinctly  audible. 
It  is  true,  that  the  sound  of  stridulous  breathing  will  interfere 
with  those  of  the  lung,  but  in  the  earlier  periods  this  inter- 
ference is  by  no  means  so  great  as  has  been  represented,  and  a 
very  little  practice  indeed  will  enable  the  stethoscopist  to  recog- 
nize the  above  phenomena,  even  when  a  considerable  amount  of 
stridulous  sound  exists. 

As  illustrative  of  the  opinion,  that  the  cause  of  obstruction  in 
this  disease  is  more  spasm  than  the  effusion  of  lymph,  I  may 
remark,  that  the  act  of  vomiting  is  often  followed  by  a  tempo- 
rary suspension  of  the  stridulous  breathing  ;  and  that  if  the 
stethoscopist  avails  himself  of  this  interval  he  will  be  able  to 
determine  the  condition  of  the  lung  with  the  greatest  accuracy, 
even  in  a  case  where  a  short  time  before,  none,  or  almost  none, 
of  the  pulmonary  phenomena  could  be  detected. 

But  in  addition  to  the  stridulous  breathing,  there  is  another 
cause  tending  to  obscure  the  pulmonary  signs.  This  is  the  violent 
action  of  the  heart,  the  loud  and  rapid  contractions  of  which  may 
be  heard  over  the  entire  chest.  Yet  even  this  does  not  cause  any 
important  difficulty,  at  least  to  the  practised  stethoscopist. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  189 

As  the  disease  subsides  the  stridulous  sound  disappears,  and 
we  almost  always  observe  a  pretty  general  sonorous  rale, 
which  may  cease  without  passing  into,  or  becoming  combined 
with  the  mucous  rattle.  This  is  particularly  observed  where 
the  treatment  is  persevered  in  after  the  disappearance  of  the 
laryngeal  symptoms. 

Treatment. — The  treatment  may  be  considered  with  respect 
to  the  precursory,  or  catarrhal,  and  the  confirmed  stages.  We 
have  seen  in  many  cases,  that  the  obstruction  of  the  larynx  does 
not  come  on  suddenly,  but  is  preceded  by  a  stage  of  slight 
irritation  of  the  mucous  membrane,  generally  affecting  both  the 
larynx  and  bronchial  tubes.  Now,  if  at  this  period  the  physician 
interferes  with  judgment,  he  will  generally  succeed  in  cutting 
short  the  attack.  The  circumstances  that  should  excite  alarm 
are  the  wheezing  respiration,  with  slight  hoarseness,  and  some 
change  in  the  character  of  the  cough.  These  symptoms  may 
exist  although  the  child  seems  cheerful  and  free  from  fever,  yet 
be  not  the  less  premonitory  of  a  severe  laryngitis.  Under  these 
circumstances  the  child  should  be  confined  to  his  room,  all 
stimulating  food  withheld,  and  an  emetic  immediately  prescribed 
so  as  to  secure  its  full  and  speedy  operation  ;  for  this  purpose  we 
may  employ  the  vinum  ipecacuanha,  as  recommended  by  Dr. 
Cheyne,  or  the  tartar  emetic.  I  much  prefer  the  latter  on  account 
of  its  greater  certainty  and  unstimulating  nature,  as  well  as  from 
its  known  power  of  controlling  bronchial  inflammation.  After 
the  vomiting  the  child  should  be  kept  in  bed,  the  bowels  opened, 
he  should  drink  warm  diluents,  and  the  exhibition  of  small  doses 
of  ipecacuan  will  generally  place  him  in  safety. 

But  on  the  setting  in  of  the  confirmed  stage  our  treatment 
must  be  prompt,  decided,  and  energetic ;  for  in  most  cases  the 
life  of  the  patient  depends  on  what  is  done  in  the  first  six  or 
eight  hours  of  this  attack.  Now  the  remedies  on  which  we  may 
place  the  greatest  confidence  are  general  and  local  bleeding,  and 
the  exhibition  of  tartar  emetic. 

In  performing  general  bleeding  we  may  open  a  vein  in  the  arm, 
or  perform  the  operation  on  the  jugular  itself;  and  in  consequence 
of  the  turgid  state  of  the  latter  vein  it  will  be  often  easier  to 
bleed  from  this  situation  than  in  the  arm.  There  are  some 
objections,  however,  to  bleeding  from  the  jugular  vein,  the  prin- 
cipal of  which  is  the  difficulty  of  commanding  the  hemorrhage ; 


+- 


190  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

and  it  may  happen,  even  after  the  most  careful  arrangement  of 
the  wound,  that  the  act  of  vomiting  shall  cause  a  fresh  discharge 
of  blood,  which  may  be  repeated  so  often  as  to  endanger  the  life 
of  the  patient.     This  circumstance  alone  is  a  strong  argument 
against  opening  the  jugular  vein,  unless  when  the  practitioner 
can  remain  with  his  patient ;  for  if  from  the  fear  of  vomiting  we 
suspend  the  exhibition  of  the  tartrate  of  antimony,  we  deprive 
ourselves  of  the  most  powerful  agent  in  the  treatment  of  the 
disease.     After  the  general  bleeding  leeches  should  be  applied  to 
the  region  of  the  larynx,  in  numbers  proportioned  to  the  age  and 
strength  of  the  patient,  and  their  application  should  be  renewed 
again  and  again,  until  a  decided  impression  is  made  on  the  disease. 
But  though  a  warm  advocate  of  the  importance  of  general  and 
local  bleeding,  yet  I  look  on  them  as  merely  assistants  to  the 
principal  remedy,  which  is  the  tartar  emetic,  the  exhibition  of 
which  may  be  commenced  from  the  very  first  period  of  the  treat- 
ment ;  and  I  would  advise  that  the  medicine  should  be  so  exhi- 
bited as  to  produce  free  vomiting,  at  least  once  in  every  three- 
quarters  of  an  hour.    In  this  state  the  patient  should  be  kept  for 
several  hours,  when,  according  to  circumstances,  the  remedy  may 
be  given  less  actively.     The  solution  which  I  employ  contains 
one  grain  of  the  salt  to  each  ounce  of  distilled  water,  and  of  this 
a  dessert  spoonful  is  given  every  quarter  of  an  hour,  or  half  hour, 
I  according  as  the  case  may  be.     I  am  aware  that  in  advocating 
the  treatment  by  repeated  vomiting  I  am  at  issue  with  a  high 
authority  on  this  subject,  Mr.  Porter,  who  has  recommended  the 
remedy  in  smaller  closes,  and  so  managed  as  to  keep  up  a  state 
of  permanent   nausea,  without  vomiting.     But  without  at  all 
impugning  this  practice,  which  indeed  I  could  not  do  after  having 
witnessed  its  success  so  frequently,  I  must  declare,  that  I  have 
seen  more  cases  of  marked  and  rapid  relief  where  vomiting  had 
been  produced,  than  where  the  patient  had  been  kept  in  mere 
nausea.    This  is  the  treatment  which  has  been  recommended  by 
Dr.  Cheyne,  and  to  its  efficacy  I  can  bear  the  fullest  testimony. 
That  distinguished  physician,  in  describing  the  treatment  of  the 
disease,  advises  that  "the  dose  of  tartar  emetic  may  be  from 
a  quarter  to  a  half  grain,  and  this  may  be  repeated  according  to 
its  effect,  and  to  the  urgency  of  the  attack."     He  adds,  "  that 
sickness  ought  to  be  excited,  and  hence  the  dose,  if  it  have  no 
such  effect,  ought  to  be  repeated  in  half  an  hour ;  and  if  great 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  191 

prostration  bs   not  produced,  the   dose  ought  afterwards  to  be 
repeated  hourly  while  symptoms  of  inflammation  continue.* 

For  the  introduction  of  this  inestimable  remedy  in  the  treat- 
ment of  croup,  the  science  is  indebted  to  Dr.  Cheyne.  In  his 
essay  on  Cynanche  Trachealis,  published  in  Edinburgh  in  the 
year  1801,  we  find  the  treatment  recommended  ;  and  it  is  no 
small  evidence  in  its  favour,  that  in  the  year  1832,  after  an  expe- 
rience greater  than  falls  to  the  lot  of  most  men,  the  opinions 
of  this  philosophical  investigator  of  disease  have  remained  un- 
altered. How  changed  would  be  the  character  of  medicine,  if  in 
support  of  many  of  our  remedies,  there  could  be  brought  forward 
such  evidence  and  such  an  advocate. 

I  shall  not  dwell  on  the  mercurial  treatment  of  croup,  as  I 
believe  it  to  be  insufficient  and  unnecessary.  The  uncertainty 
of  the  action  of  calomel,  the  difficulty  of  producing  ptyalism  in 
violent  acute  inflammations,  the  shortness  of  the  period  for  the 
exhibition  of  the  remedy,  and  the  various  injurious  effects  of 
mercurial  action  on  the  system  at  large,  are  sufficient  reasons 
against  the  employment  of  this  treatment  in  the  croup  of 
children ;  and  where  we  have  so  valuable  a  remedy  as  the  tartar 
emetic,  it  seems  scarcely  justifiable  to  tamper  with  the  case  by 
the  attempt  to  produce  mercurial  action. 

It  is  a  common  practice  to  apply  a  blister  to  the  throat  in  the 
early  periods  of  this  disease,  but  I  have  no  doubt  that  such  a 
proceeding  is  fraught  with  danger.  Here  I  may  refer  to  the 
observations  I  have  already  made  on  the  action  of  blisters  in 
local  inflammations  ;  and  with  reference  to  the  case  before  us,  I 
feel  happy  in  quoting  from,  and  entirely  agree  with  Mr.  Porter, 
who  declares  that  they  cannot  be  resorted  to  at  an  early  period 
without  considerable  risk  of  doing  mischief.  He  further  remarks, 
that  "it  is  always  hazardous  to  apply  a  blister  in  the  immediate 
neighbourhood  of  inflammation,  and  particularly  so  if  the  consti- 
tution has  not  been  previously  brought  down  by  bleeding  and 
evacuation.  In  the  latter  stages  of  croup,  when  the  lungs  are 
congested,  and  there  is  a  tendency  to  effusion  within  them,  there 
can  be  no  objection  to  try  the  application  of  blisters  to  the  chest, 
but  scarcely  under  any  circumstances  will  they  be  found  bene- 
ficial if  applied  near  to  the  part  affected,  "f 

*  Cyclopaedia  of  Practical  Medicine,  Art.  Croup. 

t  Observations  on  the  Surgical  Pathology  of  the  Larynx  and  Trachea.  Dublin,  1826. 


192  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

When  describing  the  treatment  of  bronchitis,  I  dwelt  particu- 
larly on  the  all-important  practical  point,  that  there  was  a  period 
in  the  disease  when  the  antiphlogistic  treatment  could  be  no 
longer  employed,  but  in  which  we  must  change  to  the  tonic  and 
stimulating  plan  ;  and  so  in  croup,  which  is  but  a  variety  of  the 
disease,  a  period  will  arrive  when  Ave  must  have  recourse  to  the 
stimulant  and  revulsive  medications.  The  coldness  of  the  sur- 
face, the  feebleness  of  the  respiratory  efforts,  the  failure  of  the 
pulse,  the  sinking  of  the  eye,  and  the  pallor  of  the  countenance, 
all  point  out  that  the  period  for  depletion  has  passed  by ;  and 
that  if  there  be  any  hope  it  must  be  from  the  exhibition  of  stimu- 
lants. Wine,  brandy,  opium,  and  ammonia  may  be  employed. 
Hot  turpentine  stupes  may  be  applied  to  the  chest  and  extremi- 
ties, and  now  and  then  the  reward  of  the  nil  desperandum 
practice  may  be  unexpectedly  obtained. 

On  the  performance  of  tracheotomy  in  this  disease  I  have  little 
to  say,  more  than  to  express  my  decided  dissent  from  it.  Indeed, 
all  the  best  authorities  are  now  agreed  on  this  point.  Experience 
has  shewn  that  the  operation  has  failed  in  the  great  majority  of 
cases  ;  and  it  is  obvious,  that  with  our  present  knowledge  of  the 
nature  of  the  disease,  we  can  scarcely  hope  for  good  from  its  per- 
formance. Among  other  causes  for  failure  there  is  one  which 
will  always  exist,  and  which  by  itself  is  generally  sufficient  to 
explain  its  inutility.  There  is  always  that  kind  of  feeling  con- 
nected with  a  surgical  operation  in  acute  diseases,  which  prevents 
its  being  proposed,  assented  to,  or  performed,  unless  under  nearly 
desperate  circumstances,  and  when  all  other  means  have  failed. 
In  the  case  before  us,  the  operation  is  performed  at  a  time  when 
the  situation  of  the  patient  is  the  worst  possible  for  success  ; 
when  the  nervous  system  has  been  profoundly  injured,  and  the 
lungs,  even  though  no  primary  complication  may  have  existed, 
have  become  extensively  congested.  But  in  original  complication 
with  pulmonary  disease,  whether  it  be  pneumonia,  ordinary 
bronchitis,  or  the  plastic  inflammation,  spreading  from  below 
upwards,  we  have  another  and  scarcely  less  important  explanation 
of  the  failure  of  this  operation ;  for  even  after  the  opening  into 
the  trachea  has  given  a  temporary  relief,  the  patient  sinks  from 
an  inflammation  of  the  lungs,  which  preceded  or  accompanied  the 
laryngeal  disease.  It  might  be  argued,  that  the  operation  has 
been  always  performed  too  late,  but  in  this  respect  it  is  like  that 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  193 

for  empyema  ;  and,  in  either  case,  will  almost  never  be  undertaken 
at  the  earlier  periods  of  the  affection.  I  am  far  from  decrying  the 
operation  of  tracheotomy  generally  ;  on  the  contrary,  it  must  be 
admitted,  that  in  many  diseases  it  is  the  only  mode  of  saving 
life,  but  'everything  turns  on  the  proper  selection  of  the  case. 
Thus,  in  the  instance  of  foreign  bodies  in  the  trachea,  of  oedema 
of  the  glottis,  and  of  other  forms  of  disease,  commencing  in, 
and  confined  to  the  upper  portion  of  the  windpipe,  where 
the  lungs  are  not  diseased,  nor  have  become  congested  from 
the  laryngeal  obstruction,  we  have  a  set  of  cases  in  which  the 
operation  may  be  undertaken  with  a  fair  prospect  of  success,  and 
indeed  is  the  only  means  of  saving  the  patient  from  a  speedy 
death. 

I  shall  conclude  this  part  of  the  subject  by  quoting  from  two 
of  our  most  eminent  authors  on  the  pathology  of  the  larynx, 
both  of  whom  are  strongly  opposed  to  the  performance  of  the 
operation.     "Before  having  recourse,"   says  Dr.   Cheyne,   "to 
the  operation,  supposing  it  easy,  safe,  and  likely  to  end  in  the 
extraction  of  the  adventitious  membrane,  it  will  be  proper  to  ask, 
is  the  false  membrane  in  the  larynx,  which  it  is  the  object  of  this 
formidable    operation  to  remove,    in  general  the   cause  of  the 
patient's  death?     We  apprehend  not.     First,  because  in  several 
dissections  which  were  long  ago  made,  with  a  view  of  determining 
the  effect  of  the  membrane  of  croup  in  obstructing  the  larynx,  it  so 
happened  that  within  that  membrane  a  space  was  left  for  a  current 
of  air  sufficient  to  support  life.     In  these  bodies  the  cellular  sub- 
stance of  the  lung  was  distended  with  serum,  the  ramifications  of 
the  bronchi  were  filled  with  puriform  matter,  by  which  the  air  was 
excluded,  and  the  bronchial  membrane  was  universally  inflamed, 
thereby  preventing  the  arterialization  of  the  blood  :  the  children 
had  perished  from  the  lungs  being  unable  to  contain  a  quantity  of 
air  sufficient  to  support  the  circulation,  and  from  the  bronchial 
membrane    being    unable    to    act    on    that    reduced     quantity. 
Secondly,  because  when  the  membrane  of  croup  fully  formed  is 
expectorated   the  disease  is  generally  fatal,    even  when  all  the 
benefits  of  the  operation  are  obtained.     If  the  disease  were  con- 
fined to  the  larynx,  then,  and  then  only,  would  bronchotomy  be 
advisable."* 

I  shall  next  quote  from  the  work  of  my  friend  and  colleague, 
*  Cyclopaedia  of  Practical  Medicine,  Art.  Croup. 
O 


194  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

Mr.  Porter,*  a  work  distinguished  for  originality,  accuracy,  and 
extensive  investigation. 

"  To  the  casual  success  of  such  an  operation  I  would  attach 
no  professional  reputation,  whilst  I  think  much  character  may  be 
lost  to  the  individual,  and  general  obloquy  heaped  on  the  pro- 
fession, by  the  too  frequent  performance  of  operations  thus  under- 
taken at  a  hazard,  and  almost  always  at  a  period  of  the  disease 
when  its  efficacy  (if  it  ever  possessed  any)  must  be  exerted  too 
late. 

"But  bronchotomy  has  in  many  cases  of  croup  been  successful. 
True — but  where  are  the  thousand  and  one  instances  to  the  con- 
trary, that  might  be  brought  against  each  single  one  of  these  ? 
I  have  performed  the  operation  myself  on  the  child,  and  have 
seen  it  frequently  done  by  others,  and  in  no  one  case  has  the  life 
of  the  patient  been  saved.  I  have  known  and  heard  of  it  often, 
but  never  understood  that  it  produced  a  recovery  ;  and  I  should 
.suppose  that  my  experience  on  the  subject  only  resembles  that 
/of  most  men  who  have  had  opportunities  of  seeing  and  treating 
.the  disease.  Most  practitioners  are  fond  of  publishing  cases  of 
•successful  operations,  but  are  not  so  willing  to  make  known  those 
of  an  opposite  description,  from  an  idea  that  these  supposed 
failures  might  lower  them  in  public  estimation,  but  these 
detached  and  solitary  expositions  of  fortunate  surgery  are  calcu- 
lated to  produce  very  serious  injury  if  they  encourage  others  to 
similar  attempts,  in  the  hope  of  similar  results.  If  it  was  possible 
to  place  a  list  of  those  cases  in  which  bronchotomy  had  not 
proved  serviceable,  in  array  against  those  wherein  it  had  seemed 
to  be  useful,  it  would  be  scarcely  necessary  to  advance  any 
.farther  argument  in  proof  of  its  uncertainty  ;  and  medical  men 
<would  rather  turn  their  attention  to  the  improvement  of  that 
internal  treatment  which  will  generally  be  efficacious  if  resorted 
.to  in  time,  than  look  for  advantage  in  the  performance  of  an 
operation  from  which  experience  holds  out  such  slender  hopes." 

But  the  operation  has  been  suggested  with  other  views  than 
merely  to  facilitate  the  entrance  of  air  into  the  lung.  Thus 
Bretonneau,t  after  having  ascertained  the  value  of  topical  appli- 
cations, in  the  diphtheritis  of  the  pharynx,  has  proposed  their 
direct  introduction  into  the  larynx  by  means  of  an  opening  into 

*  Surgical  Pathology  of  the  Larynx  and  Trachea,  by  W.  H.  Porter. 
f  Des  Inflammations  Speciales  du  Tissu  Muqueux. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  195 

the  windpipe,  so  that  in  this  way  he  might  attain  a  double 
object,  viz.,  the  free  entrance  of  air,  and  the  action  of  specific 
agents  directly  applied  to  the  diseased  membrane.  Thus,  in 
reference  to  a  particular  case,  after  describing  certain  modifica- 
tions, which  he  proposed  in  the  operation,  he  adds,  "  I  hoped 
farther,  by  means  of  the  artificial  opening  to  be  able  to  apply 
calomel  at  once  on  the  affected  surfaces,  and  I  avow  that  I  had 
great  confidence  in  the  effects  of  a  remedy  which  has  such 
remarkable  effects  in  many  ulcerous  inflammations  of  the  skin. 
I  was  also  convinced,  that  in  the  case  where  the  mercurial 
treatment  had  failed,  the  diphtheritic  inflammation  had  been 
dissipated  in  all  those  points  where  the  surface  came  directly  in 
contact  with  calomel." 

The  case  to  which  these  remarks  apply  was  one  of  what  I  have 
called  the  secondary  croup,  where  the  affection  of  the  larynx  and 
trachea  succeeded  to  the  formation  of  false  membranes  in  the 
cavity  of  the  pharynx,  and  in  which  the  symptoms  resisted  treat- 
ment, so  that  on  the  seventh  day  they  became  sufficiently  alarm- 
ing as,  in  the  opinion  of  Bretonneau,  to  demand  the  operation. 
The  opening  into  the  trachea  was  followed  by  relief  of  the 
symptoms,  and  some  fragments  of  concretion  were  expelled 
through  the  canula.  Eight  grains  of  calomel  were  blown  into 
the  trachea  by  means  of  the  canula.  For  the  further  reports  of 
this  interesting  case  I  refer  to  the  work  itself ;  it  will  suffice  to 
state,  that  the  child  was  convalescent  on  the  twentieth  day  of  the 
disease,  and  the  thirteenth  of  the  operation,  but  for  nine  or  ten 
days  after  the  operation  the  situation  of  the  patient  was  often 
extremely  critical.  The  direct  introduction  of  calomel  was 
repeated  three  times  ;  the  mode  employed  being  to  introduce  it 
along  with  water  into  the  canula,  when  by  the  efforts  of  inspira- 
tion it  was  sucked  into  the  trachea. 

It  is  plain  that  this  case  is  not  sufficient  to  establish  the 
efficacy  of  the  direct  action  of  calomel  as  a  remedial  agent  in  the 
disease.  During  the  progress  of  the  case  hardly  a  day  elapsed 
without  the  expulsion  of  some  of  the  false  membrane,  and  without 
denying  the  possibility  of  the  specific  action  of  the  remedy,  it 
seems  more  probable  that  the  recovery  was  attributable  to  the 
gradual  decline  of  the  disease  in  a  patient  whose  immediate 
death  was  prevented  by  the  operation  of  tracheotomy.  The  case, 
however,  is  full  of  interest,  and  deserves  a  careful  study. 

o  2 


196  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

Acute  Laryngitis  in  the  Adult. — The  principal  difference 
between  this  and  the  preceding  affection  is  in  the  result  of  the 
inflammation,  which  in  place  of  the  formation  of  lymph,  termi- 
nates in  an  cedematous  state  of  the  mucous  membrane  and  its 
subjacent  cellular  tissue.  This  fact  has  been  recognized  by 
various  writers,  from  the  time  of  the  second  Monro  ;  and  the 
rarity  of  the  production  of  lymph  in  the  larynx  of  the  adult  is 
now  fully  admitted ;  the  plastic  inflammation  then  may  be  con- 
sidered as  in  some  way  connected  with  that  lower  development 
which  precedes  the  period  of  puberty. 

But  there  is  another  point  of  difference  which  has  not  been 
sufficiently  noticed.  In  the  adult  the  disease  is  more  confined  to 
the  larynx  ;*  it  is  in  reality  a  laryngitis,  while,  as  we  have  seen, 
the  croup  of  children  is  commonly  complicated  with  inflammation 
of  the  trachea  and  bronchial  tubes.  And  thus  we  have  at  least 
one  reason  for  the  much  greater  success  of  tracheotomy  in  the 
laryngitis  of  the  adult  than  in  that  of  the  child.  Yet  lymph  has 
been  found  to  line  the  windpipe,  even  in  advanced  age,  and  cases 
of  this  kind  have  been  published  as  instances  of  croup  in  the 
adult.  Without  denying  the  possibility  of  a  primary  irritation  of 
the  larynx  forming  lymph,  even  under  these  circumstances,  it 
must  yet  be  admitted,  when  we  compare  the  analogous  diseases  of 
laryngitis  in  the  child  and  adult,  that  the  secretion  of  lymph  in 
the  latter  instance  is  extremely  rare.  In  the  great  majority  of 
cases  described  under  the  name  of  croup  in  the  adult,  the 
affection  of  the  larynx  was  secondary  to  some  general  or  local 
affection.  The  exudation  of  lymph  formed  first  in  the  pharynx, 
and  extended  from  this  to  the  windpipe,  and  the  disease  thus 
produced  was  what  I  have  already  described  under  the  name  of 
the  secondary  croup. 

In  most  of  these  cases  the  disease  occurred  under  the  form  of 
the  diphtheritis  of  Bretonneau  ;  in  the  putrid  sore  throat,  or 
lastly,  as  an  affection  supervening  in  the  progress,  or  towards  the 
close  of  other  diseases.  For  the  most  accurate  researches  on  this 
subject  we  are  indebted  to  M.  Louis, t  and  a  review  of  his  cases 
will  confirm  the  above  positions. 

In  his  memoir  eight  cases  are  detailed ;  the  first  is  that  of  a 
robust  man,  aged  twenty-three  years,  who,  on  tho  eighteenth 

*  Porter,  Op.  Cit.,  p.  94. 

t  Recherches  Anatomico-Pathologiques.    Du  Croup  conside're  chez  l'Adulte. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  197 

day  of  a  typhus  fever,  became  attacked  with  pain  in  the  throat, 
soon  followed  by  the  formation  of  a  false  membrane,  covering  the 
tonsils,  soft  palate,  and  pharynx.  On  the  twentieth  this  mem- 
brane had  become  more  opaque,  and  the  voice  was  altered,  but 
the  respiration  continued  natural ;  in  two  days,  however,  he  had 
the  croupy  voice,  and  brazen  respiration,  the  breath  was  foetid, 
deglutition  impossible,  and  the  patient  soon  after  sunk  with 
delirium. 

On  dissection  the  cervical  glands  were  found  enlarged,  and  the 
pharynx,  uvula,  velum  palati,  epiglottis,  and  larynx  were  lined  by 
a  false  membrane. 

In  the  second  case,  the  patient,  aged  nineteen,  had  laboured 
for  upwards  of  three  months  under  a  chronic  pleurisy,  when  it 
was  observed  that  the  sputa  were  mixed  with  portions  of  yellow 
false  membranes.  On  the  following  day  he  complained  of  a  pain 
in  the  throat,  and  the  posterior  portion  of  the  mouth  was  seen 
lined  with  a  semi-transparent  false  membrane.  Soon  after  this 
the  neck  became  slightly  swelled,  the  voice  altered,  there  was 
extreme  distress  referred  to  the  larynx.  To  these  symptoms 
succeeded  the  vox  rauca,  stridulous  breathing,  suffocation,  and 
death  :  four  days  having  elapsed  between  the  invasion  of  the 
diphtheritic  symptoms  and  the  fatal  termination. 

The  appearances  on  dissection,  as  far  as  the  pharynx  and 
windpipe  were  concerned,  were  the  same  as  in  the  former 
instance. 

The  third  case  is  an  example  of  a  similar  disease  supervening 
in  the  course  of  a  gastro-enteritis,  with  a  gangrenous  ulceration 
of  the  right  tonsil,  and  some  oedema  of  the  glottis.  In  the  fourth 
and  fifth  false  membranes  occupied  the  posterior  cavity  of  the 
mouth,  the  nasal  fossae,  the  larynx,  and  trachea.  In  the  sixth  a 
similar  affection  supervened  in  the  last  periods  of  pulmonary 
phthisis ;  and  in  the  eighth  they  occurred  during  a  typhus  fever. 
The  ages  of  these  five  last  patients  were  respectively  twenty-nine, 
sixty-two,  twenty-two,  thirty- two,  and  fifteen  years.  In  all  the 
cases  false  membranes  existed  in  the  pharynx,  and  the  disease  is 
admitted  by  Louis  to  have  spread  from  above  downwards.  Indeed, 
he  records  but  one  observation  where  this  production  was  con- 
fined to  the  windpipe  alone.  This  was  a  female,  aged  thirty-two, 
exhausted  by  misery  and  starvation,  who  died  with  symptoms 
of  angina,  accompanied  with  prostration.     On  dissection,  a  thick 


198  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

false  membrane  lined  the  larynx  and  trachea,  and  even  descended 
to  the  third  ramifications  of  the  bronchial  tubes.  It  did  not 
occur  on  the  tonsils  or  soft  palate,  where  nothing  was  found  but 
a  small  quantity  of  greyish-coloured  mucus. 

It  must  be  admitted  that  these  cases,  excepting  the  seventh, 
were  examples  of  a  disease  very  different  from  the  inflammatory 
croup  of  children.  A  great  similarity  exists  among  them ;  the 
formation  of  false  membranes  in  the  cavity  of  the  mouth,  and  its 
spreading  from  above  downwards ;  the  disease,  secondary  to 
other  local  affections,  or  to  fever  ;  the  prostration,  the  typhoid 
state,  and  the  age  of  the  patients,  form  a  group  of  circumstances 
decisive  as  to  the  nature  of  the  disease. 

Acute  laryngitis  may  vary  from  the  production  of  but  a  slight 
hoarseness,  without  stridulous  breathing,  and  with  little  or  no 
fever,  to  a  violent  irritation  of  the  mucous  membrane  and  sub- 
jacent cellular  tissue  of  the  glottis,  epiglottis,  and  upper  portion 
of  the  larynx ;  an  cedematous  state  of  the  mucous  membrane  and 
cellular  tissue  of  the  glottis  is  produced,  and  death  results  from 
the  direct  closure  of  the  tube.  Rapid  and  formidable  from  its 
nature  and  situation — the  situation  of  all  others  where  the  least 
extent  of  disease  is  the  most  dangerous,  it  demands  a  prompt  and 
energetic  treatment. 

The  disease  in  its  worst  form  is  characterized  by  a  hoarse 
cough,  with  increasing  difficulty  of  breathing, ;  the  respiration 
becomes  rapidly  stridulous  ;  the  voice  is  altered  until  it  is  only 
a  painful  whisper,  and  the  distress  and  anxiety  of  the  patient 
are  extreme.  There  is  often  great  dysphagia,  and  the  drinks  are 
returned  through  the  nose.  In  these  cases  the  epiglottis  may  be 
felt  swollen,  turgid,  and  erect,  and  on  inspection  is  seen  red  and 
shining.* 

This  affection  has  been  described  under  the  name  of  the 
oedema  of  the  glottis,  but  it  is  better  in  medical  nomenclature  to 
have  reference  to  causes  than  effects.  Besides  we  may  have 
cedema  of  the  glottis  without  violent  inflammation. 

In  the  advanced  periods  of  this  affection  the  situation  of  the 
patient  is  truly  dreadful  from  the  painful,  laboured,  and  insuffi- 
cient breathing,  and  the  paroxysms  of  cough ;  his  voice  is  too 
feeble  to  express  his  sufferings,  but  in  his  anxious  and  suppli- 
cating countenance  we  may  read  that  he  demands  relief  at  any 

*  See  Wilson  in  Med.  Chir.  Trans.,  vol.  v. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  199 

price.  The  eyes  are  staring  and  tearful,  the  face  pallid,  and  the 
skin  often  cool.  If  he  falls  asleep  for  a  moment  he  suddenly 
awakes  in  the  greatest  agitation,  and  if  relief  he  not  speedily 
afforded  he  soon  sinks  hy  coma. 

The  fatal  termination  may  occur  suddenly  and  rapidly,  or 
more  slowly,  when  it  seems  to  arise  from  the  non-arterialization 
of  the  hlood.  And  even  after  the  air  has  heen  freely  admitted  by 
bronchotomy,  the  patient  may  sink  apparently  from  the  shock 
which  the  brain  has  received.*  Such  a  result  is  more  likely 
when  the  operation  has  been  long  delayed. 

An  cedematous  swelling  of  the  neck  has  been  enumerated 
among  the  symptoms  of  this  disease,  but  with  what  degree  of 
justice  remains  to  be  settled.  I  have  seen  the  affection  more 
often  without  than  with  this  swelling ;  and  in  the  cases  where  it 
did  occur,  it  was  not  symptomatic  of  the  disease,  as  in  these 
patients  there  had  been  either  erysipelatous  inflammation,  or 
bad  scarlatina,  and  the  swelling  of  the  neck  manifestly  preceded 
the  laryngeal  symptoms. 

In  a  patient  operated  on  successfully  by  Mr.  Porter,  the 
integuments  of  the  neck  were  swollen  consecutively  to  the  laryn- 
gitis ;  but  here  the  swelling  was  from  emphysema,  and  was  a 
source  of  great  embarrassment  in  the  operation.  This  obviously 
proceeded  from  the  violent  efforts  of  cough  and  respiration,  but 
whether  the  lesion  took  place  in  the  lung  or  windpipe  is  not 
known.  Louis  observed  a  similar  occurrence  in  a  case  of  foreign 
body  in  the  trachea.t 

This  formidable  disease,  however,  may  occur  under  other 
conditions  than  as  an  acute  inflammatory  disease.  (Edematous 
obstruction  of  the  glottis  is  an  affection  arising  from  many 
causes,  of  which  the  following  may  be  enumerated. 

It  may  occur — 

1st.  From  acute  primary  inflammation,  as  in  the  form  just 
described. 

2nd.  As  a  result  of  erysipelatous  inflammation  affecting  the 
system  generally. 

3rd.  From  diffuse  inflammation  of  the  neck. 

4th.  As  a  result  of  the  lower  forms  of  scarlatina,  and  other 
exanthemata. 

*  See  Cyclopaedia  of  Pract.  Medicine,  Art.  Laryngitis,  by  Dr.  Cheyne. 
t  Med.  de  l'Acadeniie  de  Chirurgie,  tome  iv. 


200  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

5th.  Consequent  on  the  disease  called  parotiditis,  so  common 
after  fever.* 

6th.  Occurring  after  the  long  existence  of  organic  tumours 
in  the  neck. 

7th.  After  great  operations  on  the  neck.f 

In  fact  it  would  seem  likely  to  arise  in  all  cases  of  tumour  of 
the  neck,  particularly  those  where  an  irritation  of  the  cellular 
membrane  has  occurred,  and  the  fever  may  he  inflammatory  or 
typhoid. 

(Edema  of  the  glottis  then  is  not  a  disease  which  we  can 
always  meet  by  a  bold  antiphlogistic  treatment,  and  an  accurate 
investigation  into  its  causes  and  history  must  be  made  before 
its  treatment  can  be  determined  on. 

But  besides  this  formidable  disease,  there  are  other  acute 
irritations  of  the  larynx,  which  differ  from  it  in  their  history, 
symptoms,  and  danger. 

In  these  following  forms  may  be  enumerated — 

1st.  Simple  recent  hoarseness,  without  stridulous  breathing  or 
fever. 

2nd.  Hoarseness  and  fever,  with  slight  stridulous  breathing. 

3rd.  Hoarseness,  incessant  cough  ;  some  stridor,  with  pain  and 
soreness  of  the  larynx,  dysphagia,  not  proceeding  from  tumefaction 
of  the  epiglottis,  occasional  spasmodic  exacerbations. 

4th.  Symptoms  similar  to  the  preceding,  but  occurring  in  the 
course  of  typhus  or  gastric  fever,  and  in  all  the  phenomena 
analogous  to  the  other  secondary  affections  of  fever. 

5th.  Laryngeal  symptoms  arising  in  the  course  of  the  exan- 
thematous  diseases,  such  as  measles,  scarlatina,  and  small-pox.J 

6th.  Laryngeal  symptoms  arising  from  the  spreading  down- 
wards of  an  exudation  of  lymph  formed  in  the  pharynx  and  cavity 
of  the  mouth.     This  is  the  diphtherite  tracheale  of  Bretonneau,§ 

*  Of  this  disease  I  have  made  many  dissections,  and  in  no  case  was  the  parotid 
gland  affected.  The  affection  was  in  all  an  cedematous  inflammation  of  the  cellular 
membrane  posterior  to  the  angle  of  the  jaw. 

f  For  these  last  two  instances  I  am  indebted  to  Mr.  Cusack.  In  the  Museum  of  the 
Park  Street  School  of  Medicine  there  is  an  excellent  specimen  of  the  disease,  which 
occurred  in  a  patient  labouring  under  a  cancerous  tumour  below  the  jaw  ;  there  the 
mechanical  obstruction  to  the  circulation  had  probably  much  to  do  in  the  disease. 

J  See  Tweedie,  Clinical  Illustrations  of  Fever,  with  reference  to  this  and  the  last 
variety.    In  typhus  fever  I  have  never  seen  the  disease  produce  stridulous  breathing. 

§  Des  Inflammations  Speciales  du  Tissu  Muqueux,  par  P.  Bretonneau,  Paris,  1826. 
This  author  has  described  a  remarkable  epidemic  of  this  affection,  which  occurred  at 
Tours  in  1818.    To  the  original  disease  he  gives  the  name  of  the  scorbutic  gangrene, 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  201 

and  may  be  seen  in  cases  of  the  putrid  or  malignant  sore  throat. 
The  disease  may  only  produce  some  hoarseness  or  stridor,  or,  on 
the  other  hand,  cause  death  by  laryngeal  obstruction. 

7th.  Laryngitis  from  the  spreading  downwards  of  the  plastic 
inflammation,  caused  by  the  action  of  corrosive  agents  on  the 
cavity  of  the  mouth  and  pharynx. 

The  diseases  which  may  be  confounded  with  acute  idiopathic 
laryngitis  are  not  numerous.  But  in  making  our  diagnosis  we 
must  know  them  so  as  by  the  method  of  exclusion  we  may  form  a 
true  opinion.     They  may  be  enumerated  as  follows. 

I.  Secondary  inflammation  of  the  larynx,  arising  in  the  course 
of  angina  maligna,  diffuse  inflammations,  typlms  fever,  the 
exanthemata,  &c. 

"We  distinguish  this  class  of  affections  by  their  previous  history, 
by  the  character  of  the  fever,  and  by  the  pre-existence  of  signs  of 
local  disease  in  the  pharynx,  or  in  the  cellular  membrane  of  the 
neck.  The  occurrence  of  diffuse  inflammation,  of  the  exanthe- 
mata, or  typhus  fever,  are  also  most  important  in  the  diagnosis. 

II.  Foreign  Bodies  in  tlie  Larynx. — As  I  shall  dedicate  a 
separate  chapter  to  the  diagnosis  of  this  occurrence,  I  shall  not 
now  dwell  longer  on  it  than  to  remark,  that  in  general  the  sud- 
denness of  the  attack,  the  absence  of  fever,  or  other  constitutional 
disturbance,  the  healthy  state  of  the  epiglottis,  while  the  signs 
of  obstruction  are  increasing,  the  singular  remissions,  and  the 
completely  characteristic  stethoscopic  phenomena,  are  sufficient 
to  lead  to  an  accurate  conclusion. 

III.  Acute  Pericarditis. — In  a  few  instances  this  affection  has 
simulated  laryngitis  remarkably.*  In  most  of  them,  however, 
the  pharynx  and  epiglottis  have  been  found  healthy,  and  the 
disease  was  longer  in  running  its  course  than  the  ordinary  acute 


or  angina  maligna.  He  gives  the  dissections  of  eighteen  cases,  in  which  the  air 
passages  were  engaged.  In  five,  the  disease  occurred  in  children  aged  from  eight 
months  to  seven  years,  and  in  them  all  the  exudation  was  first  formed  in  the 
pharynx.  In  one  case  it  descended  into  the  minute  bronchi.  The  remaining  thirteen 
cases  present  the  disease  (with  a  single  exception)  proving  fatal  by  attacking  the  air- 
passages,  and  in  the  great  majority  first  engaging  the  pharynx.  In  one  case  the 
laryn go- bronchial  membrane  seemed  alone  affected. 

*  On  the  curious  fact  of  this  and  the  two  next  affections  simulating  laryngitis,  I 
shall  dwell  more  fully  when  I  treat  of  pericarditis.  See  Morgagni,  Epist.  Med.  xvi. 
Art.  40.  Also  J.  P.  Frank  de  Curand.  Hominum  Morbis.  Testa,  de  la  Malattie'  del 
Cuore,  Bologna,  1811,  vol.  iii.  And  lastly,  Portal,  Mem.  sur  la  Nature  et  le  Traite- 
ment  de  Plusieurs  Maladies,  Paris,  1819. 


202  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

laryngitis  of  adults.  If  to  these  we  add  the  fact,  that  the 
diagnosis  of  pericarditis  no  longer  rests  on  negative  evidence, 
we  have  sufficient  means  to  prevent  our  confounding  the  two 
affections. 

IV.  Acute  Pneumonia  and  Pleuritis. — These  diseases  are  not 
so  liable  to  simulate  laryngitis  as  the  last.  As  to  diagnosis  I 
shall  only  say,  that  the  physical  examination  of  the  chest,  which 
should  never  be  omitted  in  any  case  of  laryngitis,  will,  in  almost 
all  cases,  suffice  to  establish  the  distinction. 

V.  Aneurismal  Tumours  compressing  the  Trachea. — The 
chronicity  of  these  cases,  the  absence  of  fever,  and  the  existence 
of  pectoral  disturbance,  such  as  pain,  palpitation,  dyspnoea,  and 
cough,  long  before  the  laryngeal  symptoms  set  in,  will  generally 
point  out  their  nature.  But  there  are  other  circumstances  which 
must  be  attended  to.  Thus  we  may  observe  the  tippet-like 
swelling  of  the  neck,*  the  tumefaction  of  one  or  both  jugular 
veins,  and  the  occurrence  of  deep-seated  dysphagia.  The  upper 
portion  of  the  sternum  and  one  clavicle  will  be  generally  dull  on 
percussion,  and  the  stethoscopic  signs  of  aneurism  will  be  here 
audible.  Lastly,  if  the  patient  has  been  under  observation 
previous  to  the  setting  in  of  laryngeal  symptoms,  and  that  we 
have  discovered  a  more  than  natural  difference  between  the 
intensity  of  the  vesicular  murmur  in  either  lung,  while  there  is  no 
physical  sign  of  disease  in  these  organs,  we  may  be  certain  that 
the  obstruction  was  not  originally  in  the  windpipe,  but  first 
affected  one  bronchus,  and  from  that  extended  upwards. 

VI.  Abscesses  external  to,  and  compressing  the  Larynx. 
These  affections  may  be    recognized  and    distinguished  from 

laryngitis  by  local  tumefactions  in  the  superior  portion  of  the  neck, 
which  are  tender  to  the  touch,  and  cause  an  inability  to  open  the 
mouth.  From  the  confinement  of  the  matter  under  the  strong 
fascia  of  the  neck  fluctuation  is  seldom  perceived,  but  an 
oedematous  condition  may  exist.  According  to  Mr.  Porter,t  the 
difficulty  in  breathing,  though  great,  does  not  resemble  that 
occasioned  by  laryngeal  obstruction,  it  is  not  sibilous  or  whistling  : 
the  approach  of  the  suffocating  symptoms  is  in  general  gradual, 
and   there    is    no    appearance    of  inflammation    in   the    fauces. 

*  Dub.  Jour,  of  Med.  and  Chem.  Science.     On  the  Diagnosis  and  Pathology  of 
Aneurisms  of  the  great  Vessels,  by  W.  Stokes,  M.D.,  vol.  v. 
t  Porter,  Op.  Cit.,  pp.  127,  130. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  203 

Further,  as  the  above  author  has  observed,  we  find  that  in  pressing 
the  larynx  backwards  against  the  spine,  a  feeling  of  fulness  and 
elasticity  is  often  imparted,  and  when  we  move  the  organs 
laterally,  the  sensation  of  the  rubbing  together  of  two  firm 
substances  is  no  longer  produced. 

VII.  Spasmodic  Exacerbations  in  Chronic  Laryngitis. 

It  is  scarcely  necessary  to  dwell  on  this  case  as  distinguished 
from  acute  laryngitis  ;  for  the  previous  history,  the  suddenness  of 
the  attack  without  increase  of  fever,  and  the  condition  of  the 
fauces,  will  at  once  enable  us  to  determine  the  nature  of  the 
symptoms. 

VIII.  Hysteric  Spasm. 

Like  the  preceding,  it  is  generally  easy  to  distinguish  the 
nature  of  this  attack.  It  most  commonly  occurs  in  females,  who 
have  already  shewn  a  manifest  hysterical  or  spasmodic  tendency. 
It  is  generally  accompanied  by  other  hysterical  symptoms  ;  and 
though  the  obstruction  seems  excessive,  yet  the  patient  is  free 
from  fever.  On  the  subject  of  spasm  of  the  glottis  I  shall  here- 
after dwell  more  fully. 

Physical  Signs  of  Laryngitis  in  the  Adult. — I  shall  defer 
the  consideration  of  this  subject  until  we  examine  the  history  of 
chronic  laryngitis.  I  do  this  in  order  to  avoid  repetition,  for  the 
causes  and  nature  of  the  physical  signs  are  nearly  similar  in  both 
diseases. 

Treatment  of  Acute  Laryngitis  in  the  Adult. — There  is 
abundant  evidence  to  shew  that  in  a  certain  period  of  the 
idiopathic  disease  Ave  may  succeed  in  reducing  the  inflammation 
by  vigorous  antiphlogistic  treatment.  It  is  hardly  necessary  to 
observe,  that  this  treatment  is  only  proper  or  safe  in  the  earlier 
periods,  while  the  strength  of  the  patient  is  but  little  impaired, 
and  particularly  while  the  blood  is  sufficiently  arterialized.  But 
after  long- continued  stridulous  breathing,  or  even  when  it  is  recent, 
but  severe  and  increasing,  and  when  we  find  the  countenance  waxy 
or  livid,  and  the  lip  pale,  it  becomes  nearly  useless,  and  often 
dangerous,  to  draw  blood.*     Then  we  must  not  lose  time,  but 

*  See  Cheyne,  Cycl.  of  Pract.  Medicine,  Art.  Laryngitis.  Also  Armstrong,  Practi- 
cal Illustrations  of  Typhus  Fever.  Porter,  Surgical  Pathology  of  the  Larynx  and 
Trachea,  p.  101.  Dr.  Cheyne  remarks,  after  detailing  some  successful  cases  of  blood- 
letting in  laryngitis,  that  in  none  of  them  had  lividity  occurred  ;  and  also,  that  where 
bleeding  is  performed,  it  should  not,  as  Baillie  has  advanced,  be  carried  so  far  as  to 
cause  syncope. 


204  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

give  the  patient  his  best  chance,  namely,  the  performance  of 
tracheotomy.  There  is  no  disease  of  an  inflammatory  nature  in 
which  the  period  for  antiphlogosis  is  so  short ;  for  the  result  is 
generally  oedema,  and  the  organ,  as  compared  with  others,  that 
in  which  the  least  amount  of  tumefaction  or  effusion  causes  the 
greatest  depressing  effects. 

In  the  milder  forms  of  the  disease  we  may  often  apply  leeches 
with  benefit,  but  I  have  seldom  seen  them  of  advantage  in  the 
more  violent  cases.  Dr.  Cheyne  has  suggested  that  they  should 
be  applied  to  the  mucous  membrane,  as  near  as  possible  to  the 
epiglottis ;  and  certainly  this  mode  would  be  that  most  likely  to 
afford  relief  if  such  is  to  be  obtained  by  local  bleeding.*  With 
respect  to  blistering,  there  is  as  yet  no  evidence  in  its  favour  as  a 
remedial  measure  in  this  disease. 

In  fact  if  the  inflammation  does  not  yield  to  the  early  and 
vigorous  use  of  the  lancet,  the  operation  of  tracheotomy  must  not 
be  delayed  ;  and  it  is  consoling  to  know  that  it  affords  an  ex- ' 
cellent  chance  for  recovery.  And  further,  that  even  under  circum- 
stances apparently  the  most  hopeless,  it  may  be  successfully 
performed.  In  a  case  quoted  by  Dr.  Cheyne,  the  operation  was 
performed  by  Mr.  Goodeve,  after  the  pulse  had  ceased  at  the  wrist, 
the  face  suffused,  and  the  lips  livid,  yet  recovery  took  place.  I 
shall  not  soon  forget  the  case  of  a  gentleman,  aged  upwards  of 
sixty  years,  who  had  recently  recovered  from  a  violent  pneumonia, 
and  was  attacked  with  the  most  violent  form  of  acute  laryngitis, 
which  baffling  all  efforts  to  control  it,  brought  the  patient  into  the 
jaws  of  death  in  little  more  than  twelve  hours.  It  was  determined 
that  Mr.  Porter  should  be  sent  for  to  operate,  but  before  he 
arrived  the  patient  had  become  nearly  insensible.  The  operation 
was  proceeded  with,  but  respiration  ceased  before  the  trachea  was 
opened.  The  operator  paused,  it  was  a  fearful  moment,  and  then 
rapidly  opened  the  trachea,  yet  no  sound  of  inspiration  followed. 
Applying  his  mouth  to  the  wound  he  inflated  the  lungs,  and 
produced  artificial  respiration  at  least  seven  times,  when  a  loud 
and  rattling  inspiration,  followed  by  full  and  free  breathing, 
proclaimed  the  triumph  of  art.  The  occurrence,  strange  and  un- 
expected, excited  at  the  moment  feelings  of  a  higher  order  ;  and 
among  those  who  participated   in  them   there    was   none  more 

*  See  a  paper  on  the  A[  plicaifon  of  Leeches  to  Internal  Surfaces,  by  P.  Crampton, 
M.D.,  Dub.  Hosp.  Reports,  vul.  ii;. 


DISEASES    OF   THE    LARYNX   AND    TRACHEA.  205 

sincerely  affected  than  the  intrepid,  experienced,  and  scientific 
operator  himself. 

In  these  cases  it  sometimes  happens  that  the  obstruction 
rapidly  subsides  after  the  operation  ;  but  in  many  others  it  is 
necessary  to  insert  a  canula,  so  adapted  that  it  may  be  worn 
for  a  length  of  time.  For  further  information  on  this  point  I 
beg  again  to  refer  to  Mr.  Porter's  book,  and  shall  conclude  by 
observing,  that  general  or  local  antiphlogistic  treatment  seems 
inefficacious  in  all  the  forms  of  oedema  of  the  glottis  excepting 
the  first ;  how  far  the  performance  of  the  operation  may  be 
trusted  to  in  such  cases  must  be  determined  by  future  experience. 

Finally,  it  is  to  be  remarked,  with  respect  to  those  milder 
forms  of  laryngitis,  in  which  the  disease  seems  to  consist  of  a 
slight  thickening  of  the  mucous  membrane,  that  the  best  treat- 
ment consists  in  enjoining  silence  and  repose,  in  the  repeated 
application  of  leeches  in  small  numbers  to  the  part,  in  the  use 
of  mild  diaphoretics,  and  lastly,  in  the  exhibition  of  mercury, 
in  moderate  doses,  so  as  gently,  but  decidedly,  to  affect  the 
system.  During  this  treatment  the  strength  of  the  patient  is 
to  be  supported  by  a  mildly  nutritious  diet ;  and  if  he  has  been 
accustomed  to  the  use  of  wine,  or  spirituous  liquors,  we  must 
(particularly  if  it  be  necessary  to  draw  much  blood  by  leeching) 
allow  him  a  certain  proportion  of  his  accustomed  stimulus. 

The  necessity  of  this  will  be  admitted  by  any  practitioner  who 
has  had  to  treat  the  embarrassing  complication  of  laryngitis, 
with  delirium  tremens  from  exhaustion,  or  deprivation  of  the  usual 
stimulus.  I  have  seen  a  case  of  this  kind,  and  can  hardly 
conceive  a  more  unfortunate  complication ;  for  the  loquacious- 
ness and  excitement  of  the  patient  is  peculiarly  hurtful  in  a 
disease  in  which  silence  and  repose  are  so  absolutely  necessary.* 

CHRONIC    DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

Under  this  denomination  are  included  a  number  of  chronic 
diseases,  affecting  the  innervation,  the  mucous  membrane,  and 

*  For  valuable  observations  on  the  topical  application  of  solution  of  nitrate  of 
silver  in  acute  laryngitis,  and  on  the  superior  advantage  of  laryngotomy,  as  compared 
with  tracheotomy,  in  cases  of  oedema  of  the  glottis,  I  may  refer  to  Dr.  J.  Staunus 
Hughes'  edition  of  Sir  H.  Marsh's  clinical  lectures,  and  more  especially  to  his  own 
observations  "  on  oedema  of  the  glottis,  its  clinical  history,  pathology,  and  treatment." 
Dublin,  1872.     (Ed.) 


206  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

the  more  deep  seated  tissues  of  the  larynx.  The  greatest 
variety  exists  in  the  characters,  consequences,  and  complications 
of  these  affections,  aud  I  shall  not  attempt  to  give  more  than  a 
sketch  of  the  subject. 

Like  the  preceding  form,  we  may  have  chronic  irritation  of 
the  larynx'as  an  idiopathic  disease,  or  depending  on  some  specific 
condition  of  the  system.  In  the  first  instance  we  see  it  arising 
from  the  ordinary  causes  of  internal  disease  in  an  uncontami- 
nated  constitution,  while  in  the  second  it  is  met  with  as  a  result 
of  syphilitic  or  scrofulous  disease,  and  often  combined  with 
chronic  affections  of  the  lung. 

The  effects  of  chronic  irritation  on  the  larynx  vary  from  a 
slight  vascularity  and  thickening  to  changes  so  extensive  as  to 
completely  obliterate  and  destroy  the  natural  appearance  of  the 
cavity. 

In  commenting  on  these  various  alterations  I  need  scarcely 
remark,  that  in  many  instances  several  of  them  may  occur  in 
the  same  case,  either  primarily  or  consecutively.  A  simple 
mucous  inflammation  may  in  one  patient  be  followed  by  changes 
very  different  from  those  in  another  ;  and  nothing  can  be  more 
various  than  the  combinations  of  morbid  alteration  which  may 
thus  arise. 

Slight  Thickening  and  Vascularity  of  the  Mucous  Mem- 
brane.— I  have  placed  this  condition  the  first  in  the  list,  as  it 
represents  the  simplest  form  of  the  disease.  Its  symptoms  are  in 
general  a  slight  degree  of  hoarseness,  both  of  voice  and  cough, 
some  soreness  on  pressure,  and  slight  dysphagia.  When  recent, 
and  occurring  in  a  healthy  constitution,  it  will  generally  yield  to 
a  mild  antiphlogistic  and  mercurial  treatment ;  but  when  chronic, 
or  when  it  arises  in  the  scrofulous  constitution,  whether  that  be 
remote  or  acquired,  it  becomes  a  most  serious  disease. 

But  this  disease  may  exist  in  the  trachea  without  producing 
even  the  symptoms  above-mentioned.  In  fact,  of  the  whole 
tube,  this  portion  seems  the  least  sensible,  a  fact  proved  by  the 
phenomena  of  disease,  and  also  by  those  of  foreign  bodies  in 
the  trachea.  I  have  seen  many  cases  of  a  chronic  inflammation 
of  the  trachea,  in  which  the  diagnosis  was  made  on  negative 
grounds,  there  being  no  evidence  of  laryngitis  on  the  one  hand, 
and  no  symptoms  or  signs  of  bronchitis  on  the  other. 

The   expectoration   was  mucous   or   muco-puriform ;  and   in 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  207 

several  cases  a  tenderness  of  the  tube  on  pressure  existed.  In 
these  cases  treatment  directed  to  the  trachea  had  the  best  effect. 
Louis,  however,  has  observed,  and  I  can  corroborate  the  as- 
sertion, that  where  the  irritation  is  acute,  heat  and  pain  are  felt 
along  the  course  of  the  tube.  His  observations  were  made  in 
cases  of  phthisis.* 

Purulent  Secretion  from  the  Surface. — We  consider  this 
affection  in  its  simplest  form,  occurring  independent  of  any 
structural  change,  except  perhaps  thickening  and  vascularity. 
But  under  these  circumstances  it  is  exceedingly  rare,  so  rare, 
indeed,  that  the  co-existence  of  laryngeal  symptoms  with  purulent 
expectoration  may  be  looked  on  as  almost  decisive  of  ulceration 
of  the  larynx,  or  what  is  more  common,  of  this  combined  with 
tuberculous  ulceration  of  the  lung.  In  certain  cases,  however, 
it  arises  from  the  opening  of  abscesses  into  the  larynx,  which 
have  followed  upon  disease  of  its  cartilages,  t 

Hypertrophy  and  Induration  of  the  Sub-mucous  Cel- 
lular Tissue. — This  interesting  form  of  disease  has  been  met 
with  in  cases,  of  chronic  irritation  of  the  larynx,  when  it 
materially  interferes  with  the  action  of  the  muscles  both  of 
phonation  and  respiration  :  when  it  affects  the  epiglottis,  the 
form  and  volume  of  the  organ  are  changed,  and  dysphagia 
produced.  J 

It  will  probably  be  found  that  this  form  of  disease  coincides 
with  ulcerative  affections  of  the  canal.  I  have  seen  it  most 
remarkably  in  a  case  where  ossification  and  caries  had  affected 
both  the  laryngeal  and  tracheal  cartilages,  and  the  hypertrophy 
extended  from  the  larynx  down  to  the  bifurcation. 

Lesions  of  the  Muscles  and  Ligaments  of  the  Larynx. — 
Of  the  pathological  anatomy  of  laryngeal  disease  this  is  the 
portion  which  has  been  most  neglected.  Andral  has  noticed  the 
atrophy  and  softening  of  the  muscles,  and  has  found  them  in- 
filtrated with  mucus,  pus,  or  tuberculous  matter.  Softening 
may  also  affect  the  ligaments,  and  thus  cause  important  alter- 
ations in  the  voice.  This  author  describes  the  softening  and 
degeneration  into  an  inorganic  pulp  of  the  thyro-arytenoid  liga- 
ments, which  ultimately  disappear,  leaving  the  muscles  bare. 

*  Louis,  Recherches,  Anat.  Path,  sur  la  Phthisie,  p.  385. 

f  Porter,  Op.  Cit.,  p.  134. 

X  Andral,  Precis  d'Anatomie  Pathologique,  torn,  ii.,  part  ii. 


208  DISEASES   OP    THE    LARYNX   AND    TRACHEA. 

On  this  subject  the  same  author  observes,  that  in  certain 
cases  of  complete  aphonia  no  lesion  whatever  could  be  discovered 
on  the  internal  surface  of  the  larynx,  but  that  on  examining  the 
fibres  of  the  thyro-arytenoid  muscle  he  found  them  atrophied  and 
separated  by  morbid  depositions  either  of  pus  or  tubercle.* 

But  the  action  of  disease  in  destroying  the  tension  of  the 
whole  fibro-elastic  expansion  of  the  internal  surface  of  the 
larynx,  must  have  a  powerful  effect  in  causing  alterations  of  the 
voice.  Professor  Lauth  has  well  remarked  that  this  tissue 
fulfils  a  special  function,  namely,  to  increase  the  sound  by  its 
vibrations  ;  so  that  in  the  larynx  there  are  two  sounding  boards, 
one  external,  cartilaginous,  elastic,  and  but  little  moveable,  the 
other,  internal,  but  thin,  supple,  moveable,  yet  elastic. t 

;In  connexion  with  this  subject,  the  following  case,  which  is 
recorded  by  Dr.  Graves,  possesses  the  greatest  interest.  I  shall 
give  it  in  his  own  words. 

"  A  young  gentleman  of  delicate  constitution,  and  who  is  now 
about  sixteen  years  of  age,  continued  to  enjoy  tolerably  good 
health  up  to  his  sixth  year.  When  about  six  years  of  age,  he 
went  to  bed  one  night  in  health,  and  without  any  unusual  symp- 
tom, but,  on  getting  up  in  the  morning,  it  was  observed  that  he 
had  lost  his  speech,  and  was  unable  to  articulate  a  single  word. 
His  family  became  alarmed,  and  sent  for  a  physician  immediately ; 
the  boy  got  some  internal  medicine  and  a  stimulant  gargle,  and 
recovered  his  speech  in  a  few  days,  without  the  occurrence  of 
any  symptom  of  laryngeal  inflammation  or  cerebral  disease. 
But  what  was  remarkable  in  the  case  was  this :  the  boy,  who 
up  to  this  period  had  spoken  well  and  distinctly,  now  got  a 
terrible  stutter.  This  resisted  all  kinds  of  treatment,  and  for 
ten  years  he  continued  to  stammer  in  the  most  distressing  way, 
and  was  so  annoyed  by  it  himself,  that  when  a  boy  he  used  to 
stamp  on  the  ground  with  vexation  whenever  he  failed  in  utter- 
ing what  he  wished  to  express.  In  the  month  of  May  last  he 
got  an  attack  of  chronic  laryngitis  of  a  scrofulous  character,  and 
evidently  the  precursor  of  phthisis.  Indeed  he  is  at  present 
labouring  under  phthisis  ;  Dr.  Stokes  and  I  have  examined  him, 
and  we  feel  convinced  that  tubercular  deposition  is  going  on  in 

*  Ibid.,  p.  494. 

f  Remarques  sur  la  Structure  du  Larynx,  &c,  Mem.  de  l'Academie  Royale  de  la 
Medecine. 


DISEASES    OF   THE    LARYNX   AND    TRACHEA.  209 

the  lungs.  But  what  is  most  curious  in  the  case  is  this — 
after  he  got  the  laryngitis,  a  very  peculiar  change  took  place ; 
the  laryngeal  inflammation  modified  the  tone  of  his  voice  so  as 
to  make  it  a  little  husky,  hut  the  stammering  has  completely 
ceased."* 

In  this  case  Dr.  Graves  supposes  that  the  alteration  in 
structure  or  vitality  of  the  mucous  memhrane  covering  the  deli- 
cate muscular  fibres,  so  modified  the  disposition  of  the  parts,  as 
to  render  them  incapable  of  undergoing  those  rapid  contractions 
necessary  to  produce  stammering,  by  closing  the  glottis  at  the 
moment  it  should  remain  open.  On  this  interesting  point 
further  observations  are  necessary.  It  is  obvious  that  morbid 
anatomy  and  pathology  have  not  been  sufficiently  applied  to  the 
subject  of  phonation.  The  field  is  open,  and  promises  a  rich 
harvest. 

Linear  Contraction  of  the  Ventricles. — In  this  condition,  which 
I  have  found  to  be  exceedingly  common  in  a  variety  of  chronic 
diseases  of  the  larynx,  the  ventricles  are  narrowed  in  the  trans- 
verse direction ;  so  that  in  the  more  advanced  stages  of  the 
disease  they  are  represented  merely  by  a  depressed  line.  This 
seems  to  arise  from  the  thickening  and  approximation  of  the 
edges  of  the  cavities ;  and  it  is  not  improbable  that  this  ap- 
proximation may  be  in  part  owing  to  a  paralyzed  condition 
of  these  muscular  fibres,  which  act  in  dilating  the  ventricles. 
A  condition  similar  to  that  of  which  I  have  already  spoken, 
as  affecting  the  circular  muscles  of  Reissessen,  probably  occurs, 
also  in  the  larynx,  and  by  the  paralysis  of  those  portions  of 
the  thyro-arytenoid  muscles,  which  dilate  the  ventricles,  their 
cavities  become  gradually  obliterated. 

Morbid  States  of  the  Epiglottis. — The  simplest  form  of  disease 
of  the  epiglottis  is  its  enlargement  and  thickening.  We  have 
seen  what  an  important  share  this  condition  has  in  the 
phenomena  of  the  acute  laryngitis  of  the  adult;  yet  in  the  more 
chronic  forms,  although  the  lesion  occurs  to  a  certain  degree,  it 
is  more  an  hypertrophy  of  the  epiglottis  than  a  mere  oedema,  and 
I  have  never  known  it  to  produce  such  symptoms  as  dysphagia 
or  stridulous  breathing,  although  Andral  states  that  it  may 
produce  the  first  of  these  symptoms.     In  the  acute  laryngitis  of 

*  London  Medical  and  Surgical  Journal,  No.  174,  vol.  vii.      Clinical  Lectures 
delivered  at  the  Meath  Hospital. 

P 


210  DISEASES    OF    THE    LAKYNX   AND    TRACHEA. 

the  adult  a  sudden  tumefaction  occurs,  which  may  subside  with 
equal  rapidity  ;#  but  in  the  chronic  disease  this  increase  of  thick- 
ness goes  on  slowly,  and  not  to  the  same  degree  as  in  the  acute 
form. 

Strongly  contrasted  with  this  lesion  is  another,  which  may  be 
described  as  its  opposite  ;  I  allude  to  a  condition  which  I  propose 
to  call  the  leaf-like  expansion  of  the  epiglottis.  This  has  not 
been  described  by  any  author,  but  a  most  remarkable  preparation 
of  the  disease  exists  in  the  Museum  of  the  School  of  Anatomy 
and  Medicine  in  Park  Street.  The  epiglottis  is  thinned,  and 
singularly  elongated,  and  its  form  so  altered,  as  to  represent  the 
shape  of  a  battledore,  the  narrow  extremity  being  next  the 
glottis.  In  the  preparation  alluded  to,  it  is  fully  two  inches  in 
length,  and  coincides  with  double  perforating  ulcers  of  the  ven- 
tricles. Nothing  is  known  as  to  the  history  of  the  case,  but 
I  have  seen  more  or  less  of  a  similar  alteration  in  other  cases 
of  laryngeal  disease. 

We  have  next  to  consider  the  contraction  and  shrivelling  of  the 
epiglottis,  and  its  ulceration.  The  first  of  these  conditions  is  by 
no  means  uncommon,  and  the  organ  assumes  a  crescentic  shape, 
with  the  concavity  looking  upwards  ;  I  have  never  seen  it  without 
ulceration,  and  other  organic  disease  of  the  larynx.  We  are  still, 
as  in  the  preceding  case,  ignorant  of  the  symptoms  which  this 
condition  would  produce. 

The  laryngeal  surface  of  the  epiglottis  is  very  liable  to 
nlcerate  ;  but  as  a  simple  disease  this  form  is  seldom  seen. 
Combined  in  most  cases  with  organic  disease  of  the  larynx  and 
lung,  it  becomes  difficult  to  study  its  symptoms  separately,  and 
indeed  its  constant  complication  with  disease  of  the  rima  seems 
to  preclude  such  an  analysis. 

These  ulcers  are  generally  small,  irregularly  circular,  and 
with  little  depth,  giving  a  cribriform  appearance  to  the  epi- 
glottis. 

In  a  remai-kable  case,  which  fell  under  my  observation,  the 
patient,  an  adult  man,  suffered  for  a  great  length  of  time  under 
the  worst  form  of  tussis  ferina.  No  disease  could  be  discovered 
in  the  fauces,  the  voice  was  but  little  affected,  and  there  was  no 

*  Thus  in  a  patient  operated  on  in  the  Heath  Hospital,  the  tumefaction  of  the 
epiglottis  subsided  so  rapidly,  that  within  a  few  hours  after  the  operation,  respiration 
could  bs  performed  through  the  glottis,  and  the  enormously  swollen  epiglottis  was  no 
longer  visible. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  211 

stridor,  except  during  the  paroxysm.  The  disease  resisted  every 
treatment,  and  after  continuing  for  nearly  a  year,  the  patient 
sunk  from  an  attack  of  dysentery.  On  dissection,  we  found 
numerous  small  yellow  ulcers,  with  raised  and  indurated  edges, 
affecting  the  whole  of  the  laryngeal  face  of  the  epiglottis. 
There  was  no  other  perceptible  disease  of  the  respiratory 
system. 

In  M.  Louis'  celebrated  work  on  the  Pathology  of  Phthisis, 
we  find  the  subject  of  ulceration  of  the  epiglottis  handled  with 
that  spirit  of  philosophical  research,  which  so  distinguishes  the 
learned  author.  In  all  his  cases  the  patients  laboured  under 
tuberculous  disease  of  the  lungs  ;  but  as  some  of  them  presented 
no  perceptible  lesion  of  the  larynx  or  trachea,  the  symptoms 
having  reference  to  disease  of  the  epiglottis  may  be  studied  with 
advantage.     I  shall  give  the  general  results  in  his  own  words. 

"  Of  eighteen  cases,  which  fell  under  our  observation,  there 
were  six  in  which  the  larynx  and  trachea  were  free  from  disease. 
Among  these  four  of  the  patients  complained  of  pain,  more  or 
less  violent,  occurring  in  the  superior  part  of  the  thyroid 
cartilage,  or  between  this  cartilage  and  the  os  hyoides.  This 
pain  was  compared  to  the  sensation  of  a  sore,  to  a  pricking  feel- 
ing, or  a  heat  in  the  part ;  and  in  some  cases  it  had  lasted  for 
a  month  or  two,  while  in  others  it  occurred  but  a  few  days 
before  death.  In  these  cases,  although  the  pharynx  was  healthy, 
there  was  difficult  deglutition,  the  drinks  sometimes  even  coming 
through  the  nose." 

"  Of  the  twelve  patients,  who  had  at  once  ulcerations  in  the 
epiglottis,  larynx,  and  trachea,  there  was  dysphagia,  and  pain 
in  some  cases,  and  in  one  the  drinks  were  partly  returned  through 
the  nose." 

"  Thus  we  are  led  to  conclude,  that  the  symptoms  of  ulcera- 
tions of  the  epiglottis  are  a  fixed  pain  either  in  the  superior 
portion  of,  or  immediately  above,  the  thyroid  cartilage,  difficulty 
of  deglutition,  and  the  return  of  drinks  through  the  nostrils."* 

But  the  epiglottis  may  be  entirely  destroyed  by  ulceration, 
with  or  without  destruction  of  the  root  of  the  tongue.  Of  this 
disease  there  are  many  curious  examples  in  the  Park  Street 
Museum.     In  some  of  these  the  disease  was  cancerous. 

Ulcerations    of   the    Larynx. — Considered     merely     in     an 

*  Recherches  Anatomico-Pathologiques  sur  la  Phthisie.    Paris,  1825,  p.  255. 

p  2 


212  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

anatomical  point  of  view,  it  may  be  seen  that  the  greatest  variety- 
exists  in  the  size,  number,  seat,  and  complications  of  these 
ulcerations.  In  fact,  the  disease  may  vary  from  a  slight  abrasion 
or  minute  follicular  ulceration,  to  such  a  destruction  and  de- 
facement of  the  cavity,  as  that  its  natural  appearance  is  altogether 
destroyed.  The  disease  may  further  vary  in  its  exciting  cause, 
as  in  some  it  is  traceable  to  a  syphilitic  origin ;  in  others,  to  a 
scrofulous  ;  while  in  a  third,  it  results  from  inflammation  in  an 
apparently  uncontaminated  constitution. 

I  shall  not  enter  at  any  length  into  the  history  of  laryngeal 
ulceration,  but  shall  merely  dwell  on  some  points  not  generally 
understood. 

One  of  the  simplest  forms,  and  which  may  be  an  idiopathic 
affection,  is  the  existence  of  small  ulcers  immediately  below 
the  rima,  and  not  extending  far  into  the  cavity.  This  disease 
is  accompanied  by  a  secretion  of  lymph,  and  is  a  chronic  and 
apyrexial  affection  ;  and  as  its  principal  symptom  is  a  violent  and 
apparently  spasmodic  cough,  it  is  often  mistaken  for  pertussis, 
or  other  nervous  affections  of  the  larynx. 

We  are  not  in  possession  of  facts  to  enable  us  to  state 
whether  there  exists  any  fixed  anatomical  difference,  between 
the  specific  ulcerations  of  the  larynx.  It  is  a  difficult  question, 
as  many  of  the  cases  have  occurred  in  constitutions  in  which  the 
destructive  influences  of  scrofula,  syphilis,  and  mercury  have 
been  united.  In  the  preparations  of  the  Park  Street  Museum, 
however,  those  which  seem  to  have  been  simply  syphilitic, 
present  spreading  ulcers  of  the  mucous  membrane,  or  a  cribri- 
form condition  ;  but  in  both  instances  combined  with  watery 
excrescences,  which  so  far  seem  peculiar  to  the  syphilitic 
disease. 

In  the  phthisical  ulceration  of  the  larynx  I  have  never  seen 
these  watery  tumours ;  here  the  common  form  is  a  deep  ulcera- 
tion occupying  each  ventricle,  or  a  number  of  minute  super- 
ficial ulcerations  affecting  the  ventricles  and  cordse  vocales.  Of 
these  forms,  however,  the  first,  in  this  country  at  least,  is  by 
far  the  most  frequent.  Indeed  in  cases  of  phthisis  pulmonalis, 
when  in  the  advanced  stages  the  voice  becomes  hoarse,  and 
the  breathing  and  cough  laryngeal,  we  may  diagnosticate  this 
ventricular  ulceration  with  almost  complete  certainty.  In  one 
case,  however,  that  of  a  deaf  and  dumb  man,  the  ulcers  did  not 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  213 

affect  the  ventricles,  but  occurred  immediately  below  the  rima. 
To  this  subject  I  shall  presently  return  when  describing  the 
physical  signs  of  laryngeal  disease  ;  and  shall  merely  mention 
here,  that  the  symptoms  vary  from  a  slight  hoarseness  to  com- 
plete aphonia.  There  is  seldom  a  great  degree  of  stridor,  but 
pain,  soreness,  and  dysphagia  are  commonly  observed.  Hectic 
fever  and  purulent  expectoration  are  present  in  most  cases,  but 
their  source,  in  the  great  majority  of  instances,  is  the  tubercu- 
lous and  ulcerated  state  of  the  lung  itself.  Indeed  what  is 
called  phthisis  laryngea  seems  to  be,  in  almost  all  cases, 
phthisis  pulmonalis ;  the  affection  of  the  windpipe  being,  in  a 
few  cases  primary,  but  in  a  far  greater  proportion  secondary  to 
tubercle  of  the  lung.  How  much  of  suffering  to  the  patient, 
and  disgrace  to  the  physician,  would  be  obviated,  were  the  truth 
of  this  more  generally  recognized. 

Ulcerations  of  the  Trachea. — These  have  been  but  little 
studied  as  yet.  It  may  be  remarked,  however,  that  though  much 
less  frequent  than  the  two  last  varieties,  they  are  often  met 
with,  and  occur  with  or  without  disease  of  the  cartilages.  Louis 
states  that  in  phthisis  the  site  of  the  ulcerations  is  commonly 
along  the  musculo-membranous  portion  of  the  tube,  a  fact  which 
he  seeks  to  explain  by  referring  to  the  irritating  action  of  the 
expectorated  matter.  Without  wishing  to  defend  or  adopt  this 
doctrine,  I  may  mention  a  fact  strongly  corroborative  of  it :  I 
have  in  numerous  cases,  where  a  chronic  phthisical  abscess 
existed  in  the  lung,  observed  that  ulcerations  were  found  towards 
the  bifurcation  of  the  trachea ;  these  could  be  traced  to  the 
first  division  of  the  bronchus,  when  they  became  only  perceptible 
in  one  tube,  which  in  all  cases,  ivas  that  leading  to  the 
excavation.  In  other  instances,  where  one  lung  was  full  of 
ulcerous  cavities  of  some  standing,  while  the  other  only  con- 
tained crude,  or  recently  softened  tubercle,  I  have  found 
ulcerations  in  the  trachea,  evidently  extending  upwards  from 
the  bronchus  of  the  excavated  lung.  These  ulcerations  were 
numerous,  while  in  the  opposite  tube,  not  even  an  abrasion 
could  be  found. 

The  cure  of  extensive  ulceration  of  the  trachea  by  cicatri- 
zation, has  been  observed  by  Mr.  Porter.  The  patient  recovered 
under  the  use  of  mercury,  and  after  enjoying  good  health,  for 
upwards  of  a  year,  died  of  another  disease.     On  dissection,  an 


214  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

extensive  but  perfect  cicatrix  was  found  in  the  upper  portion  of 
the  trachea.* 

On  the  remaining  diseases  of  the  larynx  and  trachea,  and  in 
particular  those  affecting  the  cartilages,  I  shall  not  offer  any 
observations,  feeling  that  in  so  doing  I  could  only  repeat  what 
has  been  already  said  by  others.  On  this  subject  I  would  refer 
the  reader  to  the  works  of  Porter,  Andral,  and  Cruvelhier,  but  in 
particular  to  the  first.  The  diseases  of  these  important  portions 
of  the  respiratory  apparatus  were  but  little  known  previous  to  its 
appearance,  and  to  the  author  is  due  the  merit  of  first  describing 
the  mortification  of  the  laryngeal  cartilages,  a  disease  even  still 
by  no  means  sufficiently  recognized  by  pathologists. 

To  enter  into  a  description  of  the  symptoms  observed  in  these 
various  cases  of  disease  would  far  outstrip  the  limits  of  this  work. 
It  is  sufficient  to  observe,  that  although  possessing  some  general 
similarity,  they  vary  in  many  particulars.  The  symptoms  in 
general  consist  in  various  alterations  of  the  voice  ;  cough  of  a  dis- 
tressing, loud,  and  peculiar  character,  with  or  without  expecto- 
ration, which  may  be  mucous  or  purulent ;  and  signs  of  mechanical 
obstruction  about  the  glottis.  Of  this  last  symptom  it  may  be 
remarked,  that  it  is  exceedingly  various.  Thus,  in  some  cases, 
the  stridulous  breathing  goes  on  increasing  to  suffocation,  while 
in  others,  even  until  the  fatal  termination,  it  is  so  slight  as  to  be 
scarcely  perceptible.  In  one  point  of  view,  the  existence  or  ab- 
sence of  this  symptom  has  a  great  practical  importance,  namely, 
in  determining  the  condition  of  the  lung.  We  shall  find  that 
much  of  the  facility  of  this  diagnosis  turns  on  the  amount  of  the 
mechanical  obstruction  to  respiration  ;  that  where  it  is  prominent 
a  stethoscopic  examination  of  the  lung  becomes  next  to  impossible, 
while  it  is  not  prevented  by  extensive  laryngeal  disease,  so  long 
as  the  entrance  of  air  is  not  materially  obstructed. 

I  shall  first  examine  the  physical  signs  of  chronic  laryngitis, 
and  then  point  out  the  mode  of  diagnosis,  when  the  question  of 
pulmonary  complication  is  to  be  determined. 

Physical  Signs  of  Chronic  Laryngitis. — Although  this  part 
of  physical  diagnosis  has  been  neglected,  yet  we  may  derive 
advantage  from  its  investigation;    for  I  have  seen,  in  cases  of 

*  Of  these  ulcerations  of  the  epiglottis,  larynx,  and  trachea,  M.  Louis  observes,  that 
they  are  twice  as  frequent  in  men  as  in  women  ;  and  that  facts  lead  to  the  conclusion, 
that  they  are  almost  peculiar  to  phthisis. — Louis,  Op.  cit. 


DISEASES    OF    THE    LAEYNX   AND    TRACHEA.  215 

laryngeal  disease,  enough  of  variation,  both  in  the  passive  and 
active  signs,  to  persuade  me  of  the  importance  of  the  subject. 

The  sound  on  percussion  of  the  healthy  larynx,  has  a  peculiar 
hollow  character,  which  does  not  convey  that  idea  of  depth  or 
elasticity  given  by  the  pulmonary  sound.  The  best  mode  of  ex- 
amining it  is  to  throw  the  head  back,  so  as  to  stretch  the  neck, 
and  the  head  being  then  supported  by  an  assistant,  we  may  use 
mediate  percussion  over  the  thyroid  and  cricoid  cartilages.  A 
good  mode  of  percussion  is  to  place  the  back  of  the  nail  of  a 
finger  on  the  pulp  of  the  thumb,  and  to  make  a  fillip  on  the  part. 

The  laryngeal  sound  is  loud  in  proportion  to  the  development 
of  the  larynx;  and  it  may  be  observed  to  vary  in  the  same 
individual,  being  loudest  when,  from  the  raising  of  the  soft  palate, 
the  communication  between  the  glottis  and  cavity  of  the  mouth 
is  free.*  The  point  where  it  is  loudest  is  exactly  that  selected 
for  the  operation  of  laryngotomy,  namely,  the  space  between  the 
cricoid  and  thyroid  cartilages. 

I  have  not  made  sufficient  observations  to  announce  the 
alterations  in  this  sound  produced  by  disease  ;  but  I  have  seen 
enough  to  conclude  that  disease  modifies  the  sound.  Thus  in  a 
patient,  whose  thyroid  cartilage  was  torn  by  the  bursting  of  a  shell, 
the  sound,  on  percussion  of  the  larynx,  is  perfectly  dull.  Yet 
when  a  fistula  which  exists  in  the  trachea,  is  closed,  he  breathes 
through  the  glottis  with  perfect  ease,  and  his  voice  is  unaffected. 
On  the  other  hand,  we  may  find  that  such  affections  as  do  not. 
diminish  the  capacity  of  the  larynx,  may  coexist  with  the  natural 
sound  on  percussion,  as  we  find  in  the  ulceration  of  the  ventricles , 
so  common  in  phthisis. 

The  subject  is  one  open  for  investigation,  and  I  shall  merely 
remark,  that  in  the  few  observations  which  I  have  made,  the 
sound  did  not  seem  lessened  in  old  persons,  nor  was  it  diminished 
by  the  existence  of  a  considerable  oedema  of  the  neck. 

The  active  signs  are  those  of  respiration  and  voice ;  and,  as  in 
most  cases,  both  are  affected,  we  must  study  their  jmenomena 
carefully.  I  have  already  alluded  to  the  division  of  laryngeal 
diseases  into  those  with  and  those  without  notable  mechanical 
obstruction.     Few  cases,  indeed,  occur  without  some  degree  of 

*  See  a  Paper,  by  Professor  Jacob,  on  the  structure  of  the  mammary  gland  in  the 
Cetacea,  with  Observations  on  the  mechanism  of  the  month  and  soft  palate,  as 
applied  by  the  young  animal  in  sucking.  Dublin  Med.  and  Chem.  Journal,  No.  xxiii., 
1835. 


21G  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

stridor,  which  is  sometimes  only  perceptible  on  a  forced  inspira- 
tion ;  but  there  is  an  extensive  class  in  which  the  patient  hardly 
suffers  from  laryngeal  obstruction,  and  in  which  the  stridulous 
breathing  is  barely  perceptible.  In  these  cases  death  takes 
place,  not  from  laryngeal,  but  from  pulmonary  disease. 

On  the  other  hand,  great  mechanical  obstruction,  and  its 
consequent  distressing  stridor,  are  more  allied  to  laryngeal 
disease,  without  pulmonary  complication.  In  such  cases  the 
ear  at  once  points  out  that  the  obstruction  is  in  the  upper  part 
of  the  windpipe,  very  different  indeed  from  another  case  of  stridu- 
lous breathing,  where,  as  in  the  pressure  of  an  aneurismal  tumour 
on  the  trachea,  the  sound  proceeds  from  its  inferior  extremity. 

The  stethoscopic  signs  are  the  altered  character  of  the  laryn- 
geal sounds  of  inspiration  and  expiration,  and  the  existence  of  a 
rale  in  the  larynx.  With  respect  to  the  first,  we  find  that  the 
sound  of  respiration  loses  its  softness  and  smoothness,  and 
becomes  harsh,  conveying  the  idea  of  a  roughened  and  rigid 
state  of  the  laryngeal  surface.  This  is  perceptible  even  when  no 
stridulous  breathing  exists. 

In  noticing  the  existence  of  a  rale  in  the  larynx  I  must 
observe  that  I  have  examined  the  phenomenon  in  but  a  limited 
number  of  cases.  It  does  not  occur  in  all  instances,  but  when 
present  is  extremely  characteristic.  I  have  found  it  most  evi- 
dent immediately  above  the  alae  of  the  thyroid  cartilage,  where  it 
resembles  the  rapid  action  of  a  small  valve,  combined  with  a  deep 
thrumming  sound.  It  is  quite  peculiar,  it  disappears  as  we 
descend  to  the  bronchial  tubes,  and  may  even  exist  on  one  side 
of  the  larynx  without  being  perceptible  on  the  other,  as  if  it  there 
corresponded  to  a  circumscribed  ulceration. 

When  the  obstruction,  however,  is  considerable  the  loud  pro- 
longed respiration  sufficiently  points  out  the  disease.  Under 
these  circumstances  the  next  most  important  result  of  ausculta- 
tion is  the  great  feebleness  of  the  pulmonary  expansion,  as  com- 
pared with  the  violence  of  the  inspiratory  efforts.  The  impor- 
tance of  this  fact,  and  the  difficulties  which  it  throws  in  the  way 
of  physical  diagnosis,  were  first  noticed  in  a  Report  of  the  Meath 
Hospital  by  Dr.  Graves  and  myself,*  in  which  we  pointed  out 
how  a  laryngeal  obstruction  rendered  the  detection  of  pulmonary 

*  Dub.  Hos.  Reports.  Clinical  Report  of  Cases  in  the  Medical  Wards  of  the  Meath 
Hospital,  by  R.  J.  Graves,  M.D.,  and  W.  Stokes,  M.D.,  vol.  v. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  217 

disease  a  matter  of  great  difficulty.  These  observations,  however,  I 
apply  only  to  the  active  auscultatory  signs ;  and  it  is  fortunate, 
indeed,  that  the  above  cause  does  not  interfere  with  percussion. 

In  laryngeal  disease  the  vesicular  murmur  becomes  feeble  in 
proportion  to  the  obstruction.  In  severe  cases  it  can  hardly  be 
perceived ;  and  this  feebleness,  or  almost  complete  absence  of 
vesicular  murmur,  is  observed  over  the  ivhole  chest.  On  the  latter 
point  I  would  particularly  dwell,  as  it  forms  the  ground  of  a 
diagnosis,  which  I  first  pointed  out  between  laryngeal  disease  and 
the  pressure  of  aneurismal,  or  other  tumours  on  the  trachea.* 

This  diagnosis  is  founded  on  the  observation  of  the  case, 
previous  to  the  appearance  of  stridulous  breathing.  In  aneurisms 
of  the  aorta  it  often,  though  not  always,  happens,  that  the  com- 
pression is  first  exercised  on  one  of  the  bronchi,  so  that  an 
inequality  of  respiration  is  produced,  the  murmur  being  feeble  in 
one  lung,  and  of  increased  intensity  in  the  other.  As  the  disease 
advances,  however,  the  pressure  is  exercised  on  the  trachea,  and 
stridulous  breathing  produced. 

Now  in  this  primary  inequality  of  respiration  we  have  a  diag- 
nosis between  the  two  affections,  for  nothing  of  the  kind  can  occur 
when  the  obstruction  is  in  the  windpipe  from  the  first.  In  such 
a  case,  as  the  air  enters  both  lungs  with  equal  difficulty,  the 
vesicular  murmur  is  equally  feeble. 

It  would  appear  that  the  intensity  of  the  vesicular  sound  is 
directly  as  the  force  by  which  the  cell  is  dilated.  M.  Beau  has 
endeavoured  to  prove,  that  the  respiratory  murmur  of  Laennec  is 
not  produced  by  the  expansion  of  cells,  but  by  the  air  striking 
against  the  fauces  and  pharynx,  thus  causing  vibrations  which 
are  communicated  downwards  through  the  larynx  and  trachea. 
He  holds  that  the  mere  expansion  of  the  cells  produces  no  sound, 
and  supports  this  doctrine  by  adducing  the  fact,  that  where  the 
individual  breathes  so  as  to  inflate  the  lungs  without  producing 
the  guttural  sound,  the  vesicular  murmur  ceases  to  be  heard.  He 
draws  an  analogy  between  the  guttural  sound  and  its  consequent 
vesicular  murmur ;  and  the  sound  of  the  voice,  and  consequent 
bronchophonia,  both,  according  to  him,  being  produced  by  the  vibra- 
tions in  the  tubes  of  sounds  which  are  transmitted  downwards.f 

*  Researches  on  the  Diagnosis  and  Pathology  of  Aneurisms  of  the  Great  Vessels. 
Dub.  Med.  and  Chem.  Journal,  1834. 

t  Beau,  Archives  Generales  de  Medicine,  Recherches  sur  la  Cause  de3  Bruits 
Resphatoires,  tome  v.,  Aouf-,  1834. 


218  DISEASES    OF    THE    LARYNX   AND   TRACHEA. 

I  have  carefully  repeated  the  experiments  of  M.  Beau,  and  feel 
convinced  that  his  conclusions  are  erroneous,  because  I  have 
found  that  in  all  cases  in  which  his  respiration  silencieux  was 
performed,  I  could  plainly  hear  a  murmur  of  expansion  in  the 
lung.  It  is  certainly  not  so  loud  as  natural ;  but  the  reason 
of  this  is  manifestly  the  fact,  that  to  produce  silent  respiration 
we  must  inflate  the  chest  more  gently,  and  of  course  with  less 
impulse  on  the  cells  or  minute  tubes.  When  we  come  to  con- 
sider the  phenomena  of  puerile  and  bronchial  respiration  in  local 
disease  of  the  lung,  we  shall  find  that  many  circumstances  totally 
disprove  this  doctrine. 

I  shall  here  allude  to  a  single  fact,  which,  in  itself,  is  sufficient 
to  overturn  the  theory  ;  it  is  that  we  can  hear  a  natural  respira- 
tory murmur  in  patients  who  do  not  breathe  through  the.  mouth 
or  nostrils.  Of  this  we  can  easily  satisfy  ourselves  by  examining 
a  person  who  has  been  operated  on  for  laryngeal  obstruction,  and 
who  breathes  through  a  fistula  in  the  trachea.  I  have  now 
examined  eight  of  such  cases,  and  found  that  in  all  the  res- 
piratory murmur  could  be  heard  with  ease.  In  one  instance, 
indeed,  where  great  obstruction  existed  previous  to  the  operation, 
I  found  that  for  a  considerable  time  after  the  opening  of  the 
trachea  the  murmur  continued  intensely  puerile.* 

Examination  of  the  Lung  in  Cases  of  Chronic  Laryn- 
geal Disease. — It  need  hardly  be  observed,  that  the  first  step  in 

*  I  may  here  subjoin  the  stethoscopic  examination  of  a  case  of  permanent  fistula  in 
the  trachea  without  mechanical  obstruction  in  the  larynx. 

P.  K,  aged  30,  while  engaged  in  the  Burmese  War  under  Sir.  A.  Campbell,  was 
struck  by  the  explosion  of  a  canister  shot,  which  tore  the  thyroid  cartilage,  and 
formed  a  wound  six  inches  long.  There  was  great  haemorrhage,  followed  by  delirium. 
The  wound  was  dressed  by  suture,  and  healed,  with  the  exception  of  a  fistula 
immediately  below  the  situation  of  the  cricoid  cartilage. 

At  present  the  region  of  the  larynx  is  hollow,  no  trace  of  pomum  Adami  being 
visible.  The  sound  is  dull  on  percussion.  Immediately  below  the  cricoid  region  there 
is  a  fistula  capable  of  admitting  a  goose-quill,  round  which  the  skin  is  puckered. 
This  communicates  directly  with  the  trachea,  but  occasionally  small  quantities  of 
drink  and  soft  food  pass  through  it.  There  is  no  dysphagia.  The  patient  wears  a 
soft  pad  over  it,  and  is  thus  saved  from  all  inconvenience. 

When  the  fistula  is  closed  the  voice  is  natural  and  powerful,  nor  is  there  any 
stridor ;  but  when  it  is  open  the  voice  is  scarcely  articulate,  and  is  combined  with  a 
whistling  sound.  On  closing  the  mouth  and  nostrils  he  can  breathe  without 
difficulty  through  the  fistula,  yet  the  effort,  after  some  time,  fatigues  him. 

There  are  no  thoracic  symptoms,  and  when  the  fistula  is  closed  the  vesicular 
murmur  is  heard  with  its  natural  character.  When  it  is  open  it  obtains  in  the  upper 
part  of  the  chest  a  slightly  tracheal  character.  Posteriorly  and  superiorly  the  voice 
resounds  strongly ;  and  when  the  fistula  is  open  its  vibrations  are  preceded  by  a 
hissing  sound. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  219 

forming  our  prognosis  and  in  determining  our  treatment  of  laryn- 
geal disease,  will  be  to  ascertain  the  condition  of  the  lung ;  and 
there  are  few  situations  more  embarrassing  than  to  be  called  on  to 
declare  how  far  the  lung  is  diseased  when  a  chronic  affection  of 
the  larynx  is  present.  It  is  true  that  where  the  mechanical 
obstruction  is  but  slight,  we  may  use  the  stethoscope  with 
facility  and  exactness ;  but  even  in  cases  where  the  lung  is  fully 
and  freely  inflated  it  will  be  occasionally  next  to  impossible  to 
determine  (even  after  several  examinations)  whether  the  symptoms 
proceed  from  laryngeal  disease  alone,  or  from  its  combination 
with  an  affection  of  the  lung.  This  I  know  from  an  extensive 
experience,  nor  have  I  been  able  to  satisfy  myself  as  to  its  cause. 
The  first  element  in  deciding  this  important  question  is  the  fact 
of  the  frequent  complication  of  laryngeal  and  pulmonary  disease. 
Let  it  be  borne  in  mind  from  the  outset,  that  of  the  cases  Avith- 
out,  and  those  with,  disease  of  the  lung,  the  latter  are  by  far 
the  most  numerous ;  and  that  even  where  the  larynx  has  been 
first  engaged,  that  the  lung  may  become  secondarily  affected, 
and  that  where  both  diseases  exist  they  mutually  obscure  each 
other. 

If  there  be  one  form  of  disease  more  than  another  to  which 
these  observations  apply,  it  is  that  termed  phthisis  laryngea. 
I  agree  with  Andral  and  Louis  as  to  the  fact  of  the  almost  con- 
stant complication  of  this  disease  with  pulmonary  tubercle  ;  and 
I  can  avow,  that  after  ten  years  of  hospital  and  private  practice, 
I  never  saw  a  case  presenting  the  symptoms  of  laryngeal  cough, 
purulent,  or  muco-purulent  expectoration,  semi-stridulous  breath- 
ing, hoarseness  or  aphonia,  hectic  and  emaciation,  in  which  the 
patient  did  not  die  with  cavities  in  his  lung.  In  some  the 
laryngeal  affection  seemed  to  be  primary,  but  in  the  great 
majority,  symptoms  of  pulmonary  disease  existed  previous  to  its 
appearance. 

It  is  true  that  in  the  abscess  and  mortification  of  the  cartilages 
we  may  have  symptoms  of  laryngeal  cough,  purulent  expec- 
toration, and  even  hectic ;  but  these  cases  differ  in  their  symp- 
toms, as  well  as  their  pathological  anatomy,  from  the  ordinary 
phthisis  laryngea,  particularly  in  the  prominence  and  rapidity  of 
the  purely  laryngeal  symptoms. 

The  first  step  in  the  investigation  will  be  to  accurately  examine 
into  the  history  of  the  case,  and   in  particular  to    determine 


220  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

whether  the  laryngeal  affection  was  primary,  or  supervened  on  an 
already  existing  disease  of  the  lung.     We  must  examine  what 
were  the  very  first  symptoms,  and  whether  they  were  referrible  to 
the  larynx  or  lung ;  we  must  inquire  into  the  past  and  present 
state  of  the  fauces,  and  also  whether  a  syphilitic  taint  exists.   Now 
should  it  be  found  that  the  first  symptoms  were  those  of  a  larnygeal 
character,  that  the  voice  had  been  altered  from  the  outset  of  the 
disease,  or  that  a  syphilitic  taint  did  really  exist,  we  have  a  good 
probability,  not  that  the  lungs  at  the  time  of  examination  are  free, 
but  that  the  first  morbid  action  was  exercised  on  the  larynx.   But 
if,  on  the  other  hand,  we  find  that  previous  to  the  occurrence  of 
any  hoarseness  or  stridor,  or  dysphagia,  there  has  been  cough 
without  the  laryngeal  character,  particularly  if  it  was  at  first  dry, 
and  afterwards  followed  by  expectoration  ;  if  hectic  has  existed, 
although  the  expectoration  continued  mucous  ;  if  there  have  been 
hemoptysis,  pain  in  the  chest  or  shoulders  ;  and  lastly,  if  the 
patient  has  emaciated  previous  to  the  setting  in  of  the  laryngeal 
symptoms,  we  may  be  almost  certain  that  tubercle  exists,  and 
that  the  case,  so  commonly  called  laryngeal,  is  in  reality  pul- 
monary phthisis.     And  if  it  appears  that  the   patient    is  of  a 
strumous    habit,    or    has    already   lost    brothers  or  sisters   by 
tubercle,    we    may   form    our    diagnosis    with     a    melancholy 
certainty,  even  though  at  the  time  we  can  detect  no  certain  phy- 
sical sign  of  pulmonary  tubercle* 

But  in  many  cases  a  physical  examination  of  the  chest  decides 
the  question.  I  shall  first  speak  of  the  active  auscultatory  signs. 
I  have  already  stated,  that  with  respect  to  the  case  of 
diagnosis,  we  may  divide  laryngeal  diseases  into  two  classes, 
namely,  those  with  and  those  without  severe  stridulous  breathing. 
In  the  first  of  these  all  the  phenomena  of  respiration  are 
obscured,  less  from  the  loudness  of  the  stridulous  sound  than 
from  the  feebleness  with  which  the  air  penetrates  the  lung  :  so 
great  is  this  in  some  cases  that  we  can  hear  almost  nothing  of 
the  vesicular  murmur,  and  so  cannot  judge  of  its  different  local 

*  It  may  be  observed  here  that  purulent  expectoration,  in  any  quantity,  is  seldom 
seen  from  simple  disease  of  the  mucous  membrane  of  the  larynx.  From  its  small 
dimensions  and  constituent  tissues,  its  secretions,  both  in  health  and  disease,  are 
scanty  ;  and  it  may  be  stated,  that  in  cases  of  laryngeal  disease,  with  copious  puri- 
form  discharges,  there  is  either  an  abscess  in  the  neighbourhood,  and  communicating 
with  the  larynx,  or  what  is  much  more  frequently  the  case,  suppurating  tuberculous 
cavities  in  the  lung. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  221 

intensities,  and  we  lose  all  the  sounds  of  mucus  in  the  tubes, 
and  the  signs  of  anfractuosities,  or  larger  excavations.  The 
voice,  too,  being  injured,  we  cannot  avail  ourselves  of  the  vocal 
phenomena  with  satisfaction,  and  we  lay  aside  the  stethoscope  in 
despair. 

But  it  is  fortunate  that  in  the  obstruction  of  the  larynx  there  is 
nothing  to  interfere  with  the  use  of  percussion.  In  this  observa- 
tion we  are  first  accurately  to  compare  the  sound  given  by  one 
clavicle  with  the  other,  and  in  the  same  way  the  an tero- superior 
regions,  the  spines  of  the  scapulae,  the  axillre,  and  the  interscapular 
regions.  This  comparison  of  corresponding  opposite  portions 
having  been  made,  we  next  compare  the  upper  with  the  lower 
parts  of  the  chest,  and  the  observation  is  complete.  Now,  if  co- 
existent with  the  symptoms  of  laryngeal  cough,  muco-purulent 
expectoration,  semi-stridulous  breathing,  and  hectic,  we  find  a 
notable  difference  between  the  sounds  of  opposite  corresponding 
portions,  we  need  scarcely  go  farther  for  evidence  of  tuberculiza- 
tion of  the  lung.  It  may  be  stated  generally,  that  there  are  but 
two  diseases  which  produce  the  combination  of  the  physical  signs 
of  dulness  of  a  clavicle,  with  the  symptoms  of  stridulous  breath- 
ing and  laryngeal  cough ;  these  are  aneurism  of  the  aorta  or 
innominata,  and  the  disease  under  consideration,  and  it  will 
rarely  happen  that  these  can  be  confounded.  Under  any  cir- 
cumstances the  localized  dulness  points  out  that  there  is  some- 
thing more  than  laryngeal  disease,  and  we  know  from  experience, 
that  that  something  more  is  in  the  great  majority  of  cases,  the 
tuberculization  of  the  lung. 

I  may  here  remark,  that  this  is  one  of  the  cases  in  which  the 
mode  of  investigation  by  successive  observations,  is  often 
extremely  applicable ;  and  thus,  although  at  our  first  examina- 
tion no  direct  evidence  of  pulmonary  disease  can  be  obtained,  yet 
on  the  second  or  third  time  of  its  performance  the  change  may 
become  manifest.  Under  these  circumstances  the  gradual  loss  of 
sonoriety  of  either  clavicle  or  scapular  ridge  will  at  once  declare 
the  nature  of  the  disease. 

There  is  one  case  which  closely  resembles  this  disease,  namely, 
the  hectic  of  syphilis,  with  a  secondary  affection  of  the  larynx. 
Here  nothing  but  an  accurate  investigation  of  the  history  and 
period  of  duration  of  symptoms  will  suffice  to  clear  up  the  diag- 
nosis.    With  respect  to  particular  symptoms,    I  have    only  to 


222  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

remark,  that  in  this  case  I  have  never  seen  purulent  expectora- 
tion, nor  is  there  any  evidence  of  solidification  of  the  upper 
portions  of  the  lung.  On  the  other  hand,  we  must  never  forget 
that  many  of  such  cases  end  by  pulmonary  tubercle.* 

Treatment  of  Chronic  Laryngitis. — In  all  forms  of  the 
disease,  in  which  there  are  grounds  for  hope  of  recovery,  the 
physician  must  insist  on  the  patient  using  his  voice  as  little  as 
possible.  To  insist  on  absolute  silence  is  hardly  useful,  but 
all  prolonged  or  constant  exertions  of  the  voice  must  be  for- 
bidden ;  and  if  the  patient's  profession  require  such  exertions, 
he  must  give  up  its  practice  for  a  considerable  period  of  time.f 
He  should  remain  within  doors,  except  during  the  finest 
weather,  and  guard  against  all  exposure  to  fresh  cold. 

The  medical  treatment  best  calculated  to  relieve,  may  be  stated 
to  be  the  repeated  application  of  leeches,  in  small  numbers,  to 
the  trachea  and  larynx,  with  continued  counter-irritation,  by 
means  of  small  blisters,  and  the  tartar  emetic  ointment.  In 
some  cases  the  seton  has  had  a  good  effect. 

Of  internal  remedies  the  most  powerful  is  undoubtedly  mercury, 
more  especially  in  the  syphilitic  cases,  and  particularly  if  it  has 
not  been  used  before,  or  only  sparingly  employed.  But  the  most 
careful  examination  must  be  made  previous  to  having  recourse  to 
this  means  ;  for  if  a  tubercular  disposition  exist,  there  is  nothing 
so  likely  to  call  it  into  action  as  the  effect  of  mercury.  I  do  not 
know  any  case  in  which  such  caution  is  necessary  in  its  exhibi- 
tion as  this.  It  is,  however,  a  remedy  of  great  value,  and  may 
be  used  as  well  in  the  idiopathic  cases  as  in  the  secondary  syphi- 
litic affections. 

*  The  differential  diagnosis  in  these  cases  will  be  much  aided  by  the  laryngoscope, 
but  apart  from  its  use  the  difference  on  external  examination  between  the  tubercular 
and  the  syphilitic  larynx  is  very  striking.  The  former  being  not  enlarged  and  feeling 
loose  and  disintegrated  from  ulceration,  while  the  latter  is  thickened  and  firm,  the 
cartilages  being  welded  together  by  copious  fibrous  deposit.     (Ed.) 

f  Although  accurate  returns  are  still  wanting,  it  would  appear  that  individuals  of 
the  two  professions,  in  which  public  speaking  is  most  required,  namely,  lawyers  and 
clergymen,  the  latter  are  most  liable  to  laryngitis.  The  explanation  of  this  seems  to 
be,  that  the  clergyman  begins  to  exercise  his  vocal  organs  at  a  much  earlier  period 
than  the  lawyer.  The  young  clergyman,  often  of  a  feeble  and  nervous  constitution, 
and  acting  under  conscientious  motives,  to  the  neglect  of  bodily  health,  not  only  reads 
the  service,  and  preaches  once  or  twice,  or  even  more  often  in  the  week,  but  is 
exposed  to  night  air  and  the  inclemency  of  weather.  He  is  compelled  to  do  so,  while 
both  the  larynx  and  constitution  of  the  lawyer  have,  in  general,  full  time  for 
maturity  before  he  need  employ  the  one  or  expend  the  other  in  the  duties  of  his 
profession. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  223 

As  to  its  mode  of  exhibition,  we  may  employ  it  either  by 
inhalation,  or  administer  calomel  and  opium  internally.  In 
some  cases  I  have  seen  the  mildest  preparations  of  mercury  act 
well.* 

The  state  of  the  pharynx  is  to  be  carefully  attended  to  ;  for  in 
many  cases,  particularly  of  the  syphilitic  or  scrofulous  character, 
it  may  exhibit  various  lesions,  such  as  superficial  or  deep-seated 
ulcerations,  affecting  the  velum,  back  of  the  pharynx  or  tonsils  ; 
relaxations  of  the  uvula  ;  cedematous  and  vascular  conditions 
of  the  parts,  &c.  To  the  importance  of  applying  direct  remedies 
in  these  cases  the  attention  of  medical  men  has  been  strongly 
directed  by  Dr.  Graves.  We  may  employ,  according  to  circum- 
stances, either  a  solution  of  nitrate  of  silver,  containing  from 
ten  to  fifteen  grains  to  the  ounce ;  the  caustic  solution  of  iodine, 
as  recommended  by  Lugol,  or  the  inhalation  of  the  vapour  of 
iodine,  combined  with  a  narcotic. 

After  these  remedies  have  been  carried  into  effect,  we  may 
advantageously  exhibit  the  sarsaparilla  decoction  with  nitric  acid; 
or,  in  some  cases,  the  Fowler's  solution.  Counter-irritation 
should  be  still  kept  up,  and  continued  for  a  length  of  time  after 
the  subsidence  of  the  laryngeal  symptoms. 

In  some  cases  spasmodic  exacerbations  occur,  so  severe  as  to 
threaten  the  life  of  the  patient.  These  are  more  frequently  met 
with  in  females,  and  demand  a  careful  study.  The  suddenness 
and  violence  of  the  attack,  the  absence  of  corresponding  fever, 
and  of  tumefaction  of  the  epiglottis,  will,  in  general,  suffice  for 
diagnosis.  I  have  often  seen  cases  in  which  the  suffering  was  so 
severe,  as  that  the  instant  performance  of  tracheotomy  was 
advised,  yet  in  which  the  breathing  was  restored  to  its  ordinary 
condition  by  the  following  simple  treatment :  the  feet  were 
plunged  in  warm  water,  the  body  enveloped  in  blankets,  and  a 
draught,  consisting  of  camphor  mixture,  ammonia,  valerian, 
ether,  and  opium,  exhibited,  and  repeated  according  to  circum- 
stances. Under  this  treatment  symptoms  will  rapidly  subside, 
which,  from  their  character  and  continuance,  would  seem  to 
demand  the  knife  ;  and  I  would  advise,  that  in  all  cases,  previous 
to  the  performance  of  tracheotomy  in  chronic  laryngitis,    the 

*  The  perchloride  in  minute  doses  seems  to  act  better  than  any  other  preparation  of 
mercury  in  these  cases,  nor  does  the  complication  with  disease  of  the  lung  always 
contraindicate  its  employment.    (Ed.) 


-V 


■+ 


224  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

question  be  carefully  investigated,  as  to  whether  the  urgent 
symptoms  are  the  result  of  spasm  or  organic  obstruction.  Let 
it  never  be  forgotten,  that  even  where  organic  disease  and 
thickening  of  the  larynx  exist,  spasm  may  supervene,  and  be 
met  by  appropriate  treatment.  We  are  too  much  attached  to  the 
doctrine  of  diseases  being  necessarily  separate,  but  experience 
tells  us  that  nothing  is  more  common  than  to  see  spasm  follow- 
ing organic  disease,  or  organic  disease  occurring  after  a  purely 
nervous  lesion. 

In  cases  shewing  this  liability  to  spasm,  the  belladonna,  or 
other  anodyne  plasters,  may  be  usefully  employed." 

I  cannot  leave  this  part  of  the  subject  without  alluding  to  the 
effect  produced  by  relaxation  and  elongation  of  the  uvula  in  pro- 
ducing symptoms  of  laryngeal  irritation.  This  fact  has  been  long 
known,  and  I  shall  here  merely  enumerate  the  various  forms  of 
symptoms  which  I  have  known  to  be  relieved  by  the  simple 
operation  of  removing  the  lower,  or  non-muscular  portion  of  this 
process. 

1st  Case.  Cough  coming  on  at  night  on  the  patient's  lying 
down.  It  is  incessant,  and  accompanied  by  wheezing,  dyspnoea, 
and  restlessness.  Nearly  complete  absence  of  symptoms  during 
the  day. 

2nd.  Cough  of  a  laryngeal  character,  with  a  feeling  of  stuffing 
and  tickling  of  the  throat ;  alteration  of  voice,  and  hawking  up  of 
mucus. 

3rd.  Symptoms  very  analogous  to  humid  asthma,  with  a  loud 
sonorous  rale  over  the  chest. 

4th.  Symptoms  of  the  dry  catarrh  in  old  persons,  without 
laryngeal  cough,  stridor,  or  alteration  of  voice. 

5th.  Symptoms  of  chronic  laryngitis,  hoarseness,  some  stridor, 
loud  cough. 

6th.  The  preceding  symptoms,  combined  with  hectic  and 
purulent  expectoration,  so  as  to  resemble  true  phthisis  laryngea. 

7th.  All  the  usual  constitutional  symptoms  of  phthisis,  such 
as  cough,  puriform  and  bloody  expectoration,  hectic,  emaciation, 
quick  pulse,  yet  without  the  physical  signs  of  pulmonary 
tubercle. 

Such  a  variety  of  effects  only  exemplifies  the  variety  of  consti- 

*  Dublin  Hospital  Reports,  vol.  v.    Report  of  the  Meath  Hospital,  by  R.  J.  Graves 
M.D.,  and  W.  Stokes,  M.D. 


DISEASES    OF    THE    LARYNX   AND    TEA.CHEA.  225 

tutions ;  and  without  doubt  a  more  extended  experience  will 
discover  other  modifications  of  symptoms.  In  all  these,  the  ordi- 
nary treatment  either  altogether  failed,  or  was  hut  partially  suc- 
cessful, and  this  result  may  often  lead  to  the  suspicion  of  the 
disease.  But,  in  truth,  the  physician  who  neglects  the  examina- 
tion of  the  fauces  in  any  case  of  pulmonary  disease  is  neither 
doing  justice  to  his  patient  nor  himself. 

As  might  be  expected,  the  removal  of  the  exciting  cause  does 
not  always  produce  the  beneficial  effect  immediately.  In  almost 
all  chronic  functional  lesions  more  or  less  of  organic  change 
occurs ;  and  in  the  case  before  us  it  may  happen,  that  even  in- 
curable mischief  may  be  thus  produced.  Still  in  the  great 
majority  the  relief  is  most  remarkable,  and  simple  palliative 
treatment  will  suffice  to  restore  the  patient's  health. 

SPECIFIC    IRRITATIONS    OF   THE    LARYNX. 

In  the  present  state  of  our  knowledge  we  can  do  little  more 
than  announce  the  existence  of  these  forms  of  disease  ;  for  their 
history  and  diagnosis  are  still  to  be  established,  and  their  patho- 
logical anatomy  to  be  investigated.  Suffice  it  to  observe,  that 
the  various  morbid  constitutional  states  may  produce  their 
secondary  local  effects  on  the  tissues  of  the  larynx,  and  thus 
cause  symptoms,  the  treatment  of  which  requires  an  investiga- 
tion into  the  exciting  cause  and  diathesis.  Gout,  syphilis, 
scrofula,  and  scorbutus,  may  attack  the  larynx;  and  so  also 
in  typhus  fever,  in  erysipelas,  and  the  other  exanthemata,  there 
may  be  laryngeal  diseases  whose  characters  are  peculiar.  But 
though  promising  so  rich  a  harvest  this  field  is  still  unexplored. 

SPASMODIC    AFFECTIONS    OF    THE    LARYNX. 

Endowed  with  a  curious  and  complicated  muscular  apparatus, 
and  with  an  exquisite  sensibility,  the  larynx  is  liable  to  various 
forms  of  neurosis  ;  of  these  the  active  have  only,  as  yet,  been 
investigated,  while  of  the  existence  of  the  passive  forms  scarcely 
any  notice  has  been  taken.*     Under  the  first  head  we  may  class 

*  I  here  adopt  the  classification  of  neuroses  into  active  and  passive,  as  given  by 
Bronssais — Comment,  sur  les  Propositions  de  Pathologic  By  active  neuroses  are 
meant  those  with  increased  innervation,  such  as  spasm,  convulsions ;  while  the 
passive  imply  a  minus  degree  of  innervation,  or  paralysis. 

Q 


226  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

the  spasmodic  croup  of  children,  the  spasm  of  the  glottis  in 
hooping-cough,  and  the  various  forms  of  hysterical,  nervous,  and 
sympathetic  cough  ;  while  of  the  second  we  can  only  say,  that 
paralysis  of  the  muscles  of  phonation  is  seen  in  certain  cases  of 
cerebral  disease ;  and  that  reasoning  from  analogy,  we  may 
further  admit  the  existence  of  another  form  of  paralysis,  similar 
to  that  of  the  intestines  in  ileus,  and  of  the  intercostal  muscles  in 
pleurisy,  and  resulting  from  the  same  cause,  namely,  the  inflam- 
mation of  a  tissue  in  connexion  with  the  muscular  fibre. 

Spasm  of  the  Glottis  of  Children. — This  disease,  con- 
sisting essentially  in  a  spasm,  or  active  neurosis  of  the  glottis, 
seems  to  result  in  all  cases  from  cerebral  irritation,  which  may 
he  cither  'primary  or  secondary  to  some  other  disease.  Its 
existence  has  been  recognized  since  the  middle  of  the  last 
century,  and  a  host  of  authors  have  described  or  alluded  to  its 
symptoms,  but  of  these  the  latest  is  Sir  Henry  Marsh,  of  whose 
researches*  I  shall  avail  myself. 

This  disease  may  shew  itself  as  a  simple  spasmodic  affection 
of  the  larynx,  independent  of  any  other  perceptible  lesion ;  but 
this  is  the  rarest  case.     In  others  it  is  connected  with  the  irrita- 
tion of  dentition,  or  of  deranged  digestive  function  ;  while  in  a 
third  class,  it  is  symptomatic  of  primary  cerebral  disease.     Many 
circumstances  concur  to  distinguish  this  disease  from  the  laryn- 
gitis of  children.     In    the    first,    or   mildest   variety,  there  are 
paroxysms  of  stridor  ;  but  in  the  interval,  the  little  patient  may 
be    free    from    all    distress,   and  without  any  fever,  or  signs  of 
mucous  irritation.     In  the  second,  although  the  general  health 
may  be  much  deranged,  yet  the  symptoms  are  not  these  of  an 
irritation  of  the  respiratory  system.     The  child  may  have  remit- 
tent fever,  or  a  deranged  state  of  the  bowels  or  liver,  with  nervous 
irritation ;    but   the   laryngeal    symptoms    occur   in   paroxysms, 
between  which  the  breathing  remains  free.     In  such  a  case  the 
child   may  labour  under   the    symptoms   for   months,    and   the 
disease     either    subside,     or     become    complicated    with  more 
decided  signs   of  irritation  of  the  brain,   such   as  convulsions, 
strabismus,  and  coma.     Indeed,  in  this  form  a  symptom  is  com- 
monly observed,  first  described  accurately  by  Dr.  Kellie,t  namely, 

*  Dub'in  Hospital  Reports,  vol.  v.     On  a  peculiar  disease  of  children,  which  may 
he  termed  spasm  of  the  glottis,  by  H   Marsh,  M.D. 
■j-  Edin.  Med.  anl  Surg.  Journal,  Oct  >ber,  1816. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  227 

the  spasmodic  flexure  of  the  thumh  across  the  palm  of  the  hand, 
and  also  an  analogous  state  of  the  toes.  This,  it  is  unnecessary 
to  observe,  points  out  an  excited  state  of  the  nervous  centres. 
Lastly,  in  the  third  form,  there  are  generally  decided  evidences 
of  cerebro-spinal  irritation,  such  as  frequent  fits  of  convulsions, 
and  the  usual  train  of  symptoms  of  meningeal  or  encephalic 
irritation.  Here  the  spasm  of  the  glottis  is  as  symptomatic  of 
the  cerebral  disease,  as  are  the  convulsions  of  the  extremities. 

Repeated  fits  of  a  crowing  respiration,  not  followed  by  cough, 
as  Cheyne  has  remarked,  and  occurring  either  without  consti- 
tutional symptoms,  or  co-existing  with  dentition,  digestive  or 
cerebral  irritation,  form  the  characteristic  features  of  this  disease, 
which  is  easily  distinguished  from  the  true  croup.  If  to  these 
we  add  the  absence  of  laryngeal  obstruction  between  the  fits, 
and  also  that  of  the  physical  signs  of  bronchitis  we  can  have  no 
difficulty  in  forming  our  diagnosis. 


NERVOUS    AFFECTIONS    OF    THE    LARYNX    IN    THE    ADULT. 

"We  meet  with  spasm  of  the  glottis  in  the  adult,  either  with  or 
without  organic  disease  of  the  larynx,  though  in  most  cases  it 
supervenes  on  chronic  laryngeal  affections.  In  females,  however, 
we  find  it  as  one  of  the  symptoms  of  the  protean  hysteria,  wdien 
it  may  be  a  transient  or  long-continued  affection.  Here,  as  in 
the  disease  already  described,  the  spasm  is  commonly  during 
inspiration. 

I  have  not  materials  to  enable  me  to  enter  into  an  account  of 
the  various  hysterical  and  nervous  affections  of  the  larynx  in 
females,  but  shall  merely  enumerate  those  which  I  have  often 
observed,  most  of  which  have  been  long  known. 

1st.  Simple  aphonia,  supervening  on  mental  excitement.  Its 
duration  is  exceedingly  various,  and  its  disappearance  often  as 
sudden  as  its  invasion. 

2nd.  Fits  of  croupy  breathing. 

3rd.  Long-continued  stridulous  breathing,  without  fever. 

4th.  A  hard,  loud,  solitary  cough,  without  any  stridor.  In 
its  more  violent  forms  this  has  got  the  name  of  tussis  ferina. 

5th.  A  similar  cough,  followed  by  an  inspiration,  not  stridu- 
lous, but  with  the  expiration  long,  sonorous,  and  groaning,  so  as 
to  resemble  the  howling  of  a  dog. 

Q  2 


228  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

6th.  A  short  but  teasing  cough,  occurring  in  the  most  rapid 
succession ;  and  during  the  paroxysm  causing  the  greatest  distress 
and  exhaustion. 

7th.  The  most  violent  form  of  the  tussis  ferina,  with  greatly 
increased  action  of  the  heart  and  arteries,  hurried  breathing, 
loud  puerile  respiration,  and  profuse  sweatings.  In  such  a  case 
I  have  seen  the  disease  continue  to  form  more  than  a  year,  yet 
there  was  no  emaciation. 

Other  forms  may  also  occur,  but  the  above  are  those  which 
have  fallen  under  my  own  observation.  With  respect  to  diag- 
nosis the  points  of  importance  are,  the  co-existence  of  other 
hysterial  phenomena,  or  their  having  preceded  the  symptoms, 
the  absence  of  fever,  the  character  of  the  cough,  the  want  of  the 
regular  succession  of  phenomena,  as  observed  in  laryngitis,  the 
frequent  absence  of  hoarseness,  and  lastly,  the  resistance  of  the 
symptoms  to  ordinary  antiphlogistic  treatment. 

A  spasm  of  the  glottis,  however,  may  occur  independent  of  any 
hysterical  tendency.  Thus,  in  a  lady  whose  case  was  mentioned 
to  me  by  Mr.  Goodall,  there  have  been  attacks  of  this  kind  for 
many  years,  some  of  which  have  been  so  alarming  as  to  excite 
fears  for  life.  The  patient  is  now  sixty  years  of  age,  and  exhibits 
no  signs  of  hysteria.  We  are  not  in  possession  of  facts  to  prove 
that  spasm  of  the  glottis  ever  occurs  in  the  adult  male,  without 
the  previous  existence  of  organic  disease. 

We  are  indebted  to  Mr.  Kirby  for  a  case  in  which  death 
was  apparently  produced  by  spasm  of  the  glottis,  in  consequence 
of  obstruction  of  the  oesophagus  by  pieces  of  meat  and  bone.* 
The  largest  morsel  lay  immediately  behind  the  cricoid  cartilage  ; 
but  its  pressure,  nor  that  of  another  portion,  which  was  low  down 
in  the  oesophagus,  had  not  diminished  the  calibre  of  the  windpipe. 
The  epiglottis  almost  completely  concealed  the  cavity  of  the 
glottis,  which  was  so  diminished  by  the  forward  inclination  of  the 
arytenoid  cartilages  as  to  be  scarcely  discernible,  and  the  rima 
was  altogether  closed. 

Although  it  is  doubted  whether  the  symptoms  of  suffocation, 
in  the  case  of  a  foreign  body  lodging  in  the  oesophagus,  are  pro- 
duced by  a  spasm  of  the  glottis,f  yet  I  incline  to  the  possibility  of 

*  Dublin  Hospital  Reports,  vol.  ii.     A  case  in  which  suffocation  was  produced  by  a 
portion  of  solid  food  in  the  oesophagus,  by  J.  Kirby,  A.B.,  &c,  1818. 
f  Surgical  Pathology  of  the  Larynx  and  Trachea,  p.  224. 


DISEASES    OF    THE    LAEYNX   AND    TRACHEA.  229 

such  an  event,  not  merely  from  the  case  just  alluded  to,  but  from 
my  having  seen  an  instance  in  which  a  piece  of  money  was 
lodged  in  the  (esophagus,  and  where  croupy  breathing,  and  other 
laryngeal  symptoms,  were  manifestly  the  result.  In  this  instance 
the  foreign  body  was  not  lodged  in  the  fauces  or  pharynx. 

But  in  the  adult  the  spasmodic  affections  of  the  larynx  are  met 
with  most  commonly  in  connexion  with  organic  disease  either  of 
the  windpipe  or  lung,  or  of  both  combined.  In  by  far  the  greater 
number  the  organic  lesion  has  been  antecedent,  and  the  nervous 
affection  is  shewn  by  spasmodic  exacerbations  of  the  laryn- 
geal breathing,  which  are  full  of  danger.  To  these  I  have  already 
alluded,  and  shall  merely  add,  that  in  a  few  cases  the  reverse  may 
occur,  and  a  disease,  at  first  functional,  pass  into  organic  change  ; 
nor  should  the  long  continuance  of  symptoms  of  a  decidedly 
nervous  or  hysteric  character  put  the  practitioner  off  his  guard ; 
of  this  the  following  case  is  a  striking  illustration. 

A  young  female  entered  the  Meath  Hospital  labouring  under 
fever,  from  which,  after  a  relapse,  she  recovered,  but  it  was  to 
become  affected  with  a  new  and  singular  train  of  nervous  symp- 
toms. She  had  hysteria,  in  almost  all  its  forms.  Epileptic 
convulsions,  violent  spasms,  coma,  screaming,  tympanitis,  para- 
lysis of  the  bladder,  intractable  vomiting,  succeeded  one  another 
in  a  miserable  succession  ;  yet  after  many  months  of  suffering  her 
flesh  and  appearance  were  singularly  preserved :  she  lastly  was 
attacked  with  a  cough  having  every  resemblance  to  the  hysteric 
form,  and  relieved  by  antispasmodic  medicines.  This  subsided  on 
the  appearance  of  an  eruption  of  varicella,  followed  by  a  typhoid 
state,  with,  for  the  first  time,  emaciation.  This  subsided,  but 
the  cough  returned,  and  continued  for  nearly  three  weeks,  when 
she  sunk,  with  symptoms  of  suffocation.  On  dissection,  an 
abscess,  of  the  size  of  a  Spanish  mH,  was  found  involving  the 
cricoid;  and  though  all  the  cavities  were  minutely  examined 
no  other  disease  could  be  discovered.  Had  this  been  recognized, 
tracheotomy  might  have  prolonged  her  miserable  life. 

In  this  case  death  took  place  by  organic  change  of  the  larynx 
itself.  But  in  severe  or  long-continued  spasmodic  affections  of 
the  windpipe,  the  brain  is  also  in  danger  of  organic  lesion.  It 
is  a  curious  fact,  that  in  three  of  the  most  extraordinary  cases  of 
hysteric  or  nervous  cough  which  I  have  witnessed,  there  was  evi- 
dence of  such  an  occurrence.    In  one  of  long-continued  cough  and 


+ 


f 


230  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

Spasm  during  expiration,  the  patient,  a  young  female,  after 
having  recovered  of  this,  died  with  latent  meningitis.  In  the 
second  case,  the  symptoms  were  frightful  paroxysms  of  a  tearing, 
incessant  cough,  followed  by  fever,  headache,  strabismus,  and 
the  other  symptoms  of  hydrocephalus.  This  patient  recovered 
under  antiphlogistic  treatment,  and  the  use  of  mercury.  In  the 
third,  there  were  long-continued  paroxysms  of  the  most  severe 
stridulous  breathing,  tussis  ferina,  and  convulsions.  This  patient, 
after  years  of  suffering,  recovered,  but  died  suddenly.  All  these 
patients  were  young  females,  of  lymphatic  temperaments.  From 
these  cases,  and  others  which  might  be  quoted,  we  derive  the 
practical  rule,  that  even  after  puberty,  the  spasmodic  affections  of 
the  larynx  may  be  indicative  of  cerebral  disease. 

I  have  often  found,  even  in  cases  where  manifest  organic 
disease  both  of  the  larynx  and  lung  existed,  that  the  cough  was 
best  relieved  by  antispasmodic  medicines  ;  and  in  chronic  phthisis 
our  best  cough  mixture  will  often  be  a  combination  of  powerful 
antispasmodics.  And  I  have  more  than  once  observed,  that 
where  tuberculous  phthisis  supervened  on  hooping-cough,  the 
cough  preserved  its  character  even  after  extensive  cavities  were 
formed  in  the  lung,  and  until  the  fatal  termination  of  the  disease. 
From  these  facts,  and  others  which  might  be  quoted,  we  derive 
the  rule  that  the  existence  of  organic  disease  should  not  make  us 
neglect  the  use  of  antispasmodics  ;  nor  the  fact  of  long-continued 
and  apparently  functional  affections  of  the  larynx,  even  occurring 
after  puberty,  make  us  overlook  the  possible  supervention  of 
organic  change  in  the  larynx,  or  even  in  the  brain  itself. 


FOREIGN  BODIES  IN  THE  LARYNX,  TRACHEA,  OR  BRONCHIAL  TUBES. 

As  yet  we  have  no  monograph  on  this  subject ;  and  the  student 
must  wade  through  a  mass  of  periodicals  to  arrive  at  the  know- 
ledge he  seeks,  and  after  all,  he  will  find  no  general  principle  of 
diagnosis  laid  down,  but  merely  a  number  of  cases,  certainly  of 
great  interest,  but  still  not  calculated  to  satisfy  his  mind.  The 
memoirs  of  Pelletan,*  and  Louis, t  and  the  work  of  Mr.  Porter,  J 
in  which  the  subject  is  introduced,  will  be  the  principal  sources 

*  Clinique  Chirurgicale,  torn.  i.  Mem.  1. 

f  Memoire  sur  la  Bronchotomie.    Memoires  de  l'Acad.  Royale  de  Chirurgie,  torn.  xii. 

%  Surgical  Pathology  of  the  Larynx  and  Trachea. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  231 

of  his  information.  Almost  all  the  rest  will  consist  of  isolated 
examples,  published  by  practitioners  who  have  met  with  an  acci- 
dental case,  and  have  not  devoted  themselves  to  any  original 
investigation  of  the  symptoms  and  treatment  of  this  affection. 

Before  entering  on  the  different  symptoms,  I  shall  allude  to  a 
few  particulars  as  connected  with  the  entrance  of  the  foreign 
body  into  the  air  passages,  and  its  nature. 

It  would  appear  that  bodies  of  a  size  so  large  as  to  exceed  the 
ordinary  diameter  of  the  glottis,  have  yet  passed  through  that 
aperture,  and  lodged  in  the  larynx,  trachea,  or  bronchial  tubes. 
This  fact  was  first  satisfactorily  explained  by  Dr.  Houston,  in  his 
remarks  on  a  case  of  this  description.*  After  observing  on  the  rarity 
of  the  case,  and  its  interest,  as  shewing  that  a  body  apparently 
much  larger  than  the  aperture  of  the  riina  glottidis,  and  one  even 
of  different  form,  could  find  a  passage  through  that  fissure,  Dr. 
Houston  says  :  "To  understand  aright  how  a  body  of  greater 
apparent  dimensions  than  the  rirna  glottidis,  could  have  found  a 
passage  through  that  aperture,  it  is  only  necessary  to  reflect  for  a 
moment  on  the  nature  of  the  process  of  inspiration.  The  intro- 
duction of  air  to  the  lungs  with  every  breath,  is  consequent  upon 
the  enlargement  of  the  chest;  the  weight  of  the  atmosphere  pressing 
the  adjacent  column  into  the  cavity,  with  a  rapidity  proportioned 
to  the  suddenness  and  extent  of  the  dilatation,  and  with  a  force 
sufficient  to  carry  along  in  the  current  any  light  moveable  body 
which  may  happen  to  come  in  the  way.  A  small  body,  so  inter- 
cepted, will  readily  pass  with  the  air  through  the  rima,  and  be 
lodged  in  a  part  of  the  tube  lower  down.  A  body  of  inordinate 
dimensions  may  stick  so  firmly  in  the  aperture,  that  the  full 
weight  of  the  atmosphere  is  unequal  to  its  propulsion  onwards, 
and  death  from  suffocation  will  be  the  inevitable  consequence,  if 
the  foreign  body  be  not  instantly  shot  back  again  by  a  powerful 
expiratory  effort,  or  removed  by  operation.  And  a  body  of  interme- 
diate size,  viz.,  one  of  such  moderate  dimensions  as  to  be  capable 
of  passing  through  the  rima  by  stretching  and  divaricating 
the  sides  of  that  aperture,  may,  when  pressed  heavily  by  the 
atmosphere,  as  it  would  during  a  forced  inspiration,  be  driven 
past  the  obstruction,  and  thence  into  the  trachea,  or  bronchial 

*  Dublin  Journal  of  Medical  and  Chemical  Science,  No.  XXIII.,  account  of  a  case  in 
which  a  large  molar  tooth  passed  into  the  larynx,  during  the  operation  of  extraction, 
by  John  Houston,  M.D.,  &c. 


> 


232  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

tubes.  Such  latter  was  no  doubt  the  mole  by  which  the  tooth, 
in  the  case  above  related,  found  a  passage  into  the  bronchus. 
The  man  holding  his  breath  during  all  the  time  of  the  operation, 
suddenly  at  the  moment  in  which  the  extraction  was  completed, 
took  a  full  inspiration;  upon  which  the  tooth,  partly  by  its  gravity, 
(the  head  being  at  the  time  thrown  back,)  and  partly  carried  by  the 
air  rushing  to  the  windpipe,  fell  over  the  aperture  leading  into  that 
tube.  The  obstruction  caused  thereby  to  the  further  entrance 
of  air,  induced  a  spasmodic  increase  of  action  in  the  muscles  of 
inspiration,  and  a  consequent  increase  of  pressure  by  the  air  at 
the  opening,  by  which  the  tooth  was  driven  with  force  through 
the  fissure." 

The  foregoing  considerations  may  explain  why  it  is  that  a 
foreign  body  that  has  entered  the  larynx  during  inspiration  is  so 
seldom  expelled  by  expiration,  notwithstanding  the  most  violent 
efforts  of  coughing  ;  but  that  it  will  remain  in  the  air  passages, 
and  unless  removed  by  operation,  bring  on  a  train  of  formidable 
and  generally  fatal  symptoms.  It  is  obvious,  that  in  the  case  of 
a  body  which  has  only  passed  the  glottis  by  stretching  and  divari- 
cating that  aperture,  the  forces  accessary  to  its  introduction  must 
,  be  infinitely  greater  than  those  which  could  be  brought  to  bear  on 
its  expulsion  ;  for  in  the  first  case  it  is  acted  on  by  the  pressure 
of  the  atmosphere,  while  the  powerful  respiratory  muscles  are  in 
the  highest  state  of  exertion,  while  in  the  latter,  there  is  nothing 
to  expel  it  but  the  comparatively  feeble  efforts  of  expiration.  The 
dilated  state  of  the  glottis  during  a  forced  inspiration,  is  also 
a  condition  favouring  the  entrance,  though  not  availing  for  the 
expulsion  of  the  body. 

With  respect  to  the  nature  of  the  orifice  itself,  it  is  to  be 
observed,  that  the  common  idea  of  its  being  a  pyramidal  opening, 
whose  summit  varied  in  its  orifice  according  to  the  degree  of 
dilatation  or  contraction  in  which  it  was  examined,  is  now  dis- 
proved, and  the  researches  of  Liscovius  and  Malgaigne  have  been 
recently  verified  and  extended  by  Professor  Lauth  of  Stras- 
burgh. 

According  to  this  author,  the  length  of  the  glottis  increases 
with  the  volume  of  the  larynx,  according  as  we  examine  it  in  the 
infant,  the  adult  female,  or  the  male.  In  the  adult,  according  to 
the  sex,  the  extent  from  before  backwards  varies  from  seven  to 
thirteen  lines,  the  dimensions  being  taken  at  the  period  of  repose : 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  233 

he  has  never  found  it  so  long  as  fifteen  lines,  as  described  by 
Malgaigne.  But  the  length  of  the  opening  is  not  always  greater 
in  man  than  in  woman,  for  it  has  been  found,  even  in  tall  men, 
but  from  seven  to  eight  lines,  while  in  women  it  has  been  met 
with  from  eight  to  nine  lines  in  length. 

It  is  further  shewn  that  the  Iijds  of  the  opening  are  not  straight, 
but  nearly  at  the  centre  project  towards  the  mesian  line,  in  con- 
sequence of  the  prominence  of  the  anterior  apophysis  of  the 
arytenoid  cartilage.  The  base  of  the  glottis  is  also  terminated 
by  a  line,  curving  inwards,  so  that  in  the  state  of  rest  the  form 
of  the  glottis  may  be  compared  to  that  of  the  steel  of  a  halbert. 

In  consequence  of  this  disposition,  the  opening  may  be  con- 
sidered as  formed  of  three  parts,  the  anterior,  middle,  and  pos- 
terior, and  in  a  glottis  eleven  lines  in  length,  the  anterior  with  its 
portion  of  middle,  measures  seven,  and  the  posterior,  with  its 
portion  of  middle,  four  lines.  The  width  in  the  middle  portion 
is  two  lines  and  a  half. 

But  by  the  contraction  of  its  muscles  its  dimensions  are 
altered :  it  may  be  elongated  or  widened.  Lauth  has  found,  that 
in  a  glottis  of  eleven  lines  in  length,  the  opening  may  become 
twelve  lines,  while  its  width  is  diminished  to  two.  In  its 
transverse  enlargement,  however,  it  becomes  of  a  lozenge  shape, 
and  while  the  arytenoid  cartilages  can  be  separated  to  so  much 
as  five  lines  and  three-fourths,  the  length  of  the  opening  shall 
remain  the  same.  It  is  plain  that  this  condition  will  be  the  most 
favourable  for  the  entrance  of  a  foreign  body,  inasmuch  as  now 
the  opening  exhibits  its  greatest  possible  enlargement,  and  this 
change  is  produced  by  an  inspiratory  muscle — the  posterior  crico- 
arytenoid, which,  as  Lauth  remarks,  repeats  on  the  larynx  the 
action  of  the  intercostals  on  the  ribs. 

The  situations  in  which  the  foreign  body  may  remain  can  be 
enumerated  as  follows :  it  may  be  impacted  in  the  rinia  itself,  or 
pass  and  become  entangled  in  the  ventricles  of  the  larynx ;  it 
may  pass  into  the  trachea,  and  from  thence  into  the  bronchial 
tubes,  particularly  the  right,  and  from  these  situations,  by  the 
efforts  of  coughing,  be  forced  upwards  into  the  larynx,  again  to 
return  to  its  former  position. 

When  the  body  is  met  with  in  the  bronchial  tubes,  it  has 
been  observed  in  the  great  majority  of  instances,  to  be  contained 
in  the  right  bronchus,  and  this  circumstance,  so  interesting  in  a 


234  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

general  point  of  view,  I  shall  shew  to  be  of  the  utmost  importance 
with  respect  to  diagnosis.  It  has  been  supposed  that  the  cause 
of  this  phenomenon  is  to  be  found  in  the  greater  size  of  the  right 
bronchial  tube,  but  this  explanation  appears  insufficient.  It 
might  explain  the  lodgment  of  a  foreign  body  in  the  right  bronchial 
tube,  that  was  too  large  to  enter  the  left,  but  would  throw  no 
light  on  the  fact,  that  bodies  small  enough  to  enter  the  left,  are 
yet  most  commonly  found  in  the  right  tube. 

I  apprehend  that  the  true  explanation  of  this  interesting  fact 
will  be  found  in  the  anatomical  disposition  of  the  trachea  at  its 
bifurcation,  where  we  may  observe  that  the  projection  or  septum 
dividing  the  right  and  left  bronchi,  is  not  in  the  mesian  line,  but 
decidedly  to  the  left  of  it.  So  that  a  body  passing  through  the 
glottis,  will  be  thus  directed  into  the  right  bronchus.*  Another 
explanation  has  been  founded  on  the  different  directions  of  the 
two  tubes,  the  right  being  more  vertical  than  the  left,  but  the 
difference  is  scarcely  sufficient  to  explain  the  phenomenon.  It 
might  be  farther  supposed,  that  as  the  right  lung  has  a  greater 
capacity  than  the  left,  the  force  of  the  air  entering  through  the 
bronchus  would  be  proportionally  augmented ;  but  this  opinion 
loses  much  of  its  weight,  when  we  reflect  on  the  different  dia- 
meters of  the  tubes. 

When  the  foreign  body  has  passed  into  the  air  passages, 
various  results  may  be  observed.  It  may  be  violently  expelled 
through  the  glottis,  after  a  period  of  time  varying  from  a  few 
moments  to  many  years.  It  may  produce  death  by  suffocation, 
in  consequence  of  its  becoming  impacted  in  the  larynx ;  it  may 
cause  acute  inflammation  of  the  whole  lung,t  and  the  patient 
die  before  abscess  has  formed;  it  may  form  an  abscess  in  the 
lung;  or  lastly,  produce  death  with  the  symptoms  of  chronic 
consumption. 

We  are  not  in  possession  of  facts  competent  for  the  explana- 
tion of  these  different  results ;  but  they  seem  to  shew,  that  even 
if  we  admit  with  Desault,  that  the  trachea  and  bronchial  tubes 
possess  a  much  less  degree  of  animal  sensibility  than  the  glottis,  J 
yet  that  their  organic  sensibility  is  decided,  inasmuch  as  we  find 

*  For  this  observation  I  am  indebted  to  my  friend,  Mr.  Goodall. 

■f  According  to  Juergensen  catarrhal  not  croupous  pneumonia.  "  Anatomical  investi- 
gation teaches  that  these  pneumonias,  though  superficially  most  closely  resembling  the 
croupous  form,  are  not  croupous  :n  character." — Ziemssen's  Cyclop.,  vol.  v.  p.  194.   (Ed.) 

J  CEuvres  Chirurg'cales,  tcm  ii. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  235 

disease  to  result  from  the  presence  of  foreign  bodies  extremely 
various  in  their  characters.  And  it  would  also  appear,  that  this 
organic  sensibility  of  the  air  passages  varies  remarkably  in  different 
individuals,  as  in  some  an  acute,  and  in  others  an  extremely 
chronic  disease  is  induced  by  bodies  of  a  similar  nature,  and  it  is 
further  observed,  that  in  some  individuals  there  is  fixed  pain, 
while  in  others  the  most  enormous  disease  may  occur  without  any 
local  pain  whatever. 

In  certain  cases  the  expulsion  of  the  foreign  body,  even  after 
the  long  continuance  of  consumptive  symptoms,  has  been  followed 
by  recovery,  but  in  many  this  favourable  result  does  not  occur, 
and  the  patients  sink  from  the  chronic  disease  induced  by  the 
accident. 

It  has  been  conceived  that  the  physical  characters  of  the  foreign 
body  influence  the  violence  of  the  symptoms  ;  a  sharp  and  rugged 
substance,  it  is  supposed,  will  cause  greater  distress  than  one 
with  a  smooth  surface,  and  it  is  true,  that  in  many  of  the  most 
remarkable  cases  of  pain  and  distress,  occurring  from  the  first,  the 
foreign  body  has  been  of  the  former  description  ;  but  on  the  other 
hand,  bodies  of  irregular  forms  have  remained  in  the  air  passages 
without  the  production  of  pain. 

In  considering  this  subject,  we  must  separate  the  mere  occur- 
rence of  pain  from  that  of  the  other  distressing  symptoms.  Facts 
are  wanting  to  throw  light  on  the  occurrence  of  pain,  but  I  have 
little  doubt,  that  the  great  cause  of  distress  will  be  found  to  reside 
in  the  degree  of  mechanical  obstruction  produced  by  the  foreign 
body.  This  we  should  a  priori  expect,  but  in  confirmation  of  the 
opinion  I  may  observe,  that  in  all  the  cases  which  I  have  seen, 
the  distress  was  directly  as  the  feebleness  of  murmur  in  the 
affected  lung. 

Thus  if  a  smooth  body,  such  as  a  bean,  enters  the  bronchus, 
and  from  the  efforts  of  inspiration  so  obstructs  the  tube,  as 
totally  to  preclude  the  entrance  of  air,  the  distress  is  enormous, 
the  patient  being  suddenly  deprived  of  the  use  of  half  of  his 
lungs ;  while  on  the  other  hand,  an  irregular  body,  such  as  a 
tooth,  may  exist  long  in  the  same  situation,  with  comparatively 
little  distress,  because,  though  to  a  certain  degree  obstructed, 
the  tube  is  not  impermeable.  I  have  had  repeated  oppor- 
tunities of  confirming  this  opinion,  and  it  appears  that  the 
smoother  the  body,  the  greater  the  liability  of  complete  occlu- 


236  DISEASES     OF    THE    LARYNX   AND    TRACHEA. 

sion  of  the  tube.  In  one  of  the  most  remarkable  instances 
which  I  witnessed,  the  foreign  body  was  a  peeled  kidney-bean, 
and  the  extinction  of  the  respiratory  murmur  was  complete  and 
permanent.  In  two  cases,  however,  in  which  plum-stones  had 
entered,  I  observed  complete  extinction  of  respiration,  and  it  is 
probable  that  a  spasmodic  closing  of  the  tube  around  the  body  had 
then  taken  place.  We  may  also  understand,  that  an  irregularly 
formed  body,  which  can  neither  directly  plug  up  the  tube,  nor  be 
completely  grasped  by  its  spasmodic  contraction,  will  be  less  likely 
to  be  driven  into  the  trachea  by  the  effort  of  expiration,  much  of 
the  effect  of  which  will  be  expended  from  the  pervious  state  of 
the  tube.  Here  we  have  a  cause  of  the  production  of  chronic 
symptoms,  by  extraneous  substances  of  an  irregular  form. 

It  is  an  interesting  fact  in  corroboration  of  this  opinion,  that 
in  the  great  majority  of  cases,  in  which  chronic  consumptive 
symptoms  were  produced,  the  foreign  body  was  of  an  irregular 
form.  The  patients  escaped  rapid  death,  because  the  air  passage 
was  not  completely  obstructed,  and  their  symptoms  resulted 
from  the  long-continued  irritation  of  the  foreign  body. 

In  considering  the  diagnosis  of  this  accident,  I  shall  not  enter 
into  an  analysis  of  the  numerous  cases  on  record,  in  which 
foreign  bodies  have  entered  the  windpipe.  For  however  interest- 
ing these  may  be,  the  observation  of  the  symptoms  is  not  suffi- 
ciently accurate,  nor  has  there  been,  until  our  own  time,  any 
attempt  to  combine  the  evidence  of  symptoms  with  that  of  phy- 
sical signs.  I  shall  therefore  content  myself  with  giving  a  sketch 
of  such  symptoms  as  have  been  observed  previous  to  the  discovery 
of  auscultation,  and  then  examine  the  state  of  our  knowledge  as 
to  the  physical  indications. 

Diagnosis  of  Foreign  Bodies  in  the  Windpipe. — It  has 
been  long  observed,  that  when  the  foreign  body  remained  impacted 
in  the  larynx,  the  symptoms  from  the  first  were  more  violent 
and  distressing.  Incessant  cough  of  a  spasmodic  character, 
croupy  breathing,  pain  in  the  region  of  the  larynx,  paroxysms  of 
suffocation,  are  the  ordinary  symptoms.  The  termination  of  the 
case  may  be  by  sudden  death,  in  consequence  of  the  obstruction 
of  the  rima ;  or  the  foreign  body  may  be  expelled,  or  fall  into  the 
trachea,  and  an  interval  of  comparative  ease  be  induced,  succeeded 
either  by  a  return  of  the  laryngeal  symptoms,  or  by  an  acute  or 
chronic  irritation  of  the  lung  itself. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  237 

The  violence  of  these  S3'mptoms,  however,  does  not  altogether 
depend  on  the  fact  of  the  foreign  hody  heing  lodged  in  the  larynx ; 
much  depends  on  the  degree  of  mechanical  obstruction,  and  the 
nature  of  the  offending  body.  La  Martiniere  has  detailed  a  case 
in  which  a  piece  of  gold  remained  in  one  of  the  ventricles  of  the 
larynx  for  years  without  these  distressing  symptoms.*  Never- 
theless, as  a  general  rule,  the  lodgment  of  the  body  in  the 
larynx  produces  the  greatest  suffering. 

In  this  respect  we  may  divide  the  cases  into  two  classes,  those 
in  which  the  foreign  body  has  remained,  from  the  first,  impacted 
in  the  larynx ;  and  those  in  which,  after  having  passed  this 
portion  of  the  tube,  it  is  driven  upwards  from  the  trachea  to 
be  temporarily  entangled  in  the  larynx,  again  to  descend  into 
the  trachea  or  bronchial  tubes,  producing  those  remarkable  alter- 
nations of  suffering  and  comparative  ease,  so  commonly  observed 
in  cases  of  this  accident. 

But  when  the  body  has  descended  into  the  trachea,  two  orders 
of  symptoms  are  induced,  and  we  may  observe  violent  and  acute 
suffering,  or  symptoms  of  a  much  more  chronic  character. 

In  the  first  case,  the  symptoms  are  in  general  more  or  less 
remittent,  at  least  in  the  earlier  period,  and  we  observe 
violent  paroxysms  of  cough  and  suffocation,  alternating  with 
a  state  of  calm,  often  so  complete,  as  for  a  time  to  banish  all 
apprehension  from  the  minds  of  ordinary  observers  ;  thus  after  a 
paroxysm  so  violent  as  to  threaten  the  life  of  a  child,  we  may  see 
him  return  with  eagerness  to  his  play,  without  the  existence  of 
any  external  symptom  or  sign,  which  could  reveal  the  dreadful 
accident  that  has  befallen  him.  The  paroxysms,  however,  become 
more  frequent  and  severe,  and  inflammation  of  the  mucous 
membrane  begins  to  appear.  At  length  the  irritation  becomes 
permanent,  and  if  relief  be  not  speedily  afforded,  the  patient 
sinks  under  the  aggravated  sufferings  of  obstructed  respiration. 

In  these  cases  the  symptoms  of  fever  are  consecutive  to  those 
of  the  local  irritation,  and  the  paroxysms  of  suffering  are 
induced  either  by  the  body  being  driven  upwards  into  the  larynx, 
or  by  its  being  impacted  in  the  bronchus,  so  as  suddenly  and 
completely  to  obstruct  the  tube,  and  in  a  moment,  as  it  were, 
deprive  the  patient  of  one  lung.  From  the  secretion  of  the 
mucous  membrane,  a  rattling  takes  place  in  the  throat,  and  as 
*  Memoires  de  l'Academie  Royale  de  Ckirurgie. 


238 


DISEASES    OF    THE    LARYNX   AND    TEACHEA. 


the  disease  advances  the  respiration  becomes  stridulous.  Accord- 
ing to  Mr.  Porter,  however,  the  sound  is  never  so  loud  nor  harsh 
as  in  acute  cynanche  trachealis.  Louis  has  described  the  occur- 
rence of  emphysema  above  the  clavicles,  but  this  is  one  of  the 
rarest  symptoms.  Lescure,*  however,  has  mentioned  a  case  in 
which  the  lungs  were  found  emphysematous  throughout  their 
whole  extent. 

As  might  be  expected,  the  cerebral  circulation  suffers  in 
consequence  of  the  violent  cough.  Thus  convulsions  are  com- 
monly observed,  and  even  apoplexy,  particularly  if  the  patient  be 
advanced  in  years. 

In  other  cases  the  brain  may  be  so  injured,  as  that  death  shall 
take  place  with  cerebral  symptoms,  even  after  the  removal  of  the 
foreign  body. 

In  the  second  class  of  cases,  or  those  in  which  the  foreign 
body  remains  in  the  windpipe  or  bronchus,  the  greatest  variety 
of  symptoms  may  be  produced.  And  of  the  recorded  cases  the 
following  are  the  most  remarkable  : 

1.  Chronic  inflammation  of  the  larynx  and  trachea. 

2.  Chronic  phthisis. 

3.  Pulmonary  abscess. 

4.  Bronchitis,  with  or  without  haemoptysis. 

5.  Acute  pleuro-pneumonia. 

6.  Acute  phthisis. 

7.  Asthmatic  symptoms. 

The  subjoined  table,  into  which  I  have  thrown  the  most 
remarkable  cases  on  record,  will  establish  the  above  positions. 


AUTHORITY. 

SYMPTOMS. 

FOREIGN 
BODY. 

RESULT. 

Houston  f 

Sudden   laryngeal   irrita- 
tion after  the  removal 
of    the    second    molar 
tooth ;  disappearance  of 
the  tooth  ;  tendency  to 
sigh ;  occasional  cough  ; 
no  hoarseness  or  stri-. 
dor  ;      respiration      in 
right  lung  feeble,  with 
a  little  bronchitic  rale. 

The  root  & 
fangs    of 
the  tooth. 

Death  in  eleven  days  by 
bronchitis   and  pleuro- 
pneumony,     commenc- 
ing in   the  right   lung 
and  invading  also  the 
left.      The    tooth    -was 
found  in  the  right  bron- 
chus.    The  right  lung 
was  hepatized. 

*  Memoires  de  l'Academie  de  Chirurgie,  tome  v. 

■f  Dublin  Journal  of  Medical  and  Chemical  Science,  vol.  v.,  1834. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA. 


239 


AUTHORITY. 

SYMPTOMS. 

FOREIGN 
BODY. 

RESULT. 

Bonetus.* 

Cough  and  sense  of  suf- 

A cherry- 

Expulsion     after     three 

focation. 

stone. 

weeks.     Recovery. 

ARNOT.f 

Symptoms  of  phthisis. 

A  piece  of 

Expectoration      of      the 

bone. 

bone  two  months  after 
it    had     entered     the 
windpipe.     Recovery. 

GlLROY.; 

Sudden   laryngeal   irrita- 

A portion  of 

Death    in     about    three 

tion   while   at   dinner; 

chicken- 

months    from    the   en- 

violent    cough,     with 

bone 

trance     of    the    bone, 

threatened  suffocation. 

weighing 

which  was  found  in  the 

These    soon    subsided, 

six  grains. 

right    bronchus.     The 

but  slight   cough   and 

bronchial  tube  commu- 

soreness at  the  top  of 

nicated    with    a    large 

the  sternum  remained. 

abscess,          containing 

After   five   weeks,    fe- 

about   twenty    ounces 

ver,  with  violent  cough 

of  pus,  and  occupying 

when  on  assuming  the 

the  right  lung. 

erect  position  ;   hectic  ; 

purulent  expectoration ; 

foeior  of  the  breath. 

Louis.§ 

Cough.       Fever.       Hse- 

A  portion  of 

Aftrr  four  months,  expec- 

moptysis. 

veal  bone. 

toration,  with  reco- 
very. 

Lenglet.  II 

Severe    cough,    suddenly 

A  sharp 

The  bone  was  expectora- 

supervening ;    haemop- 

p;ece of 

ted  after  many  months, 

tysis,    and    consequent 

bone. 

but    the    patient    died 

foetid  and  purulent  ex- 

with abscess  of  the  left 

pectoration  ;     pain    in 

lung. 

the  left  side. 

PELLETAN.^f 

Violent  cough  with  pneu- 

A  piece  of 

The   operation   was   per- 

mon:c symptoms  ;  fail- 

flint. 

formed    after    twenty- 

ure  of   bleeding,  eme- 

two days,  and  the  fo- 

tics, and  blisters  to  re- 

reign body  driven  out 

lieve  it.     The  foreign 

by     expiration.       The 

body  could  be  felt  ex- 

cough  continued ;  pu- 

ternally. 

rulent  expectoration 
supervened.  Death, 
with  phthisical  symp- 
toms in  eight  months 
from  the  accident. 

*  Med.  Sepvem.  Collect.,  lib.  ii.  sect.  9.    De  Affect.  Asp.  Art.  cap.  viii. 

f  Edinburgh  Med.  Essays,  vol.  ii. 

$  Edinburgh  Med.  and  Surg.  Journal,  vol.  xxxv.,  1831. 

§  Mem.  de  lAcademie  de  Chirurgie. 

||   Mem.  de  lAcademie  de  Chirurgie,  torn.  v. 

^f  Clinique  Chirurgicale,  torn.  i. 


240 


DISEASES    OF   THE    LARYNX   AND    TRACHEA. 


AUTHORITY. 

symptoms. 

FOREIGN 
BODY. 

RESULT. 

Desault.* 

Sudden  and  violent  cough, 
with  dyspnoea  and  pain, 
coming    on   while    the 
person  was  eating  cher- 
ries.    Passage  of  these 
symptoms  into  those  of 
laryngeal  phthisis. 

A  cherry- 
stone. 

Death  in  two  jrears.  The 
foreign  body  was  not 
expectorated. 

t 

Violent  cough  subsiding 
in    a    few    hours.     In 
a  year,  return   of   the 
cough,  with  fever. 

A  cherry- 
stone. 

Expectoration  of  a  mass 
of  calcnreous  matter, 
with  the  cherry-stone 
in  the  centre.  Copious 
purulent  expectoration, 
and  death  soon  after- 
wards. 

Craigie.J 

Violent  laryngeal  irrita- 
tion  passing   into    the 
chronic  state. 

An  artificial 
tooth. 

After  two  years,  expecto- 
ration of  the  foreign 
body  ;  partial  recovery  ; 
hsemoptysis,  and  death, 
with  symptoms  of 
phthisis. 

DONALDSON.§ 

Sudden  &  violent  cough- 
ing, followed  after  some 
days  by  vomiting  &  foe- 
tid expectoration,  with- 
out fever.    After  some 
time    the    pulse    rose. 
Sensation  as  of  a  rough 
substance    parsing    up 
and  down  the  sternum. 

A  head  of 
grass,  {cy- 
nosurus 
cristatus.) 

Expectoration  of  the  fo- 
reign body  in  about 
seven  weeks.  Rapid 
recovery. 

Hochsteter.|| 

Hoarseness   and   emacia- 
tion,    supervening     on 
the  entrance  of  a  coin 
during  sleep. 

A  Portugal 
ducat. 

Expectoration  after  two 
years  and  a  half.  Reco- 
very. 

Bartholin.^ 

The  patient  laughed  while 
swallowing  a  nut.   Sud- 
den violent  cough,  fol- 
lowed   by    fever    and 
emaciation. 

A  nut. 

Expectoration   after  two 
months.    Recovery. 

*  (Euvres  Chirurgicales,  torn.  ii. 

f  Ephemerides.  Curios.  Nat.  Decad.  11,  Ann.  x.  Obs.  lxxii. 

%  Edin.  Med.  and  Surg.  Journal,  No.  cxx.,  1834. 

§  Ibid. 

||  Observ.  Decad.  6,  cap.  x. 

1  Hist.  Anat.  Cent.  ii.  Hist.  27. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA. 


241 


AUTHORITY. 

SYMPTOMS. 

FOREIGN 
BODY. 

RESULT. 

Lettsom.* 

Urgent    cough  ;    hoarse- 
ness ;     dyspnoea  ;    ex- 
pectoration    of     dense 
mucus  ;    night  sweats  ; 
emaciation. 

A  button. 

Expectoration  of  the  but- 
ton after  seven  or  eight 
months,  with  recovery. 

NOOTH.f 

Sense  of  weight  and  ful- 
ness  in    the  left   side, 
with    some    dyspnoea ; 
urgent  cough  ;    expec- 
toration of   dense  mu- 
cus ;    hectic,  and  irre- 
gular pulse. 

A    leaden 
shot,  one- 
eighth  of 
an  inch  in 
diameter. 

Expectoration  of  the  fo- 
reign body  after  many 
months.    Recovery. 

BORELLI.J 

Consumptive. 

A  piece  of 
nutmeg. 

Expectoration,  and  reco- 
very. 

Tulpius.§ 

Obstinate     cough,     with 
great  dyspnoea. 

A  nutshell. 

After  seven  years  the  fo- 
reign body  was  ex- 
pelled during  a  violent 
fit  of  coughing. 

BltOUSSAIS.JI 

The   patient    received    a 
ball  in   the  neck,   fol- 
lowed by  a  liability  to 
cough,  without   injury 
of    his   general  health 
for  six  years. 

A  musket 
ball. 

After  seven  years  from 
the  date  of  the  acci- 
dent, death,  with  symp- 
toms of  severe  ataxic 
fever.  For  the  two 
last  years  some  dysp- 
noea, cough,  and  night 
sweats  ;  slight  pains  in 
the  chest,  and  a  ten- 
dency to  lie  on  the  left 
side.  The  left  lung  was 
found  solidified,  with 
seven  or  eight  absces- 
ses. The  ball  was  en- 
cysted, and  lay  near 
the  root  of  the  lung. 

*  Memoir  of  the  Life  and  Writings  of  Dr.  Lettsom,  by  T.  J.  Pettigrew,  1817 
vol.  iii.  p.  82. 

■f  Transactions  of  a  Society,  &c.,  vol.  iii.,  London,  1812.  See  also  Dr.  Craigie's  paper, 
Edin.  Med.  and  Surg.  Journal,  July,  183  i. 

J  Hist.  Med.  Phys.  Cent.  Hist.,  Paris,  1656. 

§  Lib.  ii.  Obs.  vii. 

|1  Histoire  des  Phlegmasies  Chronique=,  tome  ii.  p.  105,  In  this  case  some  doubt 
may  exist  as  to  whether  the  ball  was  the  cause  of  the  fatal  symptoms.  It  was 
perfectly  encysted,  and  the  surrounding  tissue  dense  and  callous.  There  was  no 
marasmus. 


242 


DISEASES    OF    THE    LARYNX    AND    TRACHEA. 


AUTHORITY. 

SYMPTOMS. 

FOREIGN 
BODY. 

RESULT. 

Howship.* 

Sudden     and     incessant 
irritation,      pain      and 
cough  ;     mucous    and 
bloody    expectoration  ; 
wasting ;  fixed  pain  in 
the  right  lung  confined 
to    a   point  ;    frequent 
haemoptysis. 

An  iron 
nail. 

After  nearly  four  months, 
during  a  violent  fit  of 
coughing,  with  copious 
haemoptysis,    the    nail 
was  driven  into  the  ca- 
vity of  the  mouth.  The 
patient   recovered,   but 
for    many    years    was 
subject  to  cough,  with 
slight  haemoptysis,  and 
p^in  in  the  old  situa- 
tion. 

ABERCROMBIE.f 

Sudden  laryngeal    irrita- 
tion ;    gasping  ;   cough 
and  dyspnoea  recurring 
in  fits,  for   some  time 
after  the  accident;  these 
were  succeeded  by  fre- 
quent cough,  dense  mu- 
cous expectoration  and 
rapid  pulse. 

An  artificial 
tooth. 

The    foreign    body    was 
expectorated     in     two 
years  and  seven  months 
after  its  entrance  into 
the    windpipe.      Much 
rplief  followed,  and  the 
p.itient's     health     and 
strength  were  to  a  cer- 
tain   degree    restored  ; 
but  cough  and  expecto- 
ration continued,  with 
great  susceptibility   to 
bronchitis ;  haemoptysis 
supervened ;  and  death 
in  the  early  part  of  the 
fourth   year   from  the 
accident. 

HOLMAR.J 

Cough ;  haemoptysis ;  hec- 
tic ;  diarrhoea. 

A  fragment    After    fifteen    years    co- 

of    bone,  :      pious    haemoptysis   oc- 

|thsof  an  [      curred,  followed  by  the 

inch  long.,      expectoration     of     the 

bone.     Recovery. 

SUE.§ 

While  in  the  act  of  eating 
a  pigeon,  a  portion  of 
the  back  bone  entered 
the    trachea  ;     sudden 
acute  pain  below  the  la- 
rynx supervened.   This 
gradually  subsided,  but 
a  rattle  continued,  par- 
ticularly  on    speaking. 
Thus  she  continued  for 

A  portion  of 
the    ver- 
tebral co- 
lumn of  a 
pigeon. 

After   the    seventh    year 
the  pa;n  changed  its  si- 
tuation, and  was  felt  in 
the  upper  part  of  the 
chest.     The    rale    and 
hissing  sounds   subsid- 
ed,   and    she    was    re- 
lieved   from    dyspnoea 
for  four  months.     Vio- 
lent cough  and  haemop- 

*  Practical  Observations  in  Surgery,  &c.     London,  1816. 

f  See  Dr.  Craigie's  Paper,  Edin.  Med.  and  Surg.  Journal,  1834. 

J  London  Medical  Journal,  vol.  iii. 

§  Mem.  de  l'Acad.  Royale  de  Chhurgie,  tome  v.  p.  533. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA. 


243 


AUTHORITY. 

SYMPTOMS. 

FOREIGN 
BODY. 

RESULT. 

seven   years,   the   pain 
being  occasionally  vio- 
lent,  and    relieved  by 
bleeding. 

tysi-i  then  supervened, 
which    for    five    years 
recurred  every  two  or 
three  months.     For  the 
next  three  months  there 
was  only  a  slight  pain 
in  the  chest,  with  some 
haemoptysis.    The  hec- 
tic symptoms  then  re- 
appeared ;     and    after 
two  years  of  great  suf- 
fering the  bone  iocis  ex- 
pectorated,   having    re- 
mained seventeen  years 
in    the    air    passages. 
Some    relief    followed. 
Hectic  and  emaciation 
followed  and  death  in  a 
year  and  a  half  after- 
wards. 

Although,  this  collection  of  cases  might  be  enlarged,  it  is 
sufficient  to  shew  the  general  features  of  the  subject.  We  learn 
from  it  that  there  is  a  considerable  variation  in  the  symptoms 
produced  by  foreign  bodies  in  the  air  passages  ;  and  that  in  their 
symptoms  no  regular  order  or  succession  can  be  stated  to  exist. 
In  almost  all  the  phenomena  supervened  suddenly,  and  this  was 
even  observed  in  cases  where  the  foreign  body  remained  for  a 
great  number  of  years.  In  some,  as  in  the  cases  by  Pelletan, 
Broussais,  Gilroy,  and  Houston,  the  symptoms  were  those  of 
pneumonia ;  in  the  three  first  cases,  followed  by  abscess,  with 
foetid  and  purulent  expectoration,  and  in  the  last  causing  hepa- 
tization, with  lymph  on  the  pleura,  and  incipient  disease  in  the 
opposite  lung.  These  cases  were  all  fatal.  With  respect  to  the 
instance  recorded  by  Broussais,  it  is  highly  probable  that  the 
pneumonia  with  abscess  under  which  the  patient  sunk,  was  a 
recent  affection,  inasmuch  as  five  years  had  elapsed  between  the 
receipt  of  the  ball  and  the  pneumonic  symptoms,  and  the  ball 
was  firmly  encysted.  The  patient  seems  to  have  died  of  typhoid 
pneumonia,  which,  as  we  shall  hereafter  find,  commonly  engages 
the  left  lung. 

In  a  few,  signs  of  chronic  laryngeal,  rather  than  of  pulmonary 
disease,  were  the  result,  but  in  the  great  majority  the  symptoms 
were  those  of  chronic  irritation  of  the  lung. 

r  2 


244  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

In  many  of  the  cases,  such  as  those  by  Howship,  Lenglet, 
Gilroy,  Donaldson,  and  Sue,  pain  was  felt,  apparently  in  the 
situation  of  the  foreign  body,  and  it  is  interesting  to  observe,  that 
in  all  these  instances  the  foreign  body  was  of  a  sharp  and  irritating 
nature.  The  same  circumstances  occurred  in  a  case  mentioned 
by  Dr.  Brown,  of  a  child  in  whom  a  piece  of  delft  was  forced  into 
the  right  bronchus.  There  was  a  fixed  pain  in  the  upper  part  of 
the  thorax  on  the  right  side,  rather  below  the  level  of  the  upper 
bone  of  the  sternum.  The  operation  was  not  permitted,  and  the 
child  died  on  the  third  day.*  But  we  are  not  to  conclude  that 
such  bodies  uniformly  cause  local  pain,  for  in  several  instances 
where  the  body  was  of  this  description,  local  pain  was  absent, 
as  in  the  case  recorded  by  Houston,  where  the  offending 
substance,  a  large  molar  tooth,  though  it  produced  a  fatal 
pneumonia,  did  not  cause  any  local  pain.f  In  other  instances 
no  mention  is  made  of  local  pain,  so  that  it  may  be  regarded 
as  a  symptom  by  no  means  constant.  In  the  case  by  Sue  we 
observe  a  remarkable  change  in  the  situation  of  the  pain,  and 
the  symptoms  correspond  with  the  different  situations  of  the 
foreign  body. 

The  removal  of  the  foreign  body  by  expectoration,  was  not 
always  followed  by  recovery;  thus  in  the  cases  by  Lenglet, 
Pelletan,  Craigie,  and  Sue,  the  foreign  body  was  expelled,  and 
although  a  certain  amount  of  relief  was  in  some  instances 
afforded,  the  patients  subsequently  died  of  pulmonary  disease. 
Lastly,  we  learn  from  the  case  by  Sue,  that  even  with  a  foreign 
body  remaining  for  many  years  in  the  air  passages  there  may  be 
the  most  singular  remission  of  all  the  symptoms. 

If  we  now  examine  the  fatal  cases  with  respect  to  the  duration 
of  symptoms  we  find  that  this  is  exceedingly  various,  whether  we 
consider  the  case  in  which  the  foreign  body  was  expectorated  or 
those  where  it  remained  in  the  lung  until  the  fatal  termination  : 
thus  in  Dr.  Houston's  case,  death  occurred  on  the  eleventh  day, 
while  in  that  recorded  by  Sue  eighteen  years  and  a  half  elapsed 

*  An  inquiry  how  far  the  operation  of  tracheotomy  may  be  considered  advisable 
in  those  instances  in  which  a  foreign  body  is  lodged  in  either  bronchus,  <Szc.,  Edin. 
Med.  and  Surg.  Journal,  vol.  xxxv.,  1831. 

f  The  crown  of  this  tooth  had  been  broken  off  at  the  first  attempt  of  the  dentist  at 
extraction,  at  the  second  it  was  started  from  its  socket,  and  then  passed  into  the 
trachea.  For  the  first  few  dajs  the  patient  suffered  almost  nothing,  for  although  the 
body  lay  in  the  right  bronchus  it  did  not  altogether  impede  the  entrance  of  air. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  245 

after  the  entrance  of  the  foreign  body,  before  death  took  place, 
and  seventeen  years  before  it  was  expectorated. 

It  has  been  considered  by  some  that  a  great  specific  gravity  of 
the  foreign  body  would  prevent  its  expectoration.  But  although 
in  the  majority  of  cases,  the  body  expectorated  was  of  a  light 
nature,  yet  instances  are  not  wanting  in  which  very  heavy  sub- 
stances were  thus  expelled.  It  is  true  that  in  the  case  by 
Broussais,  in  which  probably  the  heaviest  body  on  record  entered 
the  lung,  it  was  not  expectorated,  but  although  it  is  likely  that 
even  if  its  size  had  permitted  it  to  enter  the  trachea  in  the  usual 
way,  its  weight  would  have  prevented  its  expulsion,  yet  it  must 
be  recollected,  that  the  case  was  one  of  gun-shot  wound,  and  that 
the  ball  was  probably  soon  encysted.  On  the  other  hand  we  find, 
that  as  in  the  case  by  Nooth  a  leaden  shot  may  be  expectorated. 
In  Hochsteter's  case  a  Portugal  ducat  was  coughed  up,  in 
Howship's  an  iron  nail,  and  in  Abercrombie's  an  artificial  tooth ; 
so  that  there  is  sufficient  evidence  for  stating,  that  however  great 
be  the  specific  gravity,  the  foreign  body  may  yet  be  expectorated. 
Finalby,  we  may  observe,  that  these  cases  afford  additional 
evidence  of  the  much  greater  liability  of  foreign  bodies  to  enter 
the  right  bronchial  tube.*' 

In  considering  the  application  of  the  stethoscope  and  percussion 
to  the  detection  of  a  foreign  body  in  the  windpipe  or  lung,  we 
find  that  the  diagnosis  is  founded  on  the  combination  of  physical 
signs  with  the  history  of  the  case,  and  the  local  and  general 
symptoms.  It  is  true  that  previous  to  the  introduction  of 
auscultation,  instances  are  not  wanting  of  successful  diagnosis  of 
the  accident,  but  in  many  cases  the  question  was  most  difficult, 
and  the  scientific  surgeon  could  not  demonstrate  the  nature  of  the 
case,  with  the  certainty  requisite  to  convince  ignorance,  and  re- 
move the  "  opposition  meurtriere  "f  on  the  part  of  other  medical 
attendants,  whose  confidence  was  greater  than  their  knowledge. 
But  in  the  application  of  the  stethoscope  and  percussion  to  this 
purpose,  we  have  one  of  the  most  splendid  examples  of  their 
utility,  and  to  Mr.  Key  is  due  the  merit  of  having  first  employed 

*  There  is  another  class  of  cases  of  foreign  bodies  in  the  lung  which  I  shall  merely 
mention,  namely  those  in  which  various  substances  are  introduced  by  wounds  of  the 
thorax  or  neck.  With  the  exception  of  that  by  Broussais,  all  the  cases  in  the  fore- 
going table  exemplify  the  entrance  of  the  offending  substance  through  the  aperture 
of  the  glottis. 

f  Louis,  Mem.  de  l'Acad.  de  Chirurgie,  tome  v. 


* 


246  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

these  means  and  of  pointing  out  the  essential  physical  indi- 
cations. 

The  observations  which  I  have  to  offer  upon  this  subject  have 
reference  solely  to  acute  cases.  I  have  had  no  opportunity  of 
examining  any  case  in  which  the  foreign  body  had  remained  long 
enough  to  produce  consumptive  symptoms. 

The  grounds  of  the  diagnosis  are,  that  in  a  case,  the  history 
and  symptoms  of  which  lead  to  the  suspicion  that  a  foreign  body 
entered  the  windpipe,  we  discover — 

1st.  Signs  of  obstruction  of  the  right  bronchus,  the  obstruc- 
tion being  either  partial  or  complete,  permanent  or  inter- 
mitting. 

2nd.   Signs  of  an  irritation  in  the  right  lung. 

3rd.  Evidence  of  the  alternation  of  the  stethoscopic  signs  of 
bronchial  obstruction,  with  the  symptoms  of  violent  laryngeal 
irritation  and  spasm. 

4th.  The  occurrence  of  all  or  any  of  these  signs  in  a  sudden 
manner,  and  in  a  patient  previously  healthy. 

We  shall  consider  each  of  those  classes  of  signs  briefly.  When, 
as  is  almost  always  the  case,  the  foreign  body  is  lodged  in  the  right 
bronchus,  one  of  two  effects  is  produced  ;  it  either  closes  the  tube 
completely,  permitting  no  air  to  pass,  or  it  lies  loosely  in  its 
cavity,  so  as  to  admit  to  a  certain  degree,  the  passage  of  air  into 
the  lung.  In  the  first  case  no  vesicular  expansion  whatever  can 
be  heard  in  the  affected  side  ;  the  sound  on  percussion  continues 
clear,  while  in  the  opposite  lung  the  respiration  is  intensely 
puerile  ;  and  thus  is  formed  a  group  of  signs  which  does  not  occur 
in  anv  other  affection  of  the  lung. 

The  most  remarkable  instance  of  this  which  I  have  witnessed, 
was  in  the  case  of  a  child  who  was  brought  to  the  Meath  Hospital, 
with  the  symptoms  and  signs  of  a  foreign  body  in  the  windpipe  : 
after  some  hours  the  alternating  signs  of  laryngeal  and  bronchial 
obstruction  disappeared,  and  the  body  became  fixed  in  the  right 
bronchus.  No  respiration  whatsoever  could  be  heard  in  the 
affected  lung.  Tracheotomy  was  performed,  but  the  foreign 
body  was  not  expelled,  nor  could  it  be  removed  with  the 
forceps.  After  more  than  twelve  hours  of  intense  sufferiug, 
it  was  obvious  that  life  was  fast  ebbing,  when  after  passing 
in  a  bullet  probe,  the  foreign  body,  a  peeled  kidney  bean 
was   suddenly  ejected,  and   recovery   followed.     This  complete 


DISEASES    OF    THE    LARYXX   AND    TRACHEA.  247 

closing  of  the  tube  was  also  observed  in  the  cases  by  Professor 
Macnamara.*' 

During  this  perfect  obstruction  of  the  bronchus  there  is  no 
stritlulous  breathing,  nor  are  any  signs  of  bronchitis  observable 
in  the  affected  lung.  The  obstruction  and  its  consequent  signs 
may  be  permanent  or  intermittent,  and  there  is  not  in  the  whole 
range  of  stethoscopy  a  more  striking  phenomenon,  than  the 
sudden  rush  of  air  into  the  lung,  on  the  foreign  body  passing 
into  the  windpipe,  or  the  equally  sudden  disappearance  of  all 
sound  of  expansion,  natural  and  morbid,  when  the  bronchus 
becomes  again  obstructed. 

But  the  signs  are  different  when  the  tube  is  but  partially  closed  ; 
we  have  then,  in  the  affected  lung,  a  murmur  diminished  in 
proportion  to  the  obstruction. 

In  this  way  a  difference  of  murmur  in  either  lung,  greater  than 
natural,  and  incapable  of  being  accounted  for  on  any  other 
supposition  than  that  of  a  foreign  body,  is  discoverable.f  This 
difference,  occurring  in  a  case  of  suspicion,  and  in  a  person  who 
had  been  previously  healthy,  and  coinciding  with  equal  clearness 
of  sound  on  both  sides,  is  an  important  diagnostic  of  partial 
closing  of  the  tube.j: 

The  next  evidence  is  founded  on  the  existence  of  signs  of  irri- 
tation in  the  trachea  and  upper  portion  of  the  lung.  As  might 
be  expected,  a  mucous  irritation,  spreading  from  the  large  to  the 
smaller  tubes,  is  soon  produced,  and  we  discover  a  sonoro-mucous 
rattle  in  the  trachea  and  upper  portion  of  the  lung  presenting  the 
feeble  respiration.  For  reasons  already  stated,  these  signs  are 
almost  always  met  with  in  the  right  lung,  so  that  under  the 
circumstances  in  question  the  sudden  occurrence  of  bronchitic 
rales  in  the  trachea  and  upper  portion  of  the  right  lung,  forms 
an  additional  diagnostic  of  the  nature  of  the  case.  Of  course 
these  phenomena  can  be  only  met  with  in  the  lung,  when  the 
closing  of  the  bronchus  is  incomplete. 

*  Cases  of  foreign  bodies  in  the  trachea.     Dublin  Hospital  Reports,  vol.  v. 

t  It  must  be  always  borne  in  mind,  that  the  vesicular  murmur  in  the  right  lung  is 
often  a  shade  less  loud  than  that  in  the  left.  I  have  found  this  difference  most  often 
in  young  females. 

%  There  are  but  three  affections  capable  of  producing  signs,  at  all  similar  to  those 
mentioned  in  the  text,  these  are  aneurismal  tumours  compressing  the  bronchus, 
■organic  tumours  of  other  descriptions,  the  obstruction  of  the  tube  by  an  hypertrophy 
of  the  mucous  membrane,  or  lastly,  a  copious  secretion  of  adhesive  mucus  or 
lymph. 


r 


248  DISEASES    OF    THE    LAKYNX    AND    TRACHEA. 

The  amount  of  this  irritation  will  of  course  vary  according 
to  many  circumstances,  and  the  physical  signs  may  proceed 
from  the  evidences  of  a  slight  hronchitis  to  those  of  congestion, 
solidification,  and  abscess. 

Observations  are  still  wanting  to  shew  how  far  the  existence  of 
a  foreign  body  may  modify  the  physical  signs  of  these  advanced 
stages  of  irritation. 

The  next  source  of  diagnosis,  namely,  the  alternation  of  the 
stethoscopic  signs  of  bronchial  obstruction  with  the  symptoms  of 
laryngeal  irritation,  forms,  when  available,  the  most  important 
and  conclusive  diagnostic. 

While  the  foreign  body  is  lodged  in  the  bronchus,  at  least  in 
the  early  stages,  the  patient  is  in  comparative  ease,  unless  the 
obstruction  be  complete,  and  we  observe  a  diminished  murmur  in 
the  affected  lung.  But  on  the  body  being  removed  by  coughing, 
and  driven  into  the  larynx,  all  these  circumstances  are  changed, 
the  suffering  of  the  patient  is  extreme,  his  existence  seems 
threatened  by  the  violence  of  the  cough  and  spasm,  and  the  lungs 
may  be  observed  to  be  equally  filled  during  inspiration.  After  a 
time  the  foreign  body  may  again  descend,  and  thus  alternately 
produce  a  train  of  phenomena  not  to  be  met  with  in  any  known 
case  of  idiopathic  pulmonary  disease. 

I  need  hardly  comment  on  the  value  of  the  last  source  of  diag- 
nosis, namely,  the  suddenness  of  the  symptoms.  We  here  apply 
to  the  detection  of  a  foreign  body,  the  principle  by  which  internal 
solutions  of  continuity  are  discovered,  namely,  the  suddenness  of 
the  appearance  of  new  and  striking  symptoms  in  a  person  either 
previously  healthy,  or  labouring  under  symptoms  of  a  totally 
different  class ;  and  in  one  respect  there  is  a  similarity  between 
the  accident  under  consideration  and  the  internal  solution  of  con- 
tinuity, namely,  the  entrance  into  a  cavity,  of  a  substance  foreign 
to  that  cavity,  so  that  we  have  an  analogy  between  the  entrance 
of  the  faecal  matter  into  the  peritoneum,  and  the  foreign  body 
into  the  trachea. 

I  need  hardly  remark,  that  although  the  sudden  supervention 
of  new  and  violent  symptoms  is  seen  in  the  majority  of  cases,  yet 
it  is  not  so  constant  as  to  be  uniformly  available.  On  the  other 
hand,  I  may  add,  that  although  suddenness  and  violence  of 
symptoms  are  generally  combined,  the  latter  is  not  nnfrequently 
absent ;  yet  here  the  sudden  supervention  of  even  mild  symptoms, 


DISEASES    OF    THE    LAKYNX   AND    TEACHEA.  249 

particularly  if  under  suspicious  circumstances,  is  of  the  utmost 
value  in  diagnosis. 

Hitherto  we  have  studied  the  signs  of  foreign  bodies  in  the  air 
passages,  with  reference  to  their  lodgment  on  one  side,  so  as  to 
admit  of  the  diagnosis  by  comparison.  I  shall  now  detail  a  case 
in  which  the  trachea  itself  was  obstructed,  producing  similar 
phenomena  on  either  side. 

A  gentleman  aged  twenty,  who  had  previously  enjoyed  the  best 
health,  while  conversing  in  the  act  of  eating  a  piece  of  cheese 
after  a  hearty  dinner,  suddenly  fell  from  his  chair  in  a  state 
of  insensibility.  On  the  supposition  that  a  foreign  body  had 
become  fixed  in  the  oesophagus,  a  probang  was  speedily  passed, 
and  after  about  ten  minutes  he  partially  recovered.  Soon  after, 
however,  the  attack  recurred  with  great  violence,  the  face  was 
strongly  congested,  and  the  breathing  spasmodic  and  stertorous. 
He  was  then  freely  bled,  but  no  improvement  followed.  Stimu- 
lating injections  and  a  second  bleeding  were  employed,  but  still 
without  relief,  the  situation  of  the  patient  becoming  every 
moment  more  critical.  A  loud  rattling  in  the  throat  now  super- 
vened. [The  patient  tossed  himself  on  the  bed,  and  threw  his  arms 
about  so  as  to  extend  the  chest  as  much  as  possible.  All  the 
muscles  of  inspiration  were  in  the  most  violent  action ;  and  the 
surface  of  the  body  became  pale  and  cold.  Hours  had  now 
elapsed  :  the  failure  of  all  means  employed  led  to  the  suspicion 
that  the  case  might  be  one  of  asphyxia  from  tracheal  obstruction, 
and  a  stethoscopic  examination  having  been  made,  the  following 
circumstances  were  observed. 

The  chest  sounded  everywhere  clear,  but  the  vesicular  murmur 
could  scarcely  be  perceived  in  any  portion  of  the  lungs,  the 
feebleness  being  equal  and  universal,  notwithstanding  that  the 
patient  made  the  most  violent  efforts  of  inspiration.  A  loud 
sonoro-mucous  rattle,  every  moment  increasing,  was  heard  in  the 
trachea,  while  the  slight  dilatation  of  the  chest  compared  with 
the  respiratory  efforts  clearly  pointed  out  some  obstruction  in  the 
windpipe. 

The  question  then  arose,  what  was  the  nature  of  this  obstruc- 
tion :  had  a  morsel  of  food  passed  into  the  trachea,  or  were  the 
symptoms  produced  by  a  spasm  of  the  glottis,  consequent  on 
cerebral  irritation  ?  The  failure  of  treatment  calculated  to  relieve 
the  brain,  and  the  evident  secretion  into  the  trachea,  as  shewn  by 


250  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

the  loud  rattle  at  the  top  of  the  sternum,  were  strongly  in  favour 
of  the  first  opinion,  and  it  was  obvious  that  as  the  patient  was 
dying  of  laryngeal  or  tracheal  obstruction,  something  should  be 
done  to  give  immediate  relief.  The  operation  of  tracheotomy  was 
then  performed,  and  a  crucial  incision  made  through  the  tube, 
and  on  the  angular  portions  between  the  incisions  being  re- 
moved, a  mass  of  pultaceous  matter  was  forcibly  ejected  through 
the  opening,  with  complete  and  instantaneous  relief  to  the  symp- 
toms. Respiration  became  easy,  the  expansion  of  the  lung  full 
and  audible,  the  patient  breathed  through  the  glottis,  and  re- 
covered without  a  bad  symptom. 

In  about  four  weeks,  however,  he  was  attacked  with  symptoms 
of  cerebral  irritation,  and  had  a  fit  resembling  epilepsy;  during  the 
next  three  months  these  attacks  recurred  several  times,  becoming 
gradually  less  severe.  They  then  altogether  subsided;  and  for 
the  last  four  years  he  has  had  no  return  of  the  disease.  The 
treatment  consisted  in  small  bleedings,  cold  to  the  head,  and  the 
use  of  turpentine. 

It  must  be  confessed,  that  there  is  some  difficulty  in  coming  to 
a  conclusion  as  to  the  nature  of  this  case,  yet,  although  its  subse- 
quent history,  and  the  fact  of  the  foreign  body  not  being  producible, 
seem  to  favour  the  idea  that  the  disease  was  from  the  first  cere- 
bral ;  there  are  circumstances  which  prove  that  it  was  in  reality 
one  of  foreign  body  in  the  trachea,  and  that  many  of  the  symp- 
toms during  the  attack  were  caused  by  obstructed  respiration. 

In  the  first  place,  the  attack  came  on  while  the  individual  was 
eating,  and  at  the  same  time  conversing,  circumstances  likely  to 
cause  the  entrance  of  a  foreign  body  into  the  windpipe. 

2nd.  Although  in  certain  cases  of  disease  in  children  and  in 
adults  of  a  high  nervous  temperament,  spasm  of  the  glottis  is 
symptomatic  of  cerebral  disease,  yet  in  a  young  and  robust  man 
J    such  a  symptom  is  exceedingly  rare. 

3rd.  We  have  the  important  symptom  of  copious  secretion 
from  the  mucous  membrane.  I  believe  that  this  is  quite  conclu- 
sive against  the  opinion  that  spasm  of  the  glottis  existed ;  such 
an  occurrence  is  not  seen  in  the  nervous  affections  of  the  tube, 
but  as  one  of  the  symptoms  of  a  foreign  body  in  the  trachea,  and 
resulting  from  its  direct  irritation,  it  has  the  highest  value.* 

*  Of  this  symptom,   Pelletan  says,  "  une  ralement,  signe  characteristique  de  la 
maladie.'- — Clinique  Chirurgicale. 


DISEASES    OF    THE    LARYNX   AXD    TRACHEA.  251 

4th.  The  result  of  the  operation  may  well  he  appealed  to; 
sudden  and  complete  relief  followed  the  expulsion  of  a  soft  matter 
from  the  trachea,  which,  from  its  nature,  and  the  violence  of  its 
expulsion,  was  scattered  so  as  to  render  it  impossihle  to  obtain 
it,  but  the  patient  breathed  easily  through  the  glottis,  from  the 
moment  of  the  operation.  No  means  were  used  to  keep  the  orifice 
open,  and  unless  the  making  of  a  wound  in  the  trachea  could  be 
supposed  capable  of  relieving  violent  and  increasing  cerebral 
disease,  there  is  no  alternative  but  the  belief  in  the  existence  of  a 
foreign  body. 

5th.  It  must  be  recollected  how  completely  the  physical  signs 
and  history  of  the  case  coincide  with  the  phenomena  which  a 
foreign  body  would  produce.  For  myself  I  have  no  doubt  of 
the  true  nature  of  the  case,  and  consider  it  as  a  decided  example 
of  foreign  body  in  the  air  passages. 

But  without  impugning  the  foregoing  observations,  or  the 
operation,  we  may  take  another  view  of  the  case,  and  inquire 
whether  the  original  attack  was  not  really  cerebral,  and  that  the 
foreign  body  entered  the  windpipe  during  the  convulsion.*  To 
this  opinion  Mr.  Read,  who  treated  the  case  throughout,  now 
inclines.  The  question  is  a  difficult  one  :  the  subsequent  history 
of  the  case  tells  both  ways  ;  for  we  might  expect  that  after  such 
a  violent  and  protracted  struggle,  some  cerebral  injury  would  be 
inflicted  ;  and  the  complete  disappearance  of  the  attacks  after 
three  months  strengthens  the  opinion,  that  they  were  but  the 
echoes  of  the  first  invasion,  which  was  induced  by  the  mechanical 
impediment  to  respiration. f 

As  illustrative  of  some  novel  and  curious  points  in  the  history 
of  foreign  bodies  in  the  windpipe,  the  following  case,  abridged 
from  the  paper  of  Professor  Macnamara,  has  considerable  interest. 

A  boy  was  brought  to  the  Meath  Hospital  on  the  5th  of 
September,  1829.  It  appeared  that  three  days  before,  he  had 
been  whistling  through  a  plum- stone,  which  was  perforated  upon 
each  side,  and  the  kernel  removed,  this  being  placed  across  the 
lips  passed  during  a  strong  inspiration  through  the  glottis,  and 

*  It  has  been  found  that  in  animals  that  have  been  killed  by  a  blow  on  the  head, 
portions  of  food  pass  into  the  trachea. — See  Med.  Jurisprudence,  by  raris  and 
Fonblanque. 

t  For  permission  to  publish  these  particulars,  I  am  indebted  to  Mr.  Read,  President 
of  the  Royal  College  of  Surgeons,  to  whose  judgment  and  de-Lsion  in  this  most 
embarrassing  case,  I  feel  happy  in  bearing  my  testimony. 


252  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

became  fixed  transversely  in  the  larynx.  So  little  inconvenience 
did  this  produce,  that  on  his  finding  even  in  this  situation  he 
could  whistle  through  the  stone,  he  went  about  for  some  hours, 
pleased  with  his  new  and  convenient  mode  of  producing  sound. 
During  three  days  previous  to  his  entrance  into  hospital,  he 
suffered  but  little  inconvenience,  except  that  he  was  now  and  then 
disturbed  with  suffocative  cough,  but  he  was  able  to  run  about, 
and  occupy  himself  in  his  childish  amusements.  On  admission 
he  did  not  complain  of  pain  on  deglutition.  He  said  that  the 
cough  caused  pain  in  his  throat,  but  only  during  severe 
paroxysms  :  he  had  a  dull  pain  in  the  epigastrium,  a  bloated 
countenance,  and  a  pulse  at  106.  The  fits  of  coughing  resembled 
those  of  suffocative  catarrh,  and  were  followed  by  white  frothy 
expectoration.  Chest  clear  on  percussion,  and  the  vesicular 
murmur  natural.  In  this  case  the  whistling  sound  in  the  trachea 
being  sufficient  to  establish  the  diagnosis,  the  operation  of  laryn- 
gotomy  was  performed,  but  during  the  struggle  and  convulsive 
cough  which  followed  the  opening,  the  patient  declared  that  he 
had  coughed  up  the  stone  and  swallowed  it. 

That  such  was  the  fact  seemed  to  be  proved  by  the  relief  of  the 
symptoms,  and  the  disappearance  of  the  whistling ;  but  it  was 
found  that  according  as  the  wound  healed,  the  distress  and 
whistling  sound  returned,  proving  that  the  foreign  body  must 
have  been  placed  above  the  opening,  and  that  the  disappearance 
of  the  whistling  in  the  first  instance,  was  owing,  not  to  a 
removal  of  the  foreign  body,  but  to  the  admission  of  air  below  the 
point  in  which  it  was  fixed.  Soon  after  this  it  was  found  to 
change  its  situation,  and  to  pass  down  the  right  bronchus,  again 
to  be  driven  upwards  into  the  larynx.  By  a  second  operation 
it  was  finally  extracted,  and  the  patient  recovered  without  any  bad 
symptom. 

From  what  has  been  now  stated  it  would  appear — 

1st.  That  bodies  of  greater  volume  than  the  ordinary  size  of 
the  glottis  would  seem  to  admit,  may  be  forced  through  that 
aperture  by  the  efforts  of  inspiration. 

2nd.  That  the  foreign  body  may  remain  impacted  in  the 
glottis,  or  become  entangled  in  the  cavity  of  the  larynx ;  it  may 
remain  in  the  trachea  either  free  or  fixed,  or  pass  into  either 
bronchial  tube. 

3rd.  That  the  cases  in  which  it  enters  the  right  bronchus  are 


DISEASES    OF   THE    LARYNX   AND    TRACHEA.  253 

so  much  more  numerous  than  those  in  which  it  occupies  the 
left,  as  to  make  the  signs  of  irritation  and  obstruction  of  the 
right  lung,  important  diagnostics  of  the  accident  in  question. 

4th.  That  the  symptoms  vary  according  to  the  situation  and 
form  of  the  foreign  body. 

5th.  That  the  diagnosis  depends  on  a  careful  comparison  of 
the  history  and  symptoms  of  the  case,  with  the  physical  signs. 

6th.  That  the  physical  signs  depend — 

a.  On  the  situation  of  the  foreign  body. 

b.  On  the  amount  of  obstruction  which  it  offers  to  the  entrance 
of  air.* 

c.  On  the  irritation  of  the  mucous  membrane  which  its 
presence  causes. 

7th.  That  when  the  foreign  body  remains  in  the  larynx 
or  trachea,  its  physical  signs  are  more  obscure  than  when  it 
occupies  but  one  bronchus,  there  being  no  difference  of 
phenomena  in  either  lung.  -r 

8th.  But  that  when  it  enters  the  bronchus  it  may  close  the 
tube  either  partially  or  completely. 

9th.  That  hence  the  vesicular  murmur  in  the  corresponding 
lung  is  either  greatly  lessened  or  altogether  extinguished,  while 
the  sound  on  percussion  remains  the  same,  and  the  opposite 
lung  presents  the  puerile  respiration. 

10th.  That  the  signs  of  partial  or  complete  obstruction  of  the 
tube  may  suddenly  disappear,  and  as  suddenly  return. 

11th.  That  in  cases  where  the  foreign  body  has  completely 
obstructed  the  bronchus,  its  passage  into  the  trachea  is  followed 
by  a  return  of  vesicular  murmur  in  the  affected  lung. 

12th.  That  the  physical  signs  of  irritation,  consisting  in  a 
sonorous,  or  sonoro-mucous  rattle,  may  be  found  at  the  top  of 
the  sternum,  and  in  the  situation  of  the  right  bronchus. 

13th.  That  the  physical  signs  in  the  commencement  are  those 
of  mucous  irritation,  varying  according  to  the  physical  changes 
of  the  lung. 

14th.  That  the  physical  signs  of  irritation  precede  the  con- 
stitutional disturbance. 

15th.  That  in  the   alternation   of   the  stethoscopic    signs  of 

*  Some  have  stated  that  they  have  been  able  to  hear  a  sound  produced  by  the 
movements  of  the  foreign  body  in  the  trachea  itself.  Indeed  I  once  believed  that  I 
had  heard  this  sound,  but  as  further  observations  seem  necessary  to  establish  it,  I  have 
not  included  it  in  the  list  of  physical  signs. 


254  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

bronchial  obstruction,  with  the  ordinary  symptoms  of  laryngeal 
distress,  we  have  a  most  important  diagnostic  of  the  accident 
in  question. 

16th.  That  in  certain  cases,  the  bronchial  obstruction  (hitherto 
observed  only  in  the  right  tube)  differs  from  all  other  examples 
of  the  same  physical  condition  from  other  causes,  in  its  being 
so  complete  and  sudden. 

17th.  That  the  sudden  appearance  of  irritation  of  the  larynx 
and  bronchus,  in  a  patient  who  had  before  presented  no  evidence 
of  thoracic  disease,  is  strong  evidence  that  a  foreign  body  has 
entered  the  air  passages. 

18th.  That  a  foreign  body  may  be  immediately  expelled  by 
coughing,  or  remain  in  the  air  passages  so  long  as  seventeen 
years. 

19th.  That  where  a  foreign  body  becomes  lodged  in  the 
bronchial  tube,  it  causes  symptoms  of  acute  irritation,  or  of 
more  chronic  disease. 

20th.  That  in  the  acute  cases,  the  patient  may  die  of  pleuro- 
pneumony,  without  suppuration  of  the  lung. 

21st.  That  in  other  cases  an  abscess  is  formed,  and  the  patient 
has  foetid  and  purulent  expectoration. 

22nd.  That  in  the  more  chronic  cases,  there  is  a  predominance 
of  either  laryngeal  or  pulmonary  irritation. 

23rd.  That  in  the  latter  case,  haemoptysis,  emaciation,  and 
hectic  are  commonly  observed,  while  in  a  few  instances,  the 
symptoms  have  more  of  an  asthmatic  character. 

24th.  That  the  situation  of  the  foreign  body  may  be  pointed 
out  by  local  pain,  but  that  this  is  not  a  constant  symptom,  even 
when  the  body  is  of  an  irritating  nature  and  irregular  form. 

25th.   That  the  removal  of  the  foreign    body   is   not  always 
followed  by  recovery  from  the  symptoms  which  it  has  produced. 
•     26th.   That  an  almost  complete  remission  of  the  symptoms, 
even  for   years,    may    occur,    although    the    foreign    body    still 
remains  in  the  lung. 

27th.  That  a  great  specific  gravity  of  a  foreign  body  does  not 
prevent  its  expectoration. 

As  the  treatment  of  this  accident  is  essentially  a  surgical 
question,  I  shall  not  discuss  the  subject  at  any  length.  It  has 
been  proposed  to  use  emetics  in  such  cases,  and  instances  are 
on  record,  where  the  use  of  stimulating  and  emetic  medicines, 


DISEASES    OF    THE   LARYNX   AND    TRACHEA.  255 

was  followed  by  the  expulsion  of  the  foreign  body.  On  the  other 
hand,  such  treatment  has  frequently  failed ;  and  when  we 
consider  the  formidable  nature  of  the  accident,  and  the  impor- 
tance of  a  speedy  extraction,  it  seems  unjustifiable  to  delay  the 
operation.  It  must  be  recollected,  that  circumstances  favour  the 
entrance  of  a  body  through  the  glottis,  much  more  than  its 
expulsion  ;  for  in  the  first  case,  the  aperture  is  dilated  to  its 
greatest  extent,  and  the  body  carried  in  by  the  force  of  the  in- 
spired air,  while  in  the  second,  it  must  be  expelled  during  ex- 
piration, when  the  irritation  on  passing  through  the  larynx  will 
probably  produce  a  spasmodic  closing  of  the  glottis.  Under 
these  circumstances,  by  causing  the  offending  substance  to 
become  impacted  in  the  glottis,  the  act  of  vomiting  might  pro- 
duce sudden  death.  Let  us  further  recollect,  that  the  foreign 
body  may  not  be  presented  to  the  rima  in  the  same  position  as 
that  in  which  it  entered.*  A  plum-stone  may  pass  through 
the  glottis  with  ease,  because  it  enters  with  its  longest  axis  fore- 
most, when  were  it  placed  transversely,  it  could  never  pass  the 
aperture.  Now  the  expulsion  of  such  a  body  by  vomiting,  would 
require  that  it  should  be  presented  to  the  glottis  in  its  first 
direction,  and  it  is  obvious,  that  we  have  no  means  of  insuring 
such  a  result.  We  learn  from  the  case  by  Professor  Macnamara, 
that  even  after  such  a  substance  has  lodged  in  the  bronchus,  in 
which,  as  shewn  by  the  physical  signs,  it  must  have  lain  in 
the  direction  of  its  longest  axis,  it  may,  when  driven  into  the 
trachea  or  larynx,  change  its  direction,  and  lie  transversely  in 
the  tube. 

If  there  be  any  case  in  which  the  emetic  plan  would  appear 
justifiable,  it  would  be  that  of  a  foreign  body  much  smaller 
than  the  glottis  during  expiration ;  of  a  smooth  surface  and 
rounded  form,  and  one  not  likely  to  increase  in  bulk  by  remaining 
in  the  air  passages.  An  inspection  of  the  table  which  I  have 
given,  will  shew  how  rarely  such  a  combination  of  circumstances 
will  be  met  with  ;  and  it  must  be  always  recollected  that  the 
earlier  the  operation  is  performed,  the  better  the  chance  of 
success,  whether  we  consider  the  extraction  of  the  body,  or  the 
prevention  of  the  consequent  injurious  results  on  the  lung, 
windpipe,  or  brain. 

On  the  performance  of  tracheotomy  in  these  cases,  and  the 

*  Surgical  Pathology  of  the  Larynx  and  Trachea,  p.  201. 


256  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

different  modifications  of  the  operation,  I  refer  the  reader  to  the 
writings  of  Louis,*  Desault,t  Pelletan,J  Burns, §  Porter,  ||  and 
Brown,^ 

TUMOURS   EXTERNAL    TO,    AND    COMPRESSING    THE    WINDPIPE. 

Under  this  head  may  be  classed  many  affections,  which 
though  agreeing  in  their  physical  effect  on  the  trachea,  yet 
differ  greatly  in  nature,  and  consequently  in  their  progress  and 
symptoms. 

We  may  classify  these  tumours  as  follows  : — 

a.  Tumours  of  the  neck. 

b.  Deep  seated  tumours. 

Under  the  first  class  we  may  place — 

1.  Abscess  of  the  neck. 

2.  Hydrocele  of  the  neck. 

3.  Enlargement  of  the  lymphatic  glands. 

4.  Hypertrophy  of  the  thyroid. 

5.  Aneurism  of  the  carotid  and  thyroid  arteries. 

6.  Solid  tumours  of  the  neck ;  often  of  a  malignant  nature. 
In  these  cases,  the  situation  of  the  disease  at  its  commence- 
ment is  above  the  clavicles.  In  the  next  class,  however,  although 
the  tumours  may  rise  up  so  as  to  deform  the  neck,  and  dislocate 
the  windpipe,  yet  the  disease  begins  within  the  chest  and 
proceeds  upwards.  Of  these  tumours  the  following  have  been 
observed  : 

1.  Aneurisms  of  the  aorta  and  innominata. 

2.  Cancerous  tumours  of  the  posterior  mediastinum  and 
lung. 

3.  Hypertrophy  of  the  bronchial  glands. 

4.  Melanotic  and  tuberculous  alterations  of  these  glands. 

5.  Hypertrophy,  and  other  diseases  of  the  thymus. 
Considered  with  relation  to  the  trachea,  we  find  that  between 

the  first  and  second  class  of  tumours,  there  is  a  difference  with 
respect   to    the  probability   of  compression.     In  the  first  case 

*  Memoires  de  l'Acad.  Eoyale  de  Chirurgie,  I.  xi:. 

f  CEuvres  Chirugicales*,  tome  ii. 

%  Clioique  Chirurgicale,  tome  i. 

§  Surgical  Anatomy  of  the  Head  and  Neck. 

||  Op.  cit. 

^f  Edinburgh  Medical  and  Surgical  Journal. 


DISEASES    OF    THE    LARYNX    AND    TRACHEA.  257 

enormous  tumours  may  form  without  encroaching  on  or  displacing 
the  windpipe,  a  fact  explicable  by  the  yielding  of  the  integu- 
ments of  the  neck,  so  that  unless  in  some  cases  of  bronchocele, 
and  hydrocele  of  the  neck,*  we  seldom  witness  tracheal  com- 
pression from  tumours  which  have  sprung  from  above  the 
clavicle. 

But  in  the  second  class  the  circumstances  of  the  tumour  are 
different,  and  we  find  it  surrounded  by  resisting  parietes,  no 
matter  whether  it  has  sprung  from  the  anterior  or  posterior 
mediastinum.  Confined  anteriorly  by  the  clavicles  and  sternum, 
its  pressure  must  be  directed  inwards,  so  as  to  engage  not  only 
the  windpipe,  but  the  great  blood  vessels,  while  on  the  other 
hand  should  it  grow  from  behind  forwards,  it  has  the  spine  and 
posterior  portions  of  the  thoracic  walls  to  force  it  against  the 
same  parts.  These  considerations  explain  why  the  tumours  of 
the  first  class  so  rarely  cause  tracheal  breathing,  and  why  this 
with  other  evidences  of  compression  is  so  common  in  the  second. 

It  must  be  borne  in  mind,  that  although  the  symptoms  of 
tracheal  compression  and  distress  are  a  frequent  result  of  these 
diseases,  yet  that  they  are  not  necessarily  present  in  any  of 
them,  and  in  many  only  appear  in  the  advanced  stages.  In 
these  cases  the  phenomena  referrible  to  the  windpipe  are  few, 
but  striking. 

They  may  be  comprehended  under  the  heads  of  compres- 
sion, displacement,  and  lesion  of  innervation.  In  most  cases 
where    one    of    these   phenomena   is   met   with,    others   either 

-  *  This  disease,  consisting  in  the  formation  of  a  number  of  aqueous  cysts  in  the 
neck,  which  increase  so  as  to  form  a  tumour  of  considerable  size,  was  first  accurately 
described  by  Professor  Maunoir  of  Geneva,  in  his  memoirs  entitled,  Sur  les  Amputa- 
tions, V Hydrocele  du  Cou,  et  V Organization  de  VIvis,  Geneva  et  Paris,  1825.  The 
only  other  author  who  has  written  on  this  subject  is  Dr.  O'Beirne  of  this  city,  who  has 
given  several  cases  similar  to  those  by  Maunoir,  and  successfully  treated  on  the  prin- 
ciples of  the  Genevese  Professor. — See  the  Lublin  Journal  of  Medical  and  Chemical 
Science,  vol.  vi.,  1835.  It  would  appear  that  the  original  memoir  was  neglected,  in 
consequence  of  the  celebrated  Baron  Percy  having  reported  unfavourably  of  its  merits 
to  the  Academy  of  Natural  Sciences  in  1817. 

This  disease  is  essentially  different  from  bronchocele,  as  after  the  evacuation  of 
the  tumour,  the  thyroid  has  been  found  perfectly  healthy.  The  tumour  may  enlarge 
so  much  as  to  seriously  interfere  with  respiration  and  swallowing,  as  was  the  case  in 
several  of  the  instances  related  by  Maunoir.  In  those  by  Dr.  O'Beirne,  the  respiratory 
function  was  not  injured,  which  may  be  explained  by  the  fact,  that  in  his  cases  the 
disease  occupied  the  side  rather  than  the  front  of  the  neck,  while  in  most  of  Maunoir's 
examples,  the  tumour,  though  commencing  at  the  side,  hai  extended  to  the  front  of 
the  neck,  so  that  its  weight  oppressed  the  trachea. 

S 


258  DISEASES    OF    THE    LARYNX    AND    TRACHEA. 

accompany  or  speedily  follow  it,  and  in  their  invasion,  succession, 
and  mutations,  there  is  the  greatest  variety,  not  only  among  cases 
of  different  natures,  but  even  those  of  the  same  disease.  I  have 
found  in  most  cases,  and  I  think  it  will  be  found  in  all,  that 
when  the  symptoms  of  tracheal  compression  can  be  observed, 
the  signs  of  pressure  on  other  parts  are  also  evident.  The 
patient  may  have  dysphagia,  turgid  jugulars,  or  displacement  of 
the  lung,  and  these  indications  will  be  often  observed  to  vary 
with  those  referrible  to  the  windpipe  :  at  the  same  time  the 
existence  of  one  of  these  evidences  of  compression  does  not 
necessarily  imply  that  we  shall  then  meet  with  the  others ; 
dysphagia  may  occur  without  tracheal  breathing,  and  so  on  with 
the  rest. 

In  almost  all  the  intra-thoracic  tumours,  their  phenomena  are 
in  the  first  instance  manifest  at  one  side ;  thus  we  may  often  see 
one  jugular  distended  and  tortuous,  while  the  other  remains 
natural  or  nearly  so  ;  an  observation  of  great  interest,  as  giving  a 
diagnosis  between  these  partial  obstructions  referrible  to  com- 
pression or  obliteration  of  a  venous  trunk,  and  those  produced  by 
disease  of  the  heart. 

In  the  instances  of  oesophageal  and  pulmonary  compression, 
the  same  may  be  observed.  The  patient  often  feels  that  the  ob- 
struction to  his  swallowing  is  at  one  side  ;  and  with  respect  to 
the  lung,  I  have  always  found  that  the  pressure  of  the  tumour 
is  greatest  at  one  side,  a  point  easily  demonstrated  by  the 
stethoscope.  In  more  advanced  cases  these  circumstances  of 
course  change.  Thus  when  the  vena  innominata  becomes  com- 
pressed, distention  of  both  jugulars  is  observed,  and  a  tumour, 
which  at  first  only  compressed  a  bronchus,  may  affect  the  trachea 
itself. 

Although  this  pressure  on  the  trachea  must,  from  an  early 
period,  cause  more  or  less  of  dislocation,  yet  this  is  not  perceptible 
until  the  tumour  rises  high  up  and  appears  above  the  clavicles. 
We  may  then  find  that  the  windpipe  will  be  pushed  far  to  the 
opposite  side.  In  a  case  of  aneurism  of  the  innominata,  I  have 
seen  the  thyroid  cartilage  so  displaced  from  the  mesian  line,  as 
to  correspond  with  a  line  drawn  from  the  posterior  angle  of  the 
jaw,  to  the  humeral  portion  of  the  clavicle.  The  right  carotid, 
the  jugular,  and  vena  innominata,  were  obliterated,  and  the  vagus 
atrophied  and  stretched. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  259 

But  much  of  the  displacement  depends  on  whether  the  clavicle 
is  dislocated  by  the  tumour.  This  may  or  may  not  occur ;  and 
it  is  hardly  necessary  to  observe  that  in  the  latter  case,  all  the 
sufferings  of  the  patient  are  greatly  aggravated.  In  the  case  to 
which  I  have  just  now  alluded,  there  was  no  yielding  of  [the 
clavicle,  and  the  consequence  was  the  extraordinary  displacement 
just  mentioned.  On  the  other  hand,  we  observe,  that  where 
great  suffering  from  pain,  dyspnoea,  stridor,  and  dysphagia  have 
existed,  the  dislocation  of  the  clavicle,  by  allowing  room  for  the 
tumour  to  expand,  has  been  followed  by  the  temporary  cessation 
of  all  these  symptoms. 

The  last  general  observation  I  shall  make  here  is  with  respect 
to  the  symptom  of  stridulous  breathing.  It  is  this  which  so 
commonly  leads  to  the  error  of  confounding  these  cases  with 
chronic  laryngitis  ;  but  as  I  have  already  remarked,  it  is  often 
easy  to  observe  from  the  sound  produced,  that  the  obstruction 
is  not  in  the  larynx,  but  really  much  lower  down.  The  stridulous 
sound  seems  to  come  from  the  upper  portion  of  the  sternal  region, 
and  if  to  this  we  are  able  to  add  the  observation  of  the  previous 
inequality  of  respiration  in  the  lungs,  the  diagnosis  will  in 
general  be  an  easy  one. 

On  the  subject  of  alterations  of  voice,  I  regret  that  I  have  but 
few  cases  in  illustration.  In  a  case  of  aneurism  I  observed  that 
the  tone  and  character  of  the  voice  underwent  a  series  of  changes 
quite  unlike  anything  observable  in  chronic  laryngitis.  It  was 
scarcely  two  days  the  same,  and  presented  alternations  of  the 
most  remarkable  acuteness,  with  the  deepest  tone ;  on  one  day 
great  hoarseness  would  be  observable,  which  would  be  succeeded 
by  a  shrill  whisper,  and  this  would  be  followed  by  a  return  of  the 
voice  to  its  natural  tone.  These  circumstances,  easily  recon- 
cileable  with  the  existence  of  an  irritation  or  intermitting 
paralysis  of  the  recurrent,  are  quite  different  from  those  observable 
in  chronic  laryngitis. 

Of  the  different  tumours  enumerated,  the  aneurismal  are  those 
which  most  frequently  simulate  laryngeal  disease.  This  may  be 
explained  by  their  greater  frequency,  the  height  to  which  they 
often  ascend  in  the  neck,  and  their  close  relation  to  the  wind- 
pipe. Their  pressure  causes  a  stridulous  breathing,  which,  like 
that  of  chronic  laryngitis,  is  variable  in  its  intensity,  while  their 
action  on  the  recurrent  nerve,  producing  hoarseness  or  aphonia, 

s  2 


260  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

• 

completes  to   the  superficial  observer  the  picture  of  laryngeal 
disease. 

It  would  seem  that  the  effect  of  pressure  on  the  trachea,  varies 
according  to  the  direction  in  which  it  is  applied.  When  we  con- 
sider the  structure  of  the  tube,  we  may  compare  it  to  an  arch, 
the  convexity  of  which  looks  anteriorly,  and  whose  apex  is  at  the 
mesian  line.  Here  then  is  its  point  of  greatest  strength,  and  it 
is  here  that  it  has  the  greatest  power  in  resisting  the  pressure  of 
external  tumours.  Thus  I  have  seen  a  case  of  violently  pulsating 
aneurism  of  the  aorta,  in  which  the  posterior  portion  of  the  sac 
had  been  absorbed,  so  that  the  rings  of  the  trachea  formed  a  part 
of  its  walls,  and  corresponded  to  the  centre  of  the  tumour,  in 
which  notwithstanding,  there  was  little  or  no  tracheal  distress, 
nor  was  the  form  of  the  tube  perceptibly  altered.  On  the  other 
hand,  I  have  found  that  in  all  the  cases  where  aneurismal 
simulated  laryngeal  disease,  the  pressure  on  the  windpipe 
was  from  the  first  lateral,  or  in  the  direction  most  likely 
to  diminish  the  calibre  of  the  tube,  and  engage  the  recurrent 
nerve. 

When  pressure  is  thus  exercised  on  the  trachea,  the  ends  of 
the  rings  next  the  tumour  are  bent  inwards,  and  the  musculo- 
membranous  portion  folded  upon  itself ;  and  though  their  direc- 
tion is  changed,  the  ends  of  the  rings  are  approximated,  and  the 
calibre  of  the  tube  diminished.  If  we  now  examine  the  recorded 
cases  of  aneurism,  with  respect  to  the  direction  of  their  pressure 
on  the  trachea,  we  shall  find  that  those  in  which  the  pressure  was 
lateral  greatly  preponderate  over  the  others,  a  fact  of  great  im- 
portance in  diagnosis. 

Without  entering  into  the  subject  of  aneurisms  in  general, 
which  will  of  course  occupy  a  separate  chapter,  I  shall  here  point 
out  briefly  the  grounds  of  diagnosis  between  laryngeal  disease 
and  the  pressure  of  an  aneurismal  tumour  on  the  trachea  ;  of 
course  I  do  not  mean  to  state  that  the  following  phenomena 
occur  in  all  cases,  but  some  of  them  are  always  present. 

1st.  Evidence  of  internal  pressure. 

a.  Signs  of  compression  of  one  bronchus. 

b.  Dysphagia,  always  deep-seated. 

c.  Turgescence  of  one  or  both  jugular  veins. 

d.  (Edema  of  the  neck. 

e.  Signs  of  displacement  of  the  lung. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  261 

2nd.  Evidence  of  solidity  more  or  less  extensive  in  the  upper 
portion  of  the  thorax. 

a.  Dulness  of  sound  of  the  upper  sternal  or  either  clavicular 
regions. 

h.  Bronchial  or  tracheal  respiration,  in  the  situation  of  the 
dulness. 

c.  Loud  resonance  of  the  voice  in  the  same  situation. 

3rd.  Proper  signs  of  an  aneurism,  such  as  pulsation,  bellows 
murmur,  &c,  dec,  generally  ohservable  in  the  sternal,  or  sub- 
clavicular regions. 

4th.  Difference  of  the  radial  pulse. 

I  feel  no  doubt  that  were  these  points  carefully  attended  to,  it 
would  rarely  happen  that  so  great  a  mistake  as  the  confounding 
an  aneurism  with  a  chronic  laryngitis,  would  ever  be  committed. 

Cancerous  Tumours  of  the  Posterior  Mediastinum. — I  have 
seen  two  instances  in  which  this  disease  produced  symptoms, 
not  unlike  those  of  aneurismal  tumour.  In  one  case,  indeed, 
the  stridulous  breathing  from  below  was  well  marked,  and  the 
tone  of  the  voice  altered.  As  I  intend,  however,  to  devote  some 
pages  to  this  disease,  I  shall  for  the  present  omit  its  further 
consideration. 

Diseases  of  the  Bronchial  Glands. — Although  as  yet  no 
separate  investigation  on  this  subject  exists,  yet  from  the  cases 
recorded  by  various  authors,  we  may  conclude  that  these  glands, 
when  hypertrophied  or  otherwise  diseased,  seldom  produce  any 
striking  symptoms.  Thus  in  a  case  recorded  by  Andral,  where 
an  enormous  mass  of  melanosis  compressed  the  right  bronchus, 
so  as  to  diminish  its  diameter  by  one-half,  there  was  no  stridulous 
breathing,  the  signs  being  a  feeble  respiration  in  one  lung,  with 
intense  puerility  in  the  other  ;*  and  Berton,  who  is  the  latest 
author  upon  the  subject,  dwells  strongly  on  the  fact,  that  the 
bronchial  glands  may  be  greatly  hypertrophied  without  causing 
compression  of  the  blood-vessels  or  air  tubes.  Andral,  however, 
states  that  tumours  of  the  bronchial  glands  frequently  cause 
tracheal  and  bronchial  compression.  I  myself  have  never  met 
with  any  instance  of  stridulous  breathing,  or  even  bronchial 
compression,  produced  by  this  disease,  but  the  subject  requires 
a  more  extended  investigation.  It  is  obvious,  however,  that  so 
far  as  the  question  between  laryngeal  disease  and  the  existence 

*  Clinique  Medicale,  tome  i. 


262  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

of  a  tumour  compressing  the  trachea  is  concerned,  the  diagnos- 
tics which  apply  to  aneurism,  with  the  exception  of  its  proper 
signs,  are  equally  available  in  the  case  under  consideration.* 

Enlargements  of  the  Thymus  Gland. — As  this  affection 
has  been  frequently  noticed  in  connexion  with  lesions  of  the 
respiratory  function,  we  may  take  a  brief  review  of  the  subject, 
which  from  the  researches  of  Sir  Astley  Cooper,  f  in  this 
country,  and  of  M.  HaugstedJ  on  the  continent,  has  acquired 
the  greatest  interest. 

Placed  in  the  closest  relation  with  the  trachea,  and  great 
arterial  and  venous  trunks,  and  not  unfrequently  extending  so 
high  as  to  be  connected  with  the  thyroid,  and  even  to  touch 
the  larynx,  and  furnished  with  arteries,  veins,  absorbents,  and 
nerves,  which  latter  seem  connected  with  one  of  the  most  im- 
portant nerves  of  respiration,  it  is  not  surprising   that  in  its 

*  An  important  subject  is  here  somewhat  summarily  dismissed.  A  reference  to 
Dr.  Walshe's  observations  on  tuberculization  of  the  bronchial  glands,  and  to  Dr. 
Quain's  exhaustive  memoir  on  their  diseases  (Brit.  Med.  Journ.,  Dec.  14th,  1878)> 
will  shew  that  these  are  not  infrequent  nor  their  symptoms  and  physical  signs  by  any 
means  insignificant  or  unimportant.  As  the  signs  of  pressure  are  common  to  these 
cases  and  to  aneurism  their  differential  diagnosis  is  sometimes  a  matter  of  difficulty. 

(In  one  remarkable  case  which  was  witnessed  by  Dr.  Stokes  while  under  my  care 
in  the  Meath  Hospital,  the  symptoms  and  physical  signs  being,  tortuous  distention  of 
the  veins  of  the  neck,  shoulder,  and  right  chest,  absence  of  respiratory  murmur  over 
the  upper  portion  of  the  same  side,  stridor,  with  ringing  cough,  and  recurring  haemop- 
tysis, no  diagnosis  of  the  exact  lesion  was  made  during  life,  it  being  in  both  our 
minds  uncertain  whether  the  signs  of  pressure  were  due  to  mediastinal  tumour  or  to 
aneurism.  On  examination  after  death  we  found  a  small  aneurism  springing  from 
the  right  side  of  the  arch,  and  a  bronchial  gland  of  the  size  and  shape  of  a  small 
chestnut;  pressure  on  the  right  bronchus  having  been  caused  by  one,  and  on  the  vena 
innominata  by  the  other.) 

Of  the  secondary  consequences  of  disease  in  these  glands  two  interesting  examples 
were  communicated  to  the  Pathological  Society  of  London  by  Dr.  Moxon. — See  Trans., 
vol.  xxiv.)  In  one  of  these  it  is  stated — "  In  a  woman  who  died  of  emphysema  of 
the  lungs  with  dilated  heart  and  dropsy,  the  right  pleura  shewed  a  considerable 
recent  pleurisy  on  the  lower  lobe,  as  is  not  unfrequent  in  such  cases.  The  lymph  in 
the  pleural  cavity  had  the  usual  characters  of  '  plastic  lymph,'  but  the  pleura  itself 
was  marked  by  a  network  of  yellowish  lines.  These  proved  to  be  lymphatics  full  of 
pus  which  the  microscope  shewed  to  be  recent  and  laudible.  A  large  old  glandular 
abscess  was  found  below  the  right  bronchus.  The  abscess  wall  was  thick  and  the 
contents  degenerate.  Dr.  Moxon  observed  that  as  such  suppuration  of  lymphatics  is 
very  rare,  its  association  with  old  glandular  obstruction  shews  that  the  bad  drainage 
due  to  this  obstruction  is  a  cause  of  local  disease  whose  importance  should  be 
recognised."     (Ed.) 

f  The  Anatomy  of  the  Thymus  Gland,  by  Sir  A.  Cooper.    London,  1832. 

J  Thymi  in  Homine  ac  per  seriem  animalium,  descriptio  anatomica,  pathologica, 
et  physiologica,  &c.  Auct.  F.  C.  Haugsted,  1832.  See  also  Archives  Generales  de 
Medicine.  1834. 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  263 

morbidly  large  and  otherwise  diseased  condition,  it  should 
excite  severe  symptoms,  the  more  important,  as  they  will  be 
commonly  observed  in  the  scrofulous  constitution. 

In  order  to  give  clear  ideas  on  this  subject,  a  short  sketch  of 
the  development  of  the  thymus  may  be  here  introduced ;  this 
gland,  the  functions  of  which  are  still  to  be  established,  is 
obviously  connected  with  the  conditions  of  infancy,  and  like 
other  organs  connected  with  the  progressive  development  of  the 
body,  each  phase  of  its  evolution  may  be  observed,  and  its  per- 
fection, decrease,  and  disappearance  be  followed  out  through 
their  different  stages. 

The  researches  of  Haugsted  have  shewn  that  the  thymus  has 
its  greatest  development  within  a  certain  period  after  birth, 
and  that  it  is  not  one  of  those  organs  which  acquire  their  highest 
development  at  the  period  of  foetal  life,  and  from  the  moment 
of  birth  become  useless  and  begin  to  decrease. 

More  exact  observations  have  shewn  that  the  thymus  does 
not  begin  to  diminish  from  the  first  period  of  extra-uterine  life, 
but  until  the  age  of  one  or  two  years,  it  grows  with  the  other 
organs  of  the  body,  and  at  the  end  of  that  time  attains  its 
greatest  magnitude.*  From  this  period,  until  the  eighth  or 
tenth  year,  the  volume  of  the  organ  undergoes  but  little  change, 
a  point  of  physiology  in  which  Haugsted  is  opposed  to  the 
authority  of  Meckel,  f  Burdach,  J  and  Hewson.§ 

But  although  its  volume  remains  unaltered,  some  change 
takes  place  in  its  structure ;  its  cells  become  smaller,  and 
their  fluid  contents  are  diminished ;  its  specific  gravity  becomes 
less  and  less,  yet  it  continues  to  live,  and  its  vessels  are  not 
obliterated  ;  nor  is  it  until  the  second  period  of  childhood,  when 
the  permanent  teeth  have  been  developed,  that  the  process  of 
atrophy  decidedly  begins.  From  the  twelfth  to  the  sixteenth 
year,  the  changes  of  the  organ  are  rapid,  until  it  is  completely 
atrophied,  and  nothing  left  but  some  adipose  tissue,  and  a  few 
particles  of  brownish  matter. 

This    process    seems    to   commence   inferiorly,    and    proceed 

*  See  on  this  subject  the  work  of  Yerheyen,  Anat.  Corp.  Hum.  tract,  in.  cap.  vi. ;  also 
Morand.  Mem.  de  l'Acad.  des  Sciences,  1759,  who  denies  the  doctrine  that  the  thymus 
is  obliterated  as  soon  as  the  infant  breathes. 

f  Manuel  d'Anat.  Gen.  Descript.  et  Pathol.,  torn?  iii. 

X  Die  Physologie  als  Erfahrungswissenschaft. 

§  Experimental  Inquiries,  vol.  iii.  p.  87. 


264 


DISEASES    OF    THE    LARYNX   AND    TRACHEA. 


upwards,  so  that  in  the  adult  the  last  portion  is  found  under 
the  upper  extremity  of  the  sternum. 

I  shall  not  apologize  for  introducing  the  following  table, 
abridged  from  that  of  M.  Haugsted.  It  is  constructed  so  as  to 
shew  the  size  of  the  human  thymus  at  different  ages. 


Thymus. 

AGE. 

Length. 

Breadth. 

Thickness. 

Weight. 

A  newly  born  child  well 
developed,  (female). 

li  line  to  3 
inches. 

1  to  2 
inches. 

2  to  4  lines. 

240  Grains. 

li     of     an 
inch. 

i     to     1J 

inch. 

2£  lines. 

84  Grains. 

(male). 

A  male   child  small  and 
thin,  of  four  weeks. 

2  inches. 

7  to  9  lines. 

2  lines. 

120  Grains. 

strong  and  well  de- 
veloped, of  nine,  months. 

2J  inches. 

ih  inches. 

4  lines. 

270  Grains. 

2^    to    3 
inches. 

1  inch. 

H  lines. 

110  Grains. 

years. 

A  female,  thin  and  scro- 
fulous, of  ten  years. 

2    to     2J 

inches. 

7  lines. 

1  line. 

36  Grains. 

A  boy,  of  seventeen  years. 

If  inch. 

|  of  inch. 

\  of  an  inch. 

90  Grains. 

of  twenty-one  years. 

... 

... 

... 

40  Grains. 

\ 


In  the  present  state  of  our  knowledge  we  may  enumerate  the 
diseases  of  the  thymus,  which  have  produced  laryngeal  symp- 
toms, as  follows :  enlargement,  inflammation,  and  tuberculous 
degeneration  ;  of  these  several  examples  are  recorded. 

In  almost  all  these  instances,  the  symptoms  produced  were  those 
of  dyspnoea  and  croupy  breathing,  varying  in  their  mode  of  invasion 
and  character,  according  to  the  age  of  the  individual ;  thus  in 
young  children,  the  disease  which  has  got  the  name  of  the  asthma 
infantum,  the  crowing  disease,  spasm  of  the  glottis,  &c,  &c, 
has  been  occasionally  found  to  co-exist  with  an  enlargement  of  the 
thymus  gland ;  this  fact  is  alluded  to  by  John  Peter  Frank,  and 
more  recently  by  Kopp,  who  has  given  to  this  disease  the  name 
of  asthma  thymicum. 

In  this  affection  it  is  held,  that  any  sudden  emotion,  causing  a 
quick  or  forced  inspiration,  may  bring  on  an  attack  of  dyspnoea 


DISEASES    OF    THE    LARYNX   AND    TRACHEA.  265 

and  suffocation,  and  even  in  some  cases  convulsions,  so  that  in  this 
way  sudden  death  may  supervene  in  a  child,  to  all  appearance 
perfectly  healthy. 

As  yet  the  etiology  of  this  disease  is  by  no  means  established, 
and  further  researches  are  necessary  to  shew  how  the  condition 
of  the  thymus  produces  so  remarkable  an  effect ;  does  it  take 
an  active  part  in  these  attacks,  or  is  its  permanent  enlarge- 
ment a  passive  cause  for  the  injury  ?  No  data  exist  to 
answer  these  questions,  but  from  the  similarity  of  cases  of  the 
crowing  disease,  with  those  in  which  an  enlarged  thymus  has 
been  found,  it  seems  probable  that  a  morbid  state  of  the 
thymus  takes  occasionally  some  part  in  causing  the  symptoms  of 
Miller's  asthma  infantum. 

But  with  respect  to  the  cases  of  sudden  death  in  infants,  in 
whom  an  enlarged  thymus  gland  has  been  found,  we  are 
not  yet  justified  in  attributing  the  death  to  this  cause.  The 
symptoms,  if  proceeding  from  pressure  on  vessels  or  nerves, 
must  result  from  a  sudden,  an  almost  instantaneous  enlargement 
of  the  gland ;  yet  its  low  innervation,  its  structure,  and  scanty 
supply  of  vessels,  militate  strongly  against  the  chance  of  such 
an  occurrence.  The  thymus  has  little  analogy  with  the  erectile 
organs ;  in  these  structures  we  observe  large  vessels,  a  highly 
vascular  structure,  and  a  great  sensibility ;  but  in  the  thymus 
nothing  of  this  kind  occurs,  and  the  subsidiary  apparatus  of 
erection  is  wanting. 

If  the  measurements  of  Haugsted  be  correct,  we  must  be 
cautious  how  we  take  the  natural  for  the  diseased  volume  of  the 
gland.  That  this  has  been  done  with  other  organs,  we  have 
abundant  evidence  of;  and  it  is  yet  to  be  proved  whether  the 
coincidence  of  the  symptom  in  question  with  the  appearance  on 
dissection,  has  not  been  accidental. 

The  enlargement  of  the  thymus  may  be  met  with  alone,  or  in 
combination  with  other  anormal  states,  of  which  the  most  remark- 
able is  the  persistence  of  the  foetal  condition  of  the  heart.  Thus 
in  many  of  the  recorded  cases  the  foramen  ovale  was  found  open, 
so  that  one  arrest  of  development  was  associated  with  the  other. 
But  this  is  by  no  means  constant,  and  as  has  been  before  stated, 
the  enlarged  thymus  may  exist  in  a  child  otherwise  healthy. 

When  the  gland,  however,  becomes  indurated  and  otherwise 
diseased,    it  may  produce  even  in  the  adult  all  the  formidable 


266  DISEASES    OF    THE    LARYNX   AND    TRACHEA. 

symptoms  of  pulmonary  and  tracheal  compression,  and  thus 
induce  death  by  asphyxia. 

In  a  case  of  this  kind  recorded  by  Sir  A.  Cooper,  the  patient, 
a  young  female,  suffered  under  severe  dyspnoea  in  the  recumbent 
position ;  and  if  she  fell  asleep  she  started  up  in  a  few  moments, 
and  struggled  violently  for  breath.  A  large  tumour  was  found  to 
occupy  the  inferior  part  of  the  neck,  projecting  above  either 
clavicle ;  this  had  existed  many  years,  but  of  late  had  suddenly 
increased.  The  symptoms  became  more  and  more  distressing, 
until  at  length  she  could  only  breathe  with  her  head  inclined 
forwards,  and  supported  by  assistants. 

In  this  case,  the  thymus  was  found  greatly  enlarged,  extending 
from  the  curvature  of  the  aorta  to  the  thyroid.  The  trachea  was 
compressed,*  and  its  transverse  diameter  lessened. 

As  no  stethoscopic  examination  in  a  case  of  diseased  thymus 
has  yet  been  published,  the  physical  signs  must  remain  undeter- 
mined. It  is  obvious,  however,  that  the  principles  of  diagnosis 
of  other  intra-thoracic  tumours,  will  apply  to  the  chronic  enlarge- 
ments of  the  thymus  gland. 

*  Sir  A.  Cooper  considers  both  the  thymus  and  thyroid  to  have  been  diseased  in 
this  case. — The  Anatomy  of  the  Thymus  Gland,  cjc.  London,  1832.  It  will  probably  be 
found  that  these  diseases  are  often  associated ;  and  the  complication  may  exist  in  those 
cases  of  bronchocele,  in  which  stridulous  breathing  occurs  at  an  early  period.  In 
Haugsted's  memoir,  we  find  references  to  cases  similar  to  this.  Thus  in  one  described 
by  Meckel,  the  paroxysms,  as  in  Sir  A.  Cooper's  case,  increased  after  an  interval  of 
great  remission.  He  quotes  a  remarkable  instance  from  Tozetti,  Raccolta  di  opusculi 
Med.  Pract.,  in  which  the  disease  had  continued  for  twenty  years,  and  terminated 
in  dropsical  effusions  ;  the  thymus  weighed  some  ounces.  Other  instances  are  given, 
so  that  there  is  sufficient  evidence  to  lead  to  the  suspicion  of  the  disease,  in  certain 
cases  of  dyspnoea,  without  apparent  cause. 


PNEUMONIA.  267 


SECTION  IV 


PNEUMONIA. 


[This  chapter  consists  partly  of  the  text  of  the  original  work,  and  partly  of  passages 
from  the  note  book  of  the  author.]  / 

If  we  take  the  general  anatomy  of  the  lung  as  a  basis  for  the 
classification  of  its  inflammatory  diseases,  we  find  that  the  line 
of  distinction  between  it  and  bronchitis  is  undefined,  and  it  be- 
comes difficult  to  say  where  bronchitis  ends,  and  pneumonia 
begins.  The  statement  that  the  first  is  an  affection  of  the 
mucous  membrane  merely,  while  the  second  engages  the  paren- 
chyma, is  satisfactory  only  to  the  theorist  or  superficial  inquirer. 
When  we  find  that  this  parenchyma  is  made  up  almost  altogether 
of  air  cells  and  minute  bronchial  tubes,  and  when  we  examine  a 
lung  in  which  pneumonia  has  passed  into  the  more  advanced 
stages,  and  observe  the  filling  up  and  distention  of  the  cells,  and 
the  exudation  into,  and  obliteration  of  the  minute  tubes,  we 
must  admit  that  he  who  would  call  pneumonia  a  bronchitis  of 
the  terminal  tubes  would  be  hardly  guilty  of  a  misnomer. 

We  may  describe  pneumonia  as  the  inflammation  of  the  cells 
and  minute  tubes,  and  believe  that  it  differs  from  bronchitis  in 
the  ordinary  acceptation  of  the  term,  merely  in  the  occurrence 
of  the  phenomena  of  a  parenchymatous  inflammation,  such  as 
solidification,  suppuration,  and  abscess,  phenomena  not  pro- 
ceeding from  any  inherent  difference  in  the  diseases,  but  a 
result  of  anatomical  structure.  The  close  approximation  of  the 
cells  and  minute  tubes  is  so  increased  by  the  disease,  that  parts 
which  in  health  are  separate,  such  as  the  pulmonary  lobules, 
unite  under  the  influence  of  a  morbid  action,  and  a  solid  is 
formed  out  of  a  cellular  or  tubular  structure.*  Like  the  other 
inflammatory  diseases  of  the  lung,  pneumonia  may  occur  as  a 
primary  or  secondary  affection,  and  its  characters  must  be  studied 
with  reference  to  this  distinction. 

*  I  do  not  deny  the  influence  -which  the  inflammation  of  the  inter-vesicular,  and 
inter-lobular  cellular  membrane  may  have  in  giving  a  character  to  pneumonia  different 
from  bronchitis.  This  tissue,  however,  is  so  sparingly  supplied,  in  comparison  with 
the  air  cells  and  minute  tubes,  that  its  affections  are  probably  of  little  importance, 
and  its  participation  would  give  no  pathological  difference  between  the  two  diseases. 


268 


PNEUMONIA. 


ACUTE    PRIMARY    PNEUMONIA. 

Before  entering  on  the  diagnosis,  I  shall  first  examine  the 
different  stages  of  this  disease. 

Laennec  has  described  three  stages  of  pneumonia  with  their 
corresponding  symptoms  and  signs,  and  his  statements  have  been 
verified  by  all  subsequent  experience.  In  his  first  stage,  the 
lung  is  engorged  with  blood,  and  a  crepitating  rale  is  heard ;  in 
the  second,  solidity  takes  place,  with  its  accompanying  physical 
signs ;  and  in  the  third,  we  find  the  interstitial  suppuration  of 
the  lung,  or  the  condition  which  precedes  the  formation  of 
abscess. 

Without  impugning  the  accuracy  of  this  description,  we  may 
inquire  whether  a  stage  previous  to  that  which  Laennec  calls  the 
first,  does  not  exist.  The  following  considerations  seem  to  prove 
that  Laennec's  first  is  really  the  second  stage  of  the  disease. 

No  one  can  doubt  that  the  crepitating  is  but  the  diminutive  of 
the  mucous  rale ;  it  is  a  phenomenon  produced  by  the  passage 
of  air  through  a  viscid  fluid,  secreted  by  the  irritated  cells,  or 
terminal  tubes,  and  its  peculiar  characters  result  from  the 
bubbles  being  necessarily  so  minute.  The  existence  of  this  sign, 
then,  points  out  that  secretion  has  taken  place  into  the  cells  and 
minute  tubes ;  so  that  Laennec's  first  is  in  reality  the  secretive 
stage  of  the  inflammation,  and  every  analogy  favours  the  opinion 
that  a  stage  of  irritation  has  existed  previous  to  the  secretion 
which  caused  the  crepitus. 

Further,  I  have  repeatedly  seen  a  condition  of  the  lung  which 
seems  really  the  first  stage.  The  pulmonary  tissue  is  drier 
than  usual,  not  at  all  engorged,  as  in  Laennec's  first  stage,  and 
of  a  bright  vermilion  colour,  from  intense  arterial  injection.  I 
have  found  this  condition  in  the  upper  portions  of  lungs,  in  the 
middle  and  lower  parts  of  which  Laennec's  first  and  second 
stages  existed.  It  is  obvious  that  this  appearance  will  be  but 
rarely  met  with,  as  a  more  advanced  stage  occurs  before  death  ; 
and  it  is  often  obscured  by  cadaveric  congestion.  I  have  found 
it  in  cases  of  pneumonia,  where  death  occurred  from  other  causes. 
In  a  child  who  died  of  an  extensive  burn,  we  found  nearly  the 
whole  of  the  lung  in  this  state  ;  and  I  have  seen  the  same 
condition  in  subjects  who  died  of  acute  phthisis,  with  severe 
inflammatory  symptoms.* 

*  See  Appendix,  Note  A. 


PNEUMONIA.  269 

[The  study  of  this  first  stage  of  pneumonia  involves  considera- 
tions not  only  important  from  their  extent,  hut  also  from  their 
application  to  px-actical  medicine.  We  have  here  a  condition, 
which  though  it  is  to  be  followed  by  physical  changes  with 
their  attendant  signs,  yet  is  not  revealed  by  any  mechanical 
phenomenon  with  which  we  are  acquainted.  I  formerly  stated 
that  a  local  puerility  of  respiration  appeared  to  indicate  this 
condition  in  certain  cases,  but  I  have  not  been  able  to  add  to 
the  evidence  on  this  point.  In  the  present  state  of  our  know- 
ledge therefore  we  ,may  consider  this  stage  of  pneumonia,  as 
preceding  that  in  which  any  products  of  inflammation  are 
formed,  and  as  one  without  certain,  or  necessary  physical  signs. 
It  may  be  termed  the  progenetic  stage  of  pneumonia,  or  that 
preceding  the  exudation  of  blood,  serum,  coagulable  lymph,  or 
any  form  of  plasma. 

Yet  we  cannot  look  on  the  establishment  of  this  condition  as 
a  question  of  pathological  inquiry  merely,  and  as  having  no 
bearing  on  practice,  for  if  it  be  true  that  the  recognition  of  the 
second  stage  of  the  disease,  by  the  discovery  of  a  crepitating  rale, 
is  of  importance  to  enable  us  to  contend  successfully  with  the 
disease,  how  much  more  important  would  it  be  if  we  could  direct 
our  remedial  measures  against  progenetic  conditions. 

In  the  present  state  of  our  knowledge  on  this  subject  we 
must  be  content  with  suggesting,  rather  than  establishing  the 
diagnosis  of  this  condition  ;  and  I  think  it  will  be  found  usually 
to  consist  in  the  co-existence  of  fever  and  local  special  symptoms 
with  absence  of  physical  signs ;  that,  in  other  words,  the  pro- 
genetic condition  is  indicated  by  vital  symptoms,  distinguishable 
from  mere  neurotic  phenomena  by  their  connexion  with  fever, 
which  symptoms  may  exist  for  a  certain  period  of  time  without 
any  physical  sign  of  disease. 

The  phenomena  of  the  two  first  stages  of  acute  disease  will 
then  be  grouped  as  follows  : — 

I.  Progenetic  stage — fever,  symptoms,  absence  of  physical 
phenomena. 

II.  Fever— symptoms,  development  of  physical  signs. 

I  do  not  wish  to  be  understood  as  stating  that  in  every  ex- 
ample of  this  condition  we  have  the  combination  of  fever  and 
vital  symptoms,  or  that  the  existence  of  symptoms  alone  without 
fever  may  not  indicate  the  very  first  stage  of  disease,  but  only 


270  PNEUMONIA. 

this,  that  where  we  have  the  combination  in  question  the  diag- 
nosis of  disease  may  often  be  made,  although  no  physical  signs 
be  present.  It  is  most  important  to  bear  this  in  mind,  as.  it 
may  save  the  practitioner  from  the  error  of  declaring  the  absence 
of  disease  in  consequence  of  the  absence  of  any  physical  signs  of 
its  presence. — Author's  Note  Book.] 

We  may  hence  enumerate  the  stages  of  pneumonia  as  fol- 
lows : — 

1st.  The  lung  drier  than  natural ;  with  intense  arterial  in- 
jection.    No  effusion  of  blood  into  the  cells. 

2nd.  (Laennec's  first.)  The  cells  engorged  with  blood.  No 
change  of  structure. 

3rd.  (Laennec's  second.)  Solidity  and  softening.  (Ramol- 
lissement  rouge  of  Andral.) 

4th.  (Laennec's  third.)     Interstitial  suppuration. 

5th.  Abscess.* 

On  the  subject  of  Laennec's  first  stage,  it  is  to  be  observed 
that  it  does  not  necessarily  precede  hepatization.  We  may  have 
complete  solidity  produced  in  a  lung  that  has  never  presented 
the  crepitating  rale,  and  the  disease  pass  on  into  the  stages  of 
suppuration  and  abscess.  This  circumstance,  so  important  in 
diagnosis,  is  met  with  in  certain  cases  of  the  typhoid  pneumonia, 
in  which  a  sudden  and  extensive  congestion  of  blood  affects  the 
lung.  It  may  then  occur,  that  a  lobe  which  to-day  was  perfectly 
permeable,  and  presenting  no  morbid  signs,  shall  in  twenty-four 
hours  be  solidified,  and  present  dulness  with  absence  of  vesicular 
murmur,  bronchophonia,  and  bronchial  respiration. 

Such  cases,  however,  are  comparatively  rare,  and  I  need 
hardly  observe,  are  full  of  danger.     The  suddenness  and  extent 

*  It  may  be  remarked  that  Dr.  Stokes  does  not  include  gangrene  among  the 
stages  or  terminations  of  pneumonia.  In  this  he  follows  Laennec,  who  says  "  it  can 
scarcely  be  ranged  among  the  terminations  of  the  pulmonary  inflammation,  and  still 
less  can  be  considered  as  the  consequence  of  its  intensity,  since  we  find  in  cases  of 
this  kind  the  inflammatory  character  very  slightly  marked,  as  well  in  regard  of  the 
symptoms  as  of  the  engorgement  of  the  pulmonary  substance."  We  have  however 
abundant  proof  that  it  does  occur  in  pneumonia  of  the  typhoid  or  congestive  type,  in 
several  forms  of  blood  dyscrasia,  and  in  pneumonia  associated  with  sources  of  in- 
fection. On  this  point  Juergensen  observes, — "  If  stasis  take  place  in  the  vessels, 
local  death  or  neurosis  ensues  in  the  tissues  nourished  by  them.  Cohnheim's  views 
again  furnish  us  with  an  explanation  of  this  lesion.  Gangrene  of  the  lungs  is  pro- 
duced in  the  part  which  is  withdrawn  from  the  influence  of  the  restorative  power  of 
the  living  organism,  its  decomposition  resulting  from  its  exposure  to  the  action  of  the 
air  and  of  the  parasitic  bodies  which  excite  putrefaction  ;  a  process  similar  to  the  de- 
composition of  albuminous  bodies  under  the  same  conditions  outside  of  the  body."  (Ed.) 


PNEUMONIA.  271 

of  the  solidification,  and  the  prostrated  condition  of  the  patient, 
combine  to  increase  the  danger,  and  in  some  cases  give  rise  to 
a  rapid  gangrene.  I  have  never  seen  this  rapid  congestion,  or 
solidification,  in  the  ordinary  sthenic  pneumonia.  All  the  cases 
were  examples  of  a  secondary  disease  of  the  lung,  supervening 
on  typhus  fever,  or  that  condition  of  the  system  in  which  diffuse 
inflammations  are  liable  to  ensue.  Thus  it  is  seen  in  cases  of 
bad  erysipelas,  and  often  in  connexion  with  analogous  diseases 
of  other  viscera.  Its  most  frequent  termination  is  in  the  stage 
of  interstitial  suppuration,  but  in  two  cases  I  have  known  a 
gangrenous  abscess  to  be  rapidly  formed ;  and  when  we  reflect 
on  the  circumstances  of  the  disease,  such  a  termination  seems 
easily  intelligible. 

The  third  stage  *  of  the  disease,  according  to  my  views,  is  but 
the  maximum  of  the  second ;  and  we  must  agree  with  Andral  in 
the  opinion,  that  the  solidity  of  acute  pneumonia  arises  not  from 
any  deposition  of  lymph,  but  merely  from  an  excessive  congestion 
of  blood.  Indeed,  any  one  who  has  witnessed  the  rapidity  with 
which  all  the  phenomena  of  solidity  will  appear  and  subside, 
must  be  of  this  opinion.  In  the  course  of  twenty-four  hours  a 
lung  which  was  perfectly  free  from  morbid  signs,  may  become 
dull,  and  its  vesicular  murmur  be  exchanged  for  bronchial  res- 
piration ;  and  the  picture  is  often  reversed,  and  we  see  these 
phenomena  as  rapidly  disappearing  under  the  influence  of  treat- 
ment, or  a  metastasis  of  disease. 

Here  it  is  necessary  to  remark,  that  although  the  sudden 
solidification  is  peculiar  to  the  typhoid  or  secondary  pneumonia, 
yet  that  we  may  observe  the  rapid  resolution  of  the  disease  in 
the  primary  and  sthenic  cases. 

I  have  nothing  of  importance  to  offer  on  the  subject  of  the 
interstitial  suppuration  of  the  lung,  and  shall  pass  on  to  consider 
the  fifth  stage,  or  that  of  abscess. 

It  is  not  difficult  to  understand  why  this  instance  of  visceral 
abscess  should  be  so  rarely  met  with ;  inflammation  is  rarely 
circumscribed  in  the  lung,  and  hence  one  important  condition 
for  the  formation  of  abscess  is  wanting.  From  the  spreading 
of  the  disease,  it  happens,  that  by  the  time  the  lower  portion  is 
about  to  form  abscess,  the  upper  is  often  solidified,  and  the 
disease    extending   to  the   opposite   lung,  death   occurs   before 

*  Laennec's  second,  or  that  of  hepatization.     (Ramollissernent  rouge.) 


272  PNEUMONIA. 

an  abscess  can  be  formed  ;  the  fatal  result  being  induced  less  by 
the  suppuration,  than  the  earlier  stages  of  disease. 

But  it  is  in  the  anatomical  structure  of  the  lung  that  we 
find  the  true  explanation  of  the  point  in  question.  If  we  compare 
the  viscera  with  respect  to  the  liability  to  form  abscess,  we  find 
that  in  those  in  which  the  earlier  products  of  the  inflammation 
can  be  got  rid  of,  there  is  the  least  liability  to  abscess.  In  the 
brain,  which  has  no  excretory  duct,  abscess  is  a  common  result 
of  inflammation  ;  abscess  of  the  liver  is  less  common  than 
that  of  the  brain,  and  more  so  than  that  of  the  lung  ;  abscess 
of  the  kidney  may  be  placed  next  in  the  scale,  and  that  of  the 
lung  decidedly  the  last  in  the  order  of  frequency.  Considering 
the  bronchial  tubes  as  excretory  ducts,  we  must  admit  that  of 
all  the  viscera,  the  lungs  have  the  most  extensive  apparatus  for 
excretion,  whether  we  consider  it  in  a  vital  or  mechanical  point 
of  view.  From  the  first,  the  products  of  irritation  are  got  rid  of 
by  expectoration,  and  even  in  the  suppurative  stage,  the  accumu- 
lation of  the  matter  is  prevented  by  the  universal  permeability 
of  the  lung. 

But  the  rarity  of  pneumonic  abscess  has  been  overrated.  I 
have  no  doubt  of  the  accuracy  of  Laennec's  observations  on  this 
subject,  and  although  in  almost  all  his  cases  the  evidence  rests 
on  physical  signs,  yet  I  would  be  sorry  to  believe  that  he  had 
been  "  deceived  by  auscultation  ,■"  this  I  say  from  the  confidence 
which  experience  has  given  me  in  Laennec's  signs  of  pulmonary 
suppuration,  signs  always  valuable,  but  nearly  infallible,  when 
as  in  most  cases  they  succeed  physical  indications  of  the  earlier 
stages,  which  precede  the  formation  of  abscess.  I  have  now 
witnessed  several  cases  in  which  this  succession  of  physical 
signs  was  observed,  and  the  disease  traced  from  its  earlier  stages 
to  the  formation  of  abscess ;  and  though  even  an  experienced 
stethoscopist  might  err,  as  to  the  signs  of  a  cavity  in  a  case  seen 
for  the  first  time,  it  becomes  next  to  impossible  that  the  error 
could  be  committed  when  the  physical  signs  have  coincided  with 
the  successive  stages  of  the  disease.  The  actually  existing  pheno- 
mena derived  a  great  value  from  those  which  have  preceded  them. 

I  have  observed  pneumonic  abscess  under  various  circum- 
stances ;  it  more  frequently  occurs  in  the  lower,  than  in  the 
upper  lobes  ;  it  may  be  the  result  of  a  localized  phlegmonous 
inflammation,  or  of  that  extensive,  but  complete  solidification 


PNEUMONIA.  273 

already  described.  To  this  subject  I  shall  return  when  speaking 
of  the  secondary  pneumonia,  and  here  only  observe,  that  in 
the  diffuse  erysipelatous  inflammations,  abscess  of  the  lung  has 
frequently  occurred  in  Dublin.*  Lastly,  I  possess  anatomical 
evidence  of  its  cure  by  cicatrization,  of  which  the  following  case 
is  an  example : 

A  young  man  of  strong  habit  was  admitted  into  hospital 
for  a  pulmonary  affection  of  some  weeks'  standing.  The  antero- 
superior  region  of  the  right  side  sounded  dull,  and  in  this 
situation,  and  likewise  over  the  shoulder,  all  the  signs  of  an 
extensive  cavity  were  observable ;  over  the  rest  of  the  thorax, 
signs  of  bronchitis  existed. 

In  a  short  time  the  patient  regained  his  looks,  health,  and 
strength,  the  pulse  became  natural,  his  appetite  was  restored, 
and  he  left  the  hospital  declaring  himself  perfectly  well,  although 
all  the  signs  of  abscess  continued  unchanged. 

After  a  few  weeks  he  returned  to  the  hospital,  the  signs  of 
the  abscess  remaining  as  before  ;  after  some  days  he  was  again 
discharged,  and  resumed  his  occupation  of  a  smith.  We  then 
lost  sight  of  him  for  a  twelvemonth,  when  he  was  again  admitted, 
labouring  under  severe  pleuropneumony,  which  had  been 
neglected,  and  was  of  five  days'  standing.  It  appeared  that 
after  his  last  dismissal,  he  had  enjoyed  the  most  perfect  health, 
although  toiling  at  his  laborious  occupation,  until  five  days 
before  admission,  when  he  was  seized  with  pain  of  the  side, 
cough,  d}-spnoea,  and  fever ;  he  continued  to  work  until  his 
sufferings  obliged  him  to  desist. 

He  then  presented  all  the  symptoms  of  the  fourth  stage  of 
pleuropneumony  of  the  right  lung.  On  percussion,  the  whole 
of  this  side,  both  anteriorly  and  posteriorly,  sounded  completely 
dull,  except  in  the  subclavicular  region,  where  it  was  compara- 
tively clear.  This  it  will  be  recollected  was  the  former  seat  of 
the  abscess.  Over  the  dull  portion,  bronchial  respiration  mixed 
with  an  intense  muco-crepitating  rale  was  audible,  but  on 
examining  the  subclavicular  region,  we  found  to  our  great  sur- 
prise, that  all  the  phenomena  of  a  cavity  had  disappeared,  and 
were  replaced  by  a  puerile  respiration. 

*  This  is  confirmatory  of  the  observations  of  Laennec,  who  states  that  while  in  the 
course  of  the  year  1823  he  met  with  more  than  twenty  cases  of  partial  peripneumcny 
terminating  in  abscess,  he  knew  of  only  two  other  well  authenticated  cases  having 
occurred  in  France  in  twenty  years.     (Ed.) 

T 


274  PNEUMONIA. 

Here  was  a  case  full  of  difficulty.  It  was  plain  that  the 
greater  portion  of  the  lung  was  solidified,  and  had  passed  into 
the  fourth  stage,  hut  why  a  small  portion  of  it  should  have 
escaped  the  disease  when  the  rest  was  so  far  advanced,  and  that 
this  portion  should  he  that  formerly  occupied  by  an  abscess,  was 
indeed  difficult  of  explanation. 

All  treatment  proved  inefficacious,  and  the  patient  sunk  on 
the  third  day,  the  stethoscopic  phenomena  having  continued 
unaltered. 

On  dissection  we  found  the  right  lung  solid  over  the  whole 
extent  indicated  by  the  stethoscope.  From  the  fourth  rib  down- 
wards, the  pleura  was  covered  with  coagulable  lymph,  which 
being  removed,  allowed  us  to  see  the  lung,  of  a  yellow  colour, 
through  the  serous  membrane.  In  the  superior  portion  the 
adhesions  were  evidently  old,  as  considerable  force  was  required 
for  their  separation.  On  the  summit  and  antero-superior  sur- 
face, a  deep  puckering  existed. 

The  lung  was  then  divided,  in  a  line  corresponding  to  the 
angles  of  the  ribs,  so  as  to  separate  it  into  two  portions,  con- 
nected only  at  the  root  of  the  lung.  This  gave  us  at  once  an 
explanation  of  the  physical  signs.  The  supero-anterior  portion, 
for  a  space  of  three  square  inches,  was  perfectly-crepitating,  and 
not  all  engorged.  This  was  separated  from  the  rest  of  the  organ 
by  the  cicatrix  of  the  abscess.  The  cavity  had  been  obliterated 
by  adhesions  of  its  walls,  so  as  to  form  a  cartilaginous  septum, 
superiorly  half  an  inch  in  thickness,  and  inferiorly  diminishing 
to  about  two  lines ;  the  whole  length  of  this  septum  was  about 
three  inches  ;  it  commenced  at  the  summit  of  the  lung,  running 
from  behind  forwards  and  downwards,  and  terminated  where 
the  large  bronchus  gives  off  its  branch  to  the  upper  lobe  ; 
this  septum  throughout  its  whole  extent  consisted  of  two 
layers,  connected  only  by  some  fine  cellular  membrane,  and 
easily  separable. 

It  was  obviously  the  cicatrix  of  the  abscess  ;  from  its  situation 
it  had  isolated  the  subclavicular  portion  of  the  lung,  or  that 
in  which  puerile  respiration  was  audible.  A  bronchial  tube 
passed  from  the  larger  trunks,  immediately  below  the  cicatrix, 
so  as  to  admit  air  into  this  portion  of  the  lung,  which  differed 
in  no  respect  from  healthy  lung,  except  that  the  interlobular 
septa  were   remarkably  hypertrophied.     The  remainder  of  the 


PNEUMONIA.  275 

upper,  with  the  middle  and  inferior  lobes,  were  solid,  of  a 
yellowish  gray  colour,  and  infiltrated  with  pus.  The  most 
careful  examination  failed  to  detect  tubercle  in  any  part  of 
the  system. 

That  this  abscess  was  really  the  result  of  phlegmonous  inflam- 
mation, there  can  be  little  doubt.  The  absence  of  the  symptoms 
of  phthisis  in  the  first  attack ;  the  formation  of  the  cavity,  after 
but  a  few  weeks'  illness  ;  the  perfect  recovery  of  the  patient,  all 
combine  to  establish  its  nature  ;  and  if  additional  evidence  was 
wanting,  the  absence  of  a  trace  of  tubercle  in  any  part  of  the 
body,  is  sufficient  to  shew  that  the  cavity  was  not  phthisical. 

I  have  given  this  case  at  length,  as  no  instance  of  the  cicatri- 
zation of  a  pneumonic  abscess  is  recorded,  and  as  its  diagnosis 
is  so  full  of  interest. 

Without  reference  to  those  purulent  collections  in  the  lung 
which  result  from  venous  absorption,  I  have  seen  acute  pneu- 
monic abscess  under  three  forms.  In  the  first,  the  abscess  is 
encysted,  and  has  all  the  characters  of  true  phlegmon.  In  the 
next  we  find  purulent  cavities,  communicating  with  the  tubes, 
but  without  any  cyst ;  the  walls  of  the  abscess  being  formed  of 
the  solidified  lung.  This  form  is  seen  in  the  secondary  or 
erysipelatous  pneumonia,  and  I  have  observed  its  formation 
by  the  stethoscope,  and  verified  the  diagnosis. 

But  in  the  third  form  which  I  first  described,  and  of  which 
a  case  is  given  in  the  chapter  on  bronchitis,  the  anatomical 
characters  are  peculiar.  The  pulmonary  tissue  is  separated 
from  the  pleura,  and  the  lobules  dissected,  so  as  to  shew  the 
structure  of  the  lung.  The  lung  lies  bathed  in  pus,  and  we 
have  an  abscess  under  the  pleura,  but  external  to  the  lung. 

Although  in  most  cases  of  pneumonic  abscess,  the  disease  is 
referrible  to  acute  irritation,  yet  we  may  find  abscesses  of  a 
chronic  character,  which  are  not  tuberculous ;  an  abscess  some- 
times of  considerable  size  occupies  the  lower  portion  of  the 
lung  ;  its  walls  are  firm,  and  of  an  iron-gray  colour,  and  the 
surrounding  lung  is  in  the  state  of  chronic  induration.  "We  have 
now  seen  several  of  such  cases ;  the  patients  did  not  present  the 
usual  symptoms  of  phthisis,  the  pulse  was  slow,  and  the  breath- 
ing easy ;  there  was  little  or  no  cough,  and  an  absence  of  fever  ; 
indeed,  with  the  exception  of  emaciation,  and  a  certain  hectic 
appearance,  there  were  no  evidences  of  constitutional  disease. 

t  2 


276  PNEUMONIA. 

On  the  upper  portions  of  the  chest,  both  the  passive  and  active 
auscultatory  signs  were  natural ;  but  the  lower  lobe  of  one  lung, 
(o-enerally  the  right)  presented  complete  dulness  and  absence 
of  vesicular  murmur,  and  gave  all  the  signs  of  a  cavity  with  free 
bronchial  communication. 

It  is,  however,  yet  to  be  determined,  whether  in  these  cases 
the  abscess  originated  in  an  acute  pneumonia,  or  was  the  result 
of  a  more  chronic  process.* 

Connected  with  the  pathology  of  pneumonia,  we  may  examine 
its  seat  and  resolution. 

Seat  of  Pneumonia. — From  the  combined  observations  of 
Andral,  Chomel,  and  Lombard,  Dr.  Forbes  has  shewn,  that  out 
of  a  total  of  1,131  cases,  the  right  lung  was  engaged  in  562, 
the  left  in  333,  and  in  236  the  disease  was  double ;  the  general 
result  of  T.hich  would  be,  that  out  of  every  ten  cases,  five  would 
be  of  the  right,  three  of  the  left,  and  two  double.  This  result 
is  probably  near  the  truth,  and  corresponds  pretty  closely  with 
my  experience ;  but  it  will  be  found  that  the  double  pneumonia 
is  more  frequent  than  appears  from  the  above  statement.  It 
commonly  happens,  that  notwithstanding  a  great  preponderance 
of  disease  in  one  lung,  a  careful  physical  examination  will  detect 
more  or  less  of  it  in  the  other,  even  though  no  local  pain  or 
distress  exist,  which  could  lead  to  its  detection. 

Under  these  circumstances,  the  first  effect  of  any  general 
treatment  will  be  seen  on  the  lung  least  engaged. 

A  long  experience  leads  me  to  conclude,  that  when  we  connect 
the  seat  and  character  of  pneumonia,  we  find  that  the  disease  in 
the  right  lung  is  more  often  of  the  sthenic,  and  that  of  the  left 
of  the  typhoid  character.  Either  lung  may  present  both  forms 
of  disease  ;  but  in  the  typhoid  pneumonia,  the  left  is  most  often 
the  seat  of  the  lesion.  When  discussing  the  secondary  pneu- 
monia, I  shall  return  to  this  point. 

Although  pneumonia  commences  in  the  lower  lobes,  in  a 
much  greater  proportion  than  in  the  upper,  we  may  often  see 
the  disease  under  the  latter  circumstances  ;  and  it  is  a  curious 
fact,  that  we  have  observed  an  epidemic  tendency  to  pneumonia 
of  the  upper  lobes.  Thus  during  the  summer  of  1833,  a  great 
number   of  cases   of   this  description   occurred   in   the  Meath 

*  The  occurrence  of  chronic  abscess  of  the  lung  has  been  noticed  by  Laennec,  as 
we  see  in  his  observations  on  chronic  pneumonia. 


PNEUMONIA.  277 

Hospital.  The  disease  was  in  almost  all  cases  of  the  typhoid 
character,  and  in  the  adult  male  subject.*  I  have  seen  it,  how- 
ever, in  females,  and  not  unfrequently  in  children,  in  whom  it  is 
often  mistaken  for  phthisis. t 

^Resolution  of  Pneumonia. — It  is  now  established,  that  reso- 
lution may  take  rplace  at  any  stage  of  this  disease  ;  but  the 
periods  at  which  this  change  begins  and  is  perfected,  are  exceed- 
ingly various.  Thus  the  signs  of  complete,  dulness  and  absence 
of  vesicular  murmur  may  disappear  within  twenty-four  or  thirty- 
six  hours ;  while  in  other  cases  many  weeks  elapse  before  the 
lung  is  restored  to  a  natural  condition. 

Among  the  many  singular  results  of  auscultation  there  is 
none  more  remarkable  than  the  discovery  of  the  rapid  changes 
which  the  lung  undergoes  in  certain  cases  of  pneumonia.  I 
have  frequently  seen  all  the  signs  of  solidification  subside 
within  two  days,  and  have  even  observed  great  modifications 
in  the  course  of  a  few  hours.  I  have  found  out  of  twenty-four 
cases  in  which  the  period  of  resolution,  or  in  other  words,  the 
time  in  which  all  physical  signs  of  disease  had  disappeared,  was 
accurately  observed,  that  in  nine  it  occurred  within  the  first 
week  of  the  disease ;  in  nine  within  the  fortnight ;  in  five  within 
three  weeks ;  and  in  one  in  a  month  from  the  period  of 
invasion.  In  eighteen  of  these  cases  hepatization  had  occurred, 
and  in  one  there  was  abscess,  the  signs  of  which  disappeared  in 
fourteen  days.  Lastly,  I  may  add  that  my  researches  do  not 
shew  any  difference  in  the  rapidity  of  resolution  comparing  the 
disease  of  the  right  or  left  lung. 

[My  experience  is  that  the  disease  is  capable  of  resolution  at 
any  stage  of  its  progress,  short  of  abscess,  and  that  it  may  be 
often  witnessed  even  when  the  whole  of  one  lung,  and  part  of 
the  other  are  engaged,  and  when  the  fourth  or  suppurative  con- 
dition is  extensively  established,  provided  that  the  antiphlogistic 
treatment  has  not  been  pushed  too  far  at  first,  and  that  the 
advanced  stages  are  treated  by  revulsives,  and  the  use  of  stimu- 
lants.    Under  these  circumstances  the  recovery  is  often  singu- 

*  An  intelligent  American  physician,  who  visited  Dublin  about  that  time,  stated  to 
me  that  a  similar  tendency  to  pneumonia  of  the  upper  lobes  had  been  observed  in  some 
of  the  cities  of  the  United  States,  and  also  in  Paris,  during  the  same  year. 

f  In  eighty  cases  of  pneumonia,  Andral  found  fifty-seven  of  the  lower  lobe,  thirty 
of  the  upper,  and  eleven  in  which  the  whole  lung  was  engaged.  I  think  this  propor- 
tion much  greater  than  what  occurs  in  this  country. 


278  PNEUMONIA. 

larly  rapid,  and  without  any  sign  of  injury  having  been  done 
to  the  pulmonary  structure,  the  lung  rapidly  regains  its  sonoriety, 
and  the  vesicular  murmur  is  frequently  restored,  either  without 
the  appearance  of  the  crepitus  redux  of  Laennec,  or,  with  its 
existence  in  a  very  trifling  degree.  It  appears  to  me  that  the 
progress  of  resolution,  in  place  of  being,  as  is  generally  supposed, 
merely  from  above  downwards,  is  rather  from  the  circumference 
to  the  centre ;  we  not  nnfrequently  have  seen  cases  in  which 
the  resolution  was  complete,  or  nearly  so,  in  the  upper  and  the 
lowest  portions  of  the  lung,  while  the  dulness  and  bronchial 
respiration  lingered  about  the  root  of  the  lung,  and  were  last 
observed  in  that  situation. — Autlior's  Note  Book.] 

Symptoms  of  Pneumonia. — So  various  are  the  circumstances 
under  which  we  meet  with  this  disease,  that  it  becomes  difficult 
to  give  any  condensed  account  of  its  symptoms ;  and  although 
we  may  enumerate  fever,  arterial  excitement,  cough,  viscid, 
bloody,  or  purulent  expectoration,  dyspnoea  and  accelerated 
breathing,  as  its  symptoms,  still  there  is  not  one  of  these  that 
may  not  occur  in  other  diseases,  or  be  absent  in  pneumonia 
itself.  Further,  we  know  that  in  most  cases  inflammation  of  the 
serous  and  mucous  tissues  complicates  that  of  the  parenchyma, 
so  as  to  make  it  difficult  to  say  what  are  the  symptoms  of  pneu- 
monia simply  considered. 

But  the  true  source  of  diagnosis  is  our  finding  the  combina- 
tion of  irritation  of  the  respiratory  system,  with  the  physical 
signs  of  pneumonia  ;  of  which  signs  it  may  be  said,  that  although 
taken  singly,  any  of  them  may  occur  in  other  affections  ;  yet 
that  in  pneumonia,  their  mode  of  succession  is  quite  charac- 
teristic. 

[For  example,  in  no  other  disease  do  the  signs  of  pulmonary 
consolidation  follow  the  development  of  true  crepitating  rale 
over  a  large  surface,  the  disease  being  acute  and  accompanied 
by  fever.  In  no  other  disease  do  the  signs  of  hepatization, 
dulness,  bronchial  respiration,  and  absence  of  vesicular  murmur, 
pass  into  those  of  that  morbid  permeability  which  occur  in  the 
fourth  stage.  And  in  no  other  affection  are  the  signs  of  abscess 
preceded  by  those  of  the  four  anterior  conditions  of  pneumonic 
disease.  Hence  the  only  true  source  of  diagnosis  is  the  com- 
bination of  the  general  and  varied  symptoms  of  pulmonary 
irritation  with  the  physical  signs  of  pneumonia,  considered  not 


PNEUMONIA.  279 

only  in  their  inherent  characters  but  in  their  order  of  suc- 
cession. 

It  may  be  stated  as  a  general  rule,  that  if  we  compare  cases  of 
acute  pneumonia  with  cases  of  acute  pleurisy,  the  former  will  be 
found  to  be  accompanied  with  less  suffering,  at  least  at  first ;  the 
pain  is  more  deep-seated,  and  less  like  that  of  pleurodynia,  and 
there  is  not  the  same  tenderness  of  the  integuments ;  the  pulse 
is  generally  more  developed,  and  the  cough  is  bronchial,  and  at 
an  early  period  accompanied  by  expectoration.  There  is  less 
dyspnoea  indeed  after  antiphlogistic  measures  have  been  used  ; 
the  respiration  may  become  perfectly  tranquil,  even  though 
extensive  hepatization  exist.  "We  cannot,  then,  measure  the 
amount  of  obstruction  by  the  degree  of  dyspnoea. — Author's 
Note  Book.] 

Although  the  sanguinolent  and  viscid  character  of  the  expec- 
torated mucus  is  observed  in  many  cases  of  pneumonia,  yet 
it  is  anything  but  constant.  In  fact,  pneumonia  may  occur  with 
all  varieties  of  expectoration,  from  a  scanty  and  colourless  mucus, 
to  the  most  different  characters*  of  secretion.  It  often  occurs 
without  any  characteristic  expectoration,  and  may  thus  pass 
even  to  its  advanced  stages.  Generally  speaking  it  may  be  said 
that  the  "  crachats  routtlcs"  of  the  French  are  found  in  the 
more  active  cases  of  pneumonia,  which  occur  in  robust  habits ; 
but  I  am  convinced  that  in  a  large  proportion  of  the  hospital 
cases,  in  which  the  disease  occurs  in  feeble  constitutions  ;  in 
the  child,  or  as  a  complication  or  a  sequel  to  fever,  the  appearance 
of  the  expectoration  has  little  value.  It  is  believed  that  the  red 
and  viscid  sputa  occur  only  at  the  height  of  the  disease.  This  is 
generally  true,  but  an  exception  to  the  rule  has  been  recorded 
by  Andral,  in  which  for  eight  or  nine  days  after  the  subsidence 
of  the  symptoms  and  signs  of  pneumonia,  the  sputa  continued 
red,  and  extremely  viscid.  He  suggests,  whether  in  this  case 
there  might  not  have  been  a  central  pneumonia,  which  could  not 
be  detected,  and  which  kept  up  the  secretion.  Such  an  opinion 
seems  improbable  from  the  disappearance  of  constitutional 
symptoms.  I  have  seen  a  case  similar  to  this,  which  illustrates 
how  little  value  can  be  placed  on  a  particular  symptom.  A 
woman  was  admitted  into  the  Meath  Hospital  for  an  injury  of 
the  chest ;  several  ribs  had  been  broken.  She  was  attacked 
with  intense   pleuro-pneumony,    accompanied   by  the   red   and 


280  PNEUMONIA.' 

viscid  expectoration  in  quantity.  All  the  physical  signs  of 
pneumonia  supervened,  and  in  a  short  time  the  lung  was  ex- 
tensively hepatized.  Under  a  most  active  treatment,  however, 
the  symptoms  disappeared,  with  the  exception  of  the  expectora- 
tion. The  dulness  ceased,  and  the  vesicular  murmur  was 
restored,  but  for  weeks  she  had  an  expectoration  of  red  mucus, 
presenting  all  the  characters  which  it  had  in  the  first  stages, 
and  so  abundant  that  on  some  days  several  pints  were  evacuated. 
Its  tenacity  was  so  great,  that  a  dressing  tray  in  which  she  ex- 
pectorated, of  twelve  inches  in  breadth,  and  not  more  than  two 
in  depth,  could,  when  full,  be  inverted  without  a  drop  escaping ; 
yet  repeated  examinations  discovered  nothing  more  than  the 
ordinary  signs  of  bronchitis. 

But  in  the  suppurative  stages  the  expectoration  is  generally 
characteristic ;  it  then  occurs  under  two  forms,  in  the  one  we 
observe  a  purplish  red  muco-puriform  fluid,  while  in  the  other 
we  find  that  the  matter  coughed  up  has  all  the  characters  of  the 
laudable  pus  of  authors.  It  is  of  a  light  yellow  colour,  perfectly 
homogeneous,  and  of  the  consistence  of  cream.  I  have  never 
seen  this  expectoration  unless  in  the  suppurative  pneumonia, 
and  it  forms  almost  the  only  instance  in  which  an  expectoration 
of  pure  pus  is  met  with. 

As  far  as  we  have  observed  there  is  no  anatomical  difference 
between  the  cases  with  prune  juice  sputa,  and  those  in  which 
there  is  a  secretion  of  healthy  pus ;  but  it  will  often  be  found, 
that  in  the  former  case  the  disease  exists  in  a  lower  type,  and 
in  broken  down  constitutions,  while  I  have  never  seen  the  latter 
except  in  cases  of  active  pneumonia  in  the  young  and  robust 
individual. 

Either  of  these  forms,  but  particularly  the  latter,  are  charac- 
teristic of  the  fourth  stage  of  the  disease,  a  condition  which 
seems  more  often  attended  with  a  peculiar  expectoration  than 
any  of  the  preceding  stages.  With  reference  to  pulmonary 
abscess,  I  have  only  to  remark,  that  in  most  of  the  cases  I  have 
seen  the  expectoration  was  not  by  any  means  characteristic.  In 
two  cases  nothing  was  coughed  up  but  a  little  bronchial  mucus, 
while  in  the  others  it  had  very  different  characters.  I  have 
found  it  foetid,  or  devoid  of  smell,  mucous,  or  muco-puriform, 
collected  into  masses  which  floated  in  serum,  or  resembling  the 
ordinary  expectoration  of  chronic  bronchitis. 


PNEUMONIA.  281 

As  a  symptom  of  pulmonary  irritation,  dyspnoea  is  much 
more  prominent  in  bronchitis  or  pleurisy,  than  in  pneumonia. 
Indeed,  the  respiration  in  this  affection,  particularly  after  anti- 
phlogistic measures  have  been  emploj'ed,  is  in  most  cases  singu- 
larly easy,  even  though  a  large  portion  of  lung  has  become 
hepatized,  so  that  the  amount  of  obstruction  cannot  be  measured 
by  the  degree  of  dyspnoea. 

In  localized  pneumonia  two  causes  exist  for  dyspnoea  with 
accelerated  breathing,  namely,  its  complication  with  extensive 
bronchitis ;  and  that  inflammatory  excitement  which  affects  the 
whole  lung.  Many  cases  will  be  met  with  in  which  both  con- 
ditions exist;  but  the  second  may  occur  independently  of  the 
first. 

Hence  there  are  three  cases  in  which  the  difficulty  and  ac- ) 
celeration  of  breathing  are  no  measure  of  the  extent  of  pneu- 
monic disease.  In  the  first  there  is  an  extensive  bronchitis ;' 
in  the  next,  the  combination  of  this  with  the  functional  excite- 
ment of  the  lung ;  and  in  the  third,  this  condition  exists  with 
scarcely  any  bronchial  irritation.  From  ignorance  of  these  facts 
we  may  commit  great  errors  in  practice ;  for  in  all  these  cases 
the  first  effect  of  treatment  is  seen  less  on  the  pneumonia  than 
on  these  accompanying  states ;  on  the  bronchitis,  on  the  one 
hand,  and  on  the  inflammatory  spasm  or  excitement  on  the 
other.* 

*  The  value  here  assigned  to  the  rational  symptoms  is  perhaps  scarcely  adequate. 
In  acute  sthenic  pneumonia  the  group  of  symptoms  attending  and  following  the  in- 
vasion are  eminently  characteristic,  and  as  has  been  remarked  by  many  observers 
frequently  constitute  both  the  only  available,  and  the  sufficient,  data  for  our  diagnosis. 
Thus  we  have  (a)  the  initiatory  rigor,  sudden,  single,  and  severe,  followed  by  sudden 
rise  of  temperature  gradually  mounting  up  from  102°  to  105°,  with  that  sensation  of 
pungent  heat  communicated  to  the  hand,  first  noticed  by  Dr.  Addison,  and  as  Wun- 
derlich  observes  sometimes  continuing  for  two  or  three  days  unattended  by  any 
auscultatory  signs  of  the  disease. 

(b)  The  aspect  of  the  patient  during  this  stage  is  peculiar :  he  has  an  anxious 
muddled  look,  and  the  face  and  brow  are  commonly  suffused,  the  appearance  resem- 
bling that  of  a  person  who  has  fallen  asleep  before  a  large  fire. 

(c)  The  respiration  is  painful  and  shallow,  and,  as  Dr.  Walshe  first  pointed  out,  is 
peculiar  to  pneumonia  in  the  altered  relation  to  the  rate  of  pulse. 

(d)  The  cough  and  expectoration  are  characteristic,  the  former  being  short,  frequent, 
and  painful,  and  brought  on  by  any  change  of  posture,  thus  controlling  the  feverish 
restlessness  which  might  otherwise  be  expected. 

It  may  be  added  that  not  unfrequently  our  diagnosis  of  the  true  nature  of  a  sup- 
posed case  of  tubercular  phthisis  will  be  assisted  and  its  successful  treatment  suggested, 
by  a  careful  inquiry  into  the  history  of  the  symptoms  of  the  invasion,  by  which  its 
inflammatory  origin  may  be  ascertained.     (Ed.) 


282  PNEUMONIA. 

Physical  Signs  of  Pneumonia. — The  sources  of  physical 
signs  in  this  disease  may  be  thus  enumerated  : — 

1st.  Evidences  of  a  local  excitation. 

2nd.  Evidences  of  sanguineous  congestion. 

3rd.  Evidences  of  the  diminished  quantity  of  air  in  the  affected 
lung. 

4th.   Signs  of  increasing  solidity  of  the  lung. 

5th.  Phenomena  of  voice. 

6th.  Phenomena  referable  to  the  circulating  system. 

7th.  Evidence  of  accompanying  lesions  of  the  pleura. 

8th.  The  diminished  volume  of  the  lung. 

In  the  above  catalogue,  no  mention  is  made  of  the  signs  of 
accumulation  or  visceral  displacement,  so  valuable  in  other 
diseases.  These  signs  are  wanting  in  pneumonia,  for  although 
the  observation  of  Broussais,  as  to  the  impression  of  the  ribs  on 
the  inflamed  lung,  may  be  often  verified,  yet  the  increase  of 
volume  goes  no  farther.  The  appearance  is  not  constant,  and  I 
have  only  observed  it  in  cases  where  the  whole  lung  had  passed 
into  interstitial  suppuration.  These  depressions  are  seldom 
more  than  three  lines  in  depth,  and  hence,  though  their  existence 
shews  that  some  tumefaction  has  occurred,  it  is  plain  that  it 
cannot  interfere  with  diagnosis,  and  make  us  confound  a  solid 
lung  with  a  distended  pleura  ;  so  far  we  may  agree  with  Laennec, 
but  his  denial  that  any  tumefaction  occurs  in  pneumonia  is  not 
borne  out  by  observation.* 

Signs  of  the  first  Stage. — The  physical  signs  of  the  first 
stage  of  pneumonia  are  still  to  be  determined  with  accuracy. 
Without  possessing  a  sufficient  number  of  observations  to  deter - 

*  See  Dr.  Forbes's  translation,  page  185.  It  is  difficult  to  explain  how  Laennec 
should  have  taken  up  his  opinion  so  strongly  on  this  subject,  for  the  appearance  is  by 
no  means  unfrequent,  and  we  should  expect  it  from  all  the  analogies  of  disease.  In 
all  my  cases,  the  pleura  had  been  inflamed,  and  the  marks  of  the  ribs  produced  by  two 
causes,  one  the  depression  in  the  lung,  and  the  other  the  less  degree  of  organization 
which  the  lymph  corresponding  to  each  rib  had  undergone.  Thus  we  have  an  alterna- 
tion of  comparatively  transparent  and  opake  spaces,  as  if  the  contact  with  the  rib  was 
less  favourable  to  orgauization  than  that  with  the  intercostal  muscles.  Looking  at  the 
analogies  of  disease,  it  appears  that  if  we  examine  the  influence  of  inflammation  in 
altering  the  volume  of  organs,  we  find  that  tumefaction  is  commonly  observable  in  the 
earlier  stages.  In  the  chronic  irritations,  on  the  contrary,  although  an  hypertrophy 
sometimes  results,  yet  diminution  of  volume  is  more  frequently  met  with  ;  and  in  the 
same  case  the  affected  organ  may  first  exceed,  and  afterwards  be  reduced  far  below  its 
natural  dimensions.  This  occurs  in  the  lung  ;  inflammation  produces  a  tumefaction 
and  afterwards  an  atrophy  of  the  organ,  which  we  can  verify  by  measurement  of  the 
chest. 


PNEUMONIA.  283 

mine  the  point,  I  am  led  to  the  belief  that  an  intense  puerility 
of  respiration  in  the  affected  part  will  be  found  to  be  the  principal 
phenomenon.*  In  cases  in  which  inflammation  was  spreading 
upwards,  I  have  often  found  that  a  puerile  respiration  preceded 
the  crepitating  rale  for  some  hours ;  and  that  this  was  not  a 
general  but  a  partial  condition  was  shewn  by  its  being  much 
more  intense  in  the  vicinity  of  the  disease  than  in  the  opposite 
lung.  Indeed  in  cases  presenting  great  puerility  of  respiration 
with  fever,  we  may  often  prognosticate  the  occurrence  of  the 
crepitating  rale.  Thus,  in  a  case  in  which  numerous  inflamma- 
tions successively  occurred,  and  in  which  the  disease  attacked 
both  lungs  as  well  as  the  pericardium,  I  observed  this  sudden 
appearance  of  intensely  puerile  respiration  on  three  distinct  oc- 
casions ;  in  two  it  was  followed  by  the  crepitating  rale,  and  other 
signs  of  pneumonia,  and  in  one  was  removed  by  bleeding  before 
the  above  signs  had  occurred. 

From  these  and  many  other  observations,  I  would  conclude 
that  we  may  diagnosticate  the  first  stage  of  pneumonia  by  the 
sudden  occurrence  of  a  local  puerility  of  respiration,  combined 
with  fever  and  excitement  of  the  respiratory  system. 

The  circumstances  which  give  value  to  this  phenomenon,  as  a 
sign  of  pneumonia,  are  obviously  its  sudden  appearance,  localiza- 
tion, and  combination  with  fever. 

Signs  of  the  second  Stage. — The  crepitating  rale,  and  the 
gradually  diminishing  vesicular  murmur  constitute  the  signs  of 
this  stage,  and  it  is  the  combination  of  these  phenomena  which 
gives  them  their  value.  It  must  be  admitted  that  Laennec  has 
not  succeeded  in  establishing  the  crepitating  rale  as  an  invariable 
phenomenon  in  this  disease.  It  is  neither  invariable  nor  posi- 
tive, but  like  all  other  physical  signs,  derives  its  value  from  the 
preceding  and  accompanying  phenomena.  As  a  physical  sign,  it 
only  points  out  a  secretion  or  effusion  into  the  pulmonary  cells, 
and  to  determine  that  this  is  pneumonic,  we  require  the  increas- 
ing dulness  and  gradual  obliteration  of  the  respiratory  murmur.f 

Laennec  has  stated,  that  the  resolution  of  solidity  is  invariably 

*  I  have  used  the  term  puerile  respiration  in  treating  of  this  condition.  Perhaps 
we  should  use  that  of  exaggerated.  We  are  still  ignorant  of  the  immediate  cause  of 
this  modification  of  the  respiratory  murmur,  which  must  be  different  from  that  of 
ordinary  puerile  respiration.  Or  have  we  been  in  error  in  considering  the  latter  as 
the  result  of  purely  mechanical  conditions  ?     {Author's  Note  Bool.) 

t  The  crepitating  rale  has  been  compared  to  various  sounds  ;  of  these  comparisons, 


284  PNEUMONIA. 

announced  by  a  return  of  the  crepitating  rale  (ronchus  crepitans 
redux),  but  my  experience  is  altogether  opposed  to  this  state- 
ment, for  I  have  often  observed  the  change  from  complete 
dulness  of  sound  and  bronchial  respiration,  to  clearness  and  return 
of  respiratory  murmur,  without  any  crepitus  of  resolution ;  and 
this  may  be  seen  in  all  varieties  of  pneumonia ;  nor  does  the 
absence  of  the  phenomenon  necessarily  imply  a  rapid  resolution, 
for  it  may  be  absent  in  cases  in  which  weeks  elapse  before  the 
dulness  of  sound  is  removed.  But  the  sign  is  common  where 
the  disease  has  passed  into  an  advanced  stage,  where  early  treat- 
ment has  been  neglected,  or  the  vital  powers  much  depressed. 

[I  formerly  believed  that  Laennec  erred  in  stating  that  the 
crepitating  rattle  necessarily  preceded  the  signs  of  hepatization. 
I  had  founded  this  opinion  on  the  fact  of  the  occurrence  of 
sudden  consolidation  without  any  previous  crepitus,  so  that  it 
would  appear  that  in  certain  cases  of  pneumonia  the  disease 
actually  commenced  by  hepatization.  Subsequent  experience, 
however,  leads  me  to  believe  that  in  many  of  these  cases  of 
sudden  consolidation,  even  though  the  after  stages  of  inflammation 
may  he  produced  in  them,  and  though  in  their  resolution  they 
exhibit  the  ordinary  signs  observable  in  sthenic  pneumonia,  yet 
that  their  pathological  nature  is  very  different  from  that  of 
ordinary  pneumonia,  and  I  now  believe  that  in  this  latter  disease 
the  crepitus  will  be  almost  invariably  found  to  precede  the  signs 
of  consolidation.  The  following  observations  of  Dr.  Walshe  are 
of  great  practical  importance :  "  When  at  its  maximum  the 
crepitant  ronchus  accompanies  the  entire  act  of  inspiration ; 
when  first  developed,  and  when  about  to  be  superseded  by 
blowing  respiration,  it  appears  before  the  close  of  the  inspiration 
only.  Under  all  circumstances  it  is  to  say  the  least  rare  to 
find  this  ronchus  co-existent  in  any  degree  with  expiration  ;  the 
statement  that  it  may  generally  be  heard  to  a  diminished  amount 
with  this  division  of  the  respiratory  act  appears  to  me  to  have 
originated  in  the  confusion  which  long  prevailed  between  the 
crepitant  ronchus  of  pneumonia  and  the  small  bubbling  ronchus 
of  capillary  bronchitis."     In  speaking  of  the  persistency  of  the 


that  by  Dr.  Williams  is  most  accurate,  namely,  the  sound  produced  by  rubbing  a  lock 
of  hair  close  to  the  ear.  This  may  be  observed  both  in  the  commencement  and  reso- 
lution of  the  disease  ;  but  all  varieties  of  crepitating  and  muco-crepitating  rales  may 
occur  in  pneumonia. 


PNEUMONIA.  285 

sign,  he  observes  that  "  other  ronchi  are  manifestly  influenced 
in  the  regularity  of  their  production  by  the  occurrence  of  ex- 
pectoration, for  example,  but  over  true  crepitation  this  appears  to 
exercise  no  immediate  control,  at  least  the  ronchus  persists 
with  all  its  characters  as  before  after  the  patient  has  relieved 
himself  by  expectoration.  The  first  effect  of  a  fit  of  coughing, 
indeed,  is  to  render  the  ronchus  more  distinct  and  abundant  even 
than  before." — Author's  Note  Book.] 

The  crepitus  of  resolution  (generally  having  much  larger  bub- 
bles than  in  the  earlier  stages)  is  to  be  heard  during  the  whole 
inspiration,  and  in  a  diminished  degree  during  expiration.  But 
in  other  cases  the  first  part  of  the  inspiration  is  pure,  and  the 
rale  only  appears  at  the  termination  of  the  effort.*  In  one  case, 
however,  I  have  observed  the  reverse  of  this,  for  we  had  first 
rale,  and  then  pure  vesicular  murmur. 

Signs  of  the  third  Stage. — In  this  condition,  the  cells 
being  obliterated,  while  the  large  tubes  remain  pervious,  dulness 
of  sound,  bronchial  respiration,  and  a  loud  resonance  of  the  voice 
are  produced,  and  within  certain  limits,  the  extension  or  in- 
tensity of  these  signs  furnish  an  accurate  measure  of  the  extent 
or  intensity  of  the  disease.  With  respect  to  the  bronchial 
respiration,  there  are  some  circumstances  not  generally  under- 
stood ;  it  requires  for  its  production  not  merely  the  solidity  of 
the  lung,  but  a  certain  expansion  of  the  side  during  respiration. 
Thus  we  find  that  if  the  whole  lung  become  solid,  the  bronchial 
respiration  ceases,  the  side  is  fixed,  an  evident  result  of  the  non- 
expansion  of  the  lung.  In  such  a  case  the  phenomenon  goes 
on  increasing  to  a  certain  point,  after  which  its  diminution 
points  out  the  extension  of  the  disease,  until  the  whole  lung  is 
solidified,  when  the  signs  are  universal  dulness,  absence  of 
respiration,  and  resonance  of  the  voice.  If  now  the  upper 
portion  begins  to  resolve,  or  if  an  abscess  be  formed,  in  either 
of  which  cases  air  again  rushes  through  the  bronchial  tubes, 
we  have  a  return,  and  for  some  time  an  increase  of  the  bronchial 
respiration,  indicative  of  resolution  on  the  one  hand,  or  abscess 
on  the  other.  These  phenomena  I  have  repeatedly  verified, 
and  have  observed  that  for  the   reproduction  of  the  bronchial 

*  Some  have  conceived  that  the  crepitating  rale  arose  from  the  effusion  of  air  into 
the  substance  of  the  lung;  the  phenomenon  just  mentioned  is  a  strong  argument 
against  this  opinion. 


•V 


286  PNEUMONIA. 

respiration  it  is  not  necessary  that  the  permeable  portion  should 
be  of  great  extent.  Thus  in  the  case  of  cicatrized  pneumonic 
abscess  which  I  have  given,  the  permeable  portion  did  not  form 
a  sixth  of  the  whole  lung,  and  was  yet  sufficient  to  induce 
bronchial  respiration  in  the  solidified  parts. 

In  cases  where  the  lung  is  universally  solidified,  the  disease 
might  be  confounded  with  an  extensive  empyema,  particularly  if 
the  previous  history  and  succession  of  physical  signs  were  not 
observed ;  but  even  here  the  diagnosis  can  be  made,  for  I  have 
never  seen  a  case  of  empyema  so  extensive  as  to  cause  general 
dulness,  in  which  there  were  not  the  signs  of  visceral  displace- 
ment, which,  with  the  absence  of  the  phenomena  of  voice,  are 
quite  sufficient  to  guide  the  diagnosis. 

In  the  ordinary  pneumonia,  the  dulness  of  sound  and  bronchial 
respiration  are  preceded  by  the  crepitating  rale,  but  I  have 
already  spoken  of  a  most  important  variety,  in  which  a  ramd 
solidification  occurs,  not  preceded  by  the  usual  signs.  Under 
these  circumstances,  the  lung  may  pass  in  the  course  of  a  few 
hours  from  apparent  health  to  complete  solidification.  The 
disease  begins  by  hepatization,  and  often  runs  its  course  with 
great  rapidity,  and  it  requires  some  diagnostic  skill  to  distin- 
guish this  case  from  pleurisy  with  copious  effusion.  This  fact, 
so  important  an  exception  to  Andral's  rule,  that  sudden  dulness 
without  crepitus  is  pathognomonic  of  pleurisy  with  effusion,  I 
was  aware  of,  and  taught  in  my  lectures  many  years  ago,  and 
my  observations  have  been  since  confirmed  by  Dr.  Hudson. 

The  principal  physical  diagnosis  between  this  typhoid  solidity 
and  a  pleural  effusion  is,  that  with  the  dulness  and  absence  of 
respiration  of  a  great  effusion,  the  signs  of  eccentric  displacement 
are  wanting ;  the  heart  is  not  displaced,  the  epigastrium  and 
hypochondria  are  concave,  and  the  intercostal  muscles  unaffected. 
But  we  can  be  assisted  by  other  points ;  the  phenomena  of 
voice,  the  greater  frequency  of  bronchial  respiration,  the  occa- 
sional occurrence  of  rale  here  and  there  will  assist  in  the 
diagnosis,  the  grand  source  of  which,  however,  consists  in  the 
application  of  the  first  rule  which  I  have  given  in  a  case  pre- 
senting the  symptoms  of  typhoid  pneumonia. 

[Signs  of  the  foubth  Stage — Intekstitial  Suppuration. — 
AVhile  the  constitutional  symptoms  continue  severe,  it  is  found 
that  a  certain  change  takes  place  in  the  physical  signs  caused 


PNEUMONIA.  287 

by  the  production  of  permeability  to  a  certain  extent.  This 
change  consists  in  the  combination,  which  is  almost  peculiar,  of 
bronchial  respiration  with  a  sharp  and  intense  muco-crepitating 
rale ;  phenomena,  which  when  taken  in  connexion  with  the  pre- 
vious history,  and  actual  symptoms,  leave  no  doubt  as  to  the 
nature  of  the  pathological  condition. 

Should  the  disease  be  still  spreading  we  may  observe  a  com- 
bination of  the  inflammatory  symptoms  of  the  earlier  stages  with 
those  indicative  of  suppuration,*  while  if  it  be  localized,  we  find 
a  species  of  acute  hectic  supplanting  the  first  inflammatory 
fever.  The  respiration  continuing  to  be  distressed,  the  pulse 
rapid,  and  feebler  than  before,  and  the  expectoration  either  of  the 
prune  juice  character,  or  consisting  of  yellowish,  creamy,  homo- 
geneous pus.  The  fact  of  the  spreading  of  disease  in  other 
portions  of  the  lung  or  its  opposite,  is  most  important  in  the 
diagnosis  of  this  condition.  We  rarely  see  resolution  in  one 
portion,  and  increase  of  disease  in  another,  so  that  if  the  new 
permeability  of  the  hepatized  lung  is  accompanied  by  signs  and 
symptoms  of  spreading  disease  in  new  portions  of  the  lung, 
there  is  a  great  probability  that  interstitial  suppuration  is 
taking  place  in  the  part  originally  engaged. 

But  again  the  return  of  permeability  is  not  accompanied  by 
that  of  the  sonoriety  of  the  chest ;  and  the  bronchial  respiration 
so  far  from  disappearing,  becomes  in  many  cases  even  more  dis- 
tinct. We  may  compare  the  two  cases  of  returning  permeability, 
the  one  from  resolution,  the  other  from  interstitial  suppuration, 
in  pairs  of  characters,  and  thus  get  a  clear  idea  of  all  the 
phenomena. 


Resolutive  Permeability. 

I.  Subsidence  of  Fever. 

II.  Distress  of  the  respiration 
ceasing. 

III.  Expectoration  ceasing  and 
becoming  bronchitic. 

IV.  No  physical  signs   of  ex- 


Suppurative  Permeability. 

I.  Increase  of  Fever  and  change 
in  its  general  character. 

II.  Distress  increasing  ;   Dysp- 
noea augmented  ;  Cough  frequent. 

III.  Expectoration  copious,  pu- 
rulent, or  puro-sanguinolent. 

IV.  Evidence  of  the  spreading 


*  "  As  long  as  the  inflammation  increases,"  says  Laennec,  "  the  crepitous  rattle 
extends  daily  round  the  hepatized  part,  or  arises  in  new  points  ;  it  precedes  the  signs 
of  hepatization,  which  commonly  are  found,  on  the  following  day,  very  distinct  in 
those  points  where  the  crepitous  rattle  had  existed  the  day  before."    (Ed.) 


288 


PNEUMONIA. 


tension  of  disease  in  other  por- 
tions. 


V.  Dulness  disappearing. 

VI.  Bronchial  respiration  be- 
coming less  distinct,  and  finally 
subsiding. 

VII.  Sub-crepitating  rale  (cre- 
pitus redux)  gradually  subsiding, 
and  replaced  by  vesicular  mur- 
mur. 


of  the  earlier  states  of  pneumonia, 
either  in  the  affected  lung  or  in 
the  opposite  ;  these  are  commonly, 
but  not  constantly  present. 

V.  Dulness  maintained. 

VI.  Bronchial  respiration  re- 
maining, and  of  a  most  distinct 
and  intense  character. 

VII.  Intense  and  permanent 
muco-crepitating  rale. 


Signs  of  Eesolution. — The  signs  of  resolution  usually  ob- 
served, are  the  gradual  return  of  clearness  of  percussion  sound 
over  the  dull  portion,  such  return  corresponding  with  the  order 
of  resolution  ;  and  the  occurrence  of  crepitus  of  resolution  mixed 
at  first  with  bronchial  breathing,  and  giving  place  gradually  to 
feeble,  but  pure  respiratory  murmur. 

The  order  of  these  phenomena  may  be  varied  in  several  ways 
— as  by  the  absence  of  crepitus.  In  the  first  edition  of  this  work 
the  fact  was  announced  that  complete  dulness  of  sound  and 
bronchial  respiration  will  often  pass  into  clearness,  and  return  of 
respiratory  murmur  without  the  occurrence  of  any  crepitus  of 
resolution.  The  truth  of  this  observation,  founded  on  no  small 
number  of  cases,  has  been  questioned  by  some  subsequent 
writers,  amongst  others  by  Grisolle,  who  argues  that  this  sign  of 
resolution  may  have  been  overlooked,  and  may  really  have  been 
present  during  the  interval  between  the  several  examinations. 
It  is  a  sufficient  answer  to  this  objection,  that  admitting  the 
crepitus  of  resolution  to  be  a  very  fugacious  sign,  it  could  scarcely 
have  escaped  observation  in  so  large  a  number  of  instances,  as 
have  occurred  before  and  since  the  above  passage  was  written ; 
and  that  this  number  more  than  compensates  for  the  supposed 
long  interval  between  two  explorations  in  any  single  case. 

Another  variation  in  the  process  of  resolution  is  sometimes 
presented  in  the  order  in  which  it  occurs.  As  a  general  rule, 
resolution  commences  in  the  part  last  hepatized  ;  to  this,  how- 
ever, there  are  numerous  exceptions,  in  which  instances  the 
crepitus  redux  appears  first  in  the  part  of  the  lung  first  in- 
flamed. 


PNEUMONIA.  289 

A  difficulty  sometimes  arises  from  the  extension  of  pneu- 
monic crepitus  to  other  parts  of  the  lung,  while  resolution  is 
progressing  in  the  portion  originally  engaged  ;  this  condition 
is  ascribed  by  Dr.  Alison*  to  the  extension  of  an  exudation 
of  a  modified  character  and  so  attenuated  as  to  be  easily 
reabsorbed. 

We  sometimes  meet  with  the  persistence  of  bronchial  respira- 
tion in  portions  of  the  side  for  a  long  time  after  pure  respiratory 
murmur  has  replaced  it  in  the  remainder,  while  in  other,  but  rare 
instances,  puerile  respiration  continues  for  a  while  over  the 
affected  portion. 

Lastly,  the  occurrence  of  frottement  over  the  inflamed  portion 
at  an  advanced  period  of  the  stage  of  resolution  must  be  con- 
sidered as  a  variation  from  the  strictly  normal  order  of  signs 
though  one  of  frequent  occurrence. 

Signs  of  fifth  Stage — Abscess. — As  the  physical  signs  of 
phlegmonous  abscesses  which  communicate  with  the  bronchial 
tubes,  do  not  essentially  differ  from  tuberculous  caverns,  we  need 
not  dwell  upon  them  here.  There  are,  however,  in  the  collateral 
circumstances  some  points  of  difference.     These  relate — 

I.  To  time. 

II.  To  the  preceding  physical  signs. 

III.  To  the  rapidity  of  changes,  whether  we  refer  to  the  ad- 
vance, or  the  cure  of  the  disease. 

If  the  duration  of  the  case  from  the  first  appearance  of  morbid 
phenomena  to  the  production  of  the  signs  of  abscess  be  con- 
sidered, it  will  be  found  greatly  less  than  what  is  observed  in 
tuberculous  suppurations.  A  tuberculous  cavity  competent  to 
give  cavernous  respiration,  gurgling,  and  pectoriloquism,  may 
take  many  weeks,  or  even  months  for  its  production,  but  in 
pneumonic  abscess  the  signs  are  much  more  rapidly  developed, 
so  that  this  principle  obtains — that  the  more  rapid  is  the  sign  of 
cavity  dating  from  the  first  appearance  of  disease,  the  greater  is 
the  probability  it  results  from  a  suppurative  pneumonia.  Acting 
on  this  principle,  I  have  more  than  once  given  a  favourable 
prognosis  in  cases  which  were  considered  to  be  examples  of 
tuberculous  caverns — in  which,  the  question  of  time  had  not 
received  the  attention  which  it  deserves.  In  these  cases  a  rapid 
and  complete  recovery  took  place. 

*  Edinb.  Month.  Jour.,  1850. 
U 


290  PNEUMONIA. 

The  pre-existing  physical  signs  in  the  two  affections  are  gene- 
rally very  different,  the  intense  crepitus,  the  dulness  generally 
occupying  the  inferior  portion  of  the  lung,  and  the  bronchial 
respiration,  constitute  a  group  of  signs,  hardly  ever  found  to 
precede  the  formation  of  a  tuberculous  ahscess. 

Finally  we  may  observe  in  many  cases  of  pneumonic  abscess 
that  the  signs  of  cavity  having  arrived  at  their  maximum,  may 
yet  disappear  with  a  singular  rapidity — so  that,  day  by  day,  we 
may  trace  the  diminution  of  the  capacity  of  the  abscess.  This, 
which  is  one  of  the  most  interesting  of  all  the  results  of  ausculta- 
tion, is,  I  believe,  never  seen  in  the  case  of  tubercular  cavity;  I 
have  repeatedly  observed  the  disappearance  of  the  signs  of  cavity, 
certainly  within  ten  days  of  the  first  development,  this  change 
coinciding  with  the  convalescence  of  the  patient. 

In  cases  where  the  abscess  occupies  the  upper  portion  of  a 
lung,  there  will  be  a  greater  liability  to  mistake  the  case  for  one 
of  phthisis ;  but  even  here,  I  am  persuaded  that  if  there  has 
been  an  opportunity  of  studying  the  disease  from  its  commence- 
ment, its  true  nature  may  be  often  determined ;  and  even  when 
the  patient  has  not  been  previously  under  observation  we  may 
often,  if  but  a  very  short  time  has  elapsed,  between  the  very  first 
symptoms  of  pulmonary  disease  and  the  occurrence  of  the  signs 
of  cavity,  make  a  diagnosis  in  favour  of  pneumonia,  which  will 
probably  be  correct. 

If  we  compare  the  phlegmonous  abscesses  with  those  occurring 
in  the  asthenic  forms  of  pneumonia,  it  will  appear  that  the  latter 
are  formed  with  greater  rapidity,  which  is  characteristic  of  this 
type  of  disease. 

In  the  case  of  dissecting  abscess  already  detailed,  where  the 
lobules  were  dissected  from  the  pleura,  the  symptoms  indicated 
suppuration,  while  the  proper  signs  of  cavity  were  absent.  In 
Louis's  case,  as  given  by  Reynaud,  no  diagnosis  was  recorded,  so 
that  the  indications  of  this  form  are  still  to  be  determined. 

Observations  are  wanting  on  the  stethoscopic  signs  of  cica- 
trization in  the  case  given  above  ;  it  will  be  recollected  that  the 
signs  were  the  total  disappearance  of  cavernous  phenomena,  and 
the  substitution  of  the  natural  vesicular  murmur. 

Phenomena  of  Voice. — These  signs,  which  are  of  compara- 
tively little  value,  are  most  evident  when  dulness  of  sound  and 
bronchial  respiration  co-exist.    We  have  then  Laennec's  accidental 


PNEUMONIA.  291 

bronchophony  always  most  evident  in  the  posterior  and  superior 
portions.  It  is  easily  distinguished  from  pectoriloquism  by  its 
greater  extent,  and  by  the  absence  of  gurgling  or  cavernous 
respiration.  I  have  found  its  character  to  be  remarkably  modified 
under  two  circumstances  when  it  approaches  to  the  cegophony  of 
pleuritis :  these  are  when  the  lung  has  passed  into  the  fourth 
stage,  or  when  it  is  resolving  from  the  third.  In  the  latter 
case,  indeed,  the  cegophonic  character  is  sometimes  very  re- 
markable. 

A  remarkable  symptom  in  certain  cases  is  the  loss  of  voice, 
and  this  without  any  marked  indication  of  laryngeal  disease. 
We  have  seen  aphonia  to  occur  as  one  of  the  first  s}^mptoms  in 
a  case  of  pneumonia  of  the  right  lung  and  continue  up  to  the 
period  of  resolution.  Some  years  ago  I  attended  a  gentleman 
who  complained  of  complete  loss  of  voice,  which  he  ascribed  to  a 
cold  contracted  some  weeks  previously.  He  had  some  cough 
with  mucous  expectoration,  but  no  dyspnoea  or  fever.  The  case 
was  considered  and  treated  as  one  of  laryngeal  disease,  but  not 
the  slightest  change  in  the  voice  was  produced.  It  was  then 
discovered  that  hepatization  of  the  lower  lobe  of  the  right  lung 
existed ;  on  this  being  removed  by  treatment,  and  on  the  lung 
regaining  its  sonoriety  the  voice  returned  although  no  treatment 
had  been  directed  to  the  larynx  for  a  length  of  time.  It  would 
be  interesting  to  determine  whether  a  pneumonia  may  affect 
the  larynx  by  inflaming  the  recurrent  nerve,  as  we  see  in 
aneurisms. — Autlwrs  Note  Book.] 

Phenomena  referrible  to  the  Circulating  System. — Our 
knowledge  on  this  subject  is  as  yet  very  limited.  Two  pheno- 
mena, however,  have  been  described,  which  must  be  here 
mentioned,  namely,  the  occurrence  of  a  bellows  sound  in  the 
heart  during  pneumonia,  and  the  throbbing  of  a  large  portion  of 
the  chest,  synchronous  with  the  heart,  pending  the  earlier  stage 
of  disease.  Both  these  circumstances  occurred  in  a  case  of 
acute  pneumonia  recorded  by  Dr.  Graves.  The  bellows'  sound 
was  distinct,  not  merely  in  the  region  of  the  heart,  but  over  the 
front  of  the  chest.  It  did  not  exist  in  the  subclavian  or  carotid 
arteries,  and  continued  without  any  abatement  for  several  day?, 
subsiding  with  the  inflammation.  As  Dr.  Graves  has  left  to 
others  the  explanation  of  this  phenomenon,  I  may  state  my 
opinion  that  the  heart  was  probably  inflamed,  either  in  the  forms 

u  2 


292  PNEUMONIA. 

of  pericarditis  or  the  endocarditis  of  Bouillaud,  in  either  of 
which  a  bellows  sound  may  occur,  and  the  complication  with 
pneumonia  may  have  caused  the  latency  of  the  carditis. 

In  the  same  case  it  was  found  that  each  pulsation  of  the  heart 
was  felt  all  over  the  front  of  the  right  lung,  and  this  occurring 
when  the  lung  was  not  hepatized,  renders  Laennec's  explanation 
unsatisfactory.  Dr.  Graves  observes,  that  if  the  pulsation  was 
propagated  through  a  solid  body,  its  strength  at  any  one  point 
would  be  weakened  in  proportion  to  the  size  of  that  body,  and 
further,  that  in  this  case  the  impulse  was  not  lateral,  but 
diastolic,  so  as  to  simulate  an  aneurismal  pulsation.  "  In  the 
soft,  engorged,  and  semifluid  state,"  to  use  the  words  of  Dr. 
Graves,  "it  is  easy  to  conceive  why  the  lung,  connected  with 
the  heart  by  such  vast  vessels,  should  pulsate  with  a  strength 
almost  equal  to  that  of  aneurism ;  the  brain  pulsates  notably 
at  each  stroke]of  the  heart,  and  cerebriform  and  fungoid  tumours 
on  the  surface  of  the  limbs  and  body  have,  for  this  very  reason, 
occasionally  a  pulsation  so  strong  and  distinct,  as  at  times 
to  have  deceived  the  surgeon  into  the  belief  of  their  being 
aneurismal." 

Owing  to  the  kindness  of  Mr.  Carmichael,  I  have  seen  a 
case  which  corroborates  the  opinion  of  Dr.  Graves  ;  a  large 
cerebriform  tumour  had  sprung  from  the  posterior  mediastinum, 
and  displaced  the  upper  lobe  of  the  left  lung.  During  life, 
the  corresponding  portion  of  the  thorax,  though  presenting 
no  external  tumour,  gave  so  distinct  and  eccentric  a  pulsation, 
as  to  leave  little  doubt  on  my  mind  as  to  the  existence  of  an 
aneurism  ;  this  opinion  was  strengthened  by  other  circumstances, 
which  shall  be  hereafter  detailed.  On  dissection,  it  was  found 
that  the  disease  engaged  the  root  of  the  lung,  and  surrounded 
the  left  division  of  the  pulmonary  artery,  the  pulsations  of  which 
were  thus  transmitted  over  the  entire  tumour.* 

From  these  observations  we  may  infer,  that  in  a  semifluid 
condition  of  the  lungs,  the  pulsations  of  the  heart  may  be  pro- 

*  In  some  cases  of  this  nature,  says  Dr.  Graves,  the  action  of  the  heart  is  sufficient 
to  induce  pulsation  and  throbbing,  not  merely  in  the  inflamed  lung,  with  which  it  is 
directly  connected  by  means  of  enlarged  vessels,  but  also  in  the  superficial  veins  of 
the  extremities,  an  occurrence  proving  the  correctness  of  the  explanation  of  pul- 
monary throbbing  which  I  have  given.  Thus,  in  the  case  of  a  gentleman  labouring 
under  pneumonia,  attended  by  Mr.  M.  Collis  and  myself,  the  action  of  the  heart  was 
very  powerful,  and  a  distinct  pulsation,  corresponding  to  each  stroke  of  the  left  ven- 
tricle, was  perceptible  in  all  the  veins  of  the  back  of  the  hand.— Op.  cit.,  p.  54. 


PNEUMONIA.  293 

pagated  through  these  organs,  and  cause  phenomena  analogous 
to  those  of  aneurism. # 

Phenomena  eefereible  to  the  Pleura. — In  this  disease 
there  are  three  conditions  of  the  pleura  which  produce  physical 
signs  ;  these  are  the  effusions  of  lymph  ;  of  sero-purulent  fluid  ; 
and,  lastly,  the  effusion  of  air.  I  have  arranged  these  in  the 
order  of  their  frequency  ;  the  first  is  almost  constant,  the  next 
is  comparatively  rare,  and  out  of  many  hundred  cases,  I  have 
only  seen  one  example  of  the  third. 

The  occurrence  of  lymph  on  the  pleura  does  not  necessarily 
induce  corresponding  physical  signs  ;  hence  the  frottement  of 
Laennec  is  not  a  common  sign  of  pneumonia,  and  is  rarely 
observed  in  the  advanced  stages,  or  at  the  resolution  of  the 
disease.  I  have  never  found  it  after  the  lung  had  become 
solid.  In  a  few  cases,  however,  of  acute  and  extensive  pleuro- 
pneumonia in  the  earlier  stages,  I  have  observed  it  over  a  large 
surface.  In  a  case  where  both  lungs  and  the  heart  were  engaged, 
frottement  existed  in  the  pericardium,  as  well  as  in  both  pleurae. 
For  some  time  the  belly  was  tympanitic,  which  gave  to  the  rub- 
bing sounds  a  completely  metallic  character,  constituting  the 
most  singular  modification  of  a  stethoscopic  phenomenon  which  I 
have  ever  had  occasion  to  observe.  But  this  was  a  rare  case,  for 
even  where  pain  in  the  side  occurs,  frottement  is  commonly 
absent.  Is  this  owing  to  the  diminished  motion  of  the  inflamed 
lung,  or  to  the  rapid  obliteration  of  the  cavity,  by  that  mode  of 
almost  direct  adhesion,  in  which  little  or  no  lymph  is  effused  ? 
The  absence  of  frottement  during  resolution  is  in  favour  of  this 
supposition. 

As  the  combination  of  pneumonia  with  liquid  effusion  presents 
some  interesting  points  connected  with  the  diagnosis  of  empyema, 
I  shall  return  to  it  when  considering  that  subject. 

*  A  case  has  been  recently  published  by  Dr.  Popham  of  Cork,  of  pneumonia  in 
the  upper  lobe  of  the  left  lung,  attended  with  loud  bellows  murmur  and  increased 
pulsation  of  the  subclavian  artery  of  the  same  side.  The  signs  and  symptoms  of  the 
pneumonia  were  well  marked.  The  patient  recovered,  but  nine  months  afterwards 
was  attacked  with  typhus  fever,  and  secondary  inflammation  of  the  lower  lobe  of 
the  same  lung,  of  which  she  died.  "  On  a  post  mortem  examination,"  says  Dr.  Popham, 
"  I  was  desirous  to  see  the  state  of  the  upper  part  of  the  left  lung  which  had  formerly 
been  attacked  with  inflammation.  It  had  contracted  such  adhesion  to  the  margin  of 
the  sternum  and  the  costal  walls  that  no  degree  of  force  could  detach  it,  so  that  it  was 
obliged  to  be  cut  out ;  the  lower  part  of  the  same  lung  adhered,  but  the  adhesions 
were  recent  and  allowed  separation.  The  upper  part  was  of  a  steel-grey  colour, 
tough,  and  much  more  fleshy  than  the  lung  feels  when  healthy." — Author's  Note  Book. 


294  PNEUMONIA. 

But  of  all  these  signs,  the  most  remarkable  is  the  tympanitic 
clearness  over  the  diseased  lung,  a  phenomenon  evidently  pro- 
ceeding from  an  effusion  of  air  by  secretion  into  the  serous 
cavity.  The  first  writer  who  has  noticed  this  subject  is  Dr. 
Graves,  who  published  early  in  1835  the  remarkable  case  to 
which  I  before  alluded,  of  pneumonia  with  bruit  de  soufflet  and 
throbbing  of  the  chest.  On  the  fourth  day  of  the  disease,  after 
hepatization  had  occurred,  the  antero- superior  portion  of  the 
affected  side  gave  a  preternaturally  clear  and  hollow  sound,  and 
as  no  respiration  whatever  could  be  heard  in  this  region,  he  con- 
cluded that  the  lung  was  here  pushed  back,  and  compressed  by 
an  effusion  of  air.  In  the  course  of  sixteen  hours,  the  region 
which  presented  this  singular  sign  had  become  as  dull  as  pos- 
sible, and  a  feeble  murmur,  with  some  crepitus,  could  be  then 
heard.     The  patient  ultimately  recovered. 

Dr.  Graves  has  also  described  a  case  of  pneumonia  in  a  child, 
in  which  the  heart  was  dislocated  to  the  right  side,  without  any 
evidence  of  liquid  effusion  into  the  left  pleura ;  over  the  cardiac 
region,  on  the  contrary,  a  morbidly  clear  sound  existed,  as  if  an 
effusion  of  air  had  displaced  the  heart.  The  patient  recovered, 
but  the  heart  had  returned  to  its  natural  situation  many  days 
previous  to  the  resolution  of  the  pneumonia. 

Subsequently  to  the  publication  of  Dr.  Graves's  papers,  Dr. 
Hudson,  in  an  admirable  memoir  on  typhoid  pneumonia,*  has 
given  four  cases,  in  which,  according  to  him,  this  phenomenon 
existed.  As  two  of  these  occurred  in  the  Meath  Hospital,  the 
patients  being,  in  fact,  under  my  own  care,  I  must  observe  that 
in  neither  of  them,  in  my  opinion,  did  the  sign  in  question 
exist.  In  the  first  case,  the  tympanitic  resonance  proceeded 
obviously  from  the  stomach,  while  the  second  was  an  example 
of  solidified  lung,  with  mucus  in  the  tubes,  giving  the  bruit  de 
pot  fele.  Dr.  Hudson  states  that  the  other  two  cases  which  he 
observed  in  his  own  hospital  were  similar  to  the  first  which  I 
have  noticed.  If  this  be  so,  I  can  only  say,  that  I  quite  agree 
with  him  as  to  the  absence  of  air  in  his  cases. 

I  have  only  once  observed  this  phenomenon  :  a  female,  long 
addicted  to  the  use  of  ardent  spirits,  was  attacked  with  a  severe 
typhoid  pneumonia,  in  which  the  lung  ran  rapidly  into  hepati- 
zation.    On  the  eighth  or  ninth  day  of  the  disease,  the  antero- 

*  Dublin  Journal  of  Medical  Science,  vol.  vii. 


PNEUMONIA.  295 

superior  portion  of  the  left  side,  where,  on  the  day  previously, 
there  had  been  a  complete  dulness,  gave  a  clear,  sonorous,  tym- 
panitic sound,  similar  to  what  is  produced  by  the  stomach  in 
the  highest  degree  of  flatulent  distention  ;  this  extended  from 
the  clavicle  to  the  cardiac  region  ;  immediately  under  the  cla- 
vicle a  slight  murmur  was  audible,  while  about  the  eighth  rib 
the  pulmonary  friction  sound  could  be  heard.  On  the  next 
day  the  tympanitic  clearness  had  extended  to  the  postero- 
superior  portion  of  the  chest,  but  on  the  day  following,  all  had 
subsided,  and  the  chest  was  again  dull,  with  absence  of  vesicular 
murmur. 

This  patient  recovered,  but  as  is  usual  in  the  typhoid  pneu- 
monia, her  convalescence  was  extremely  slow  ;  the  lung  con- 
tinued long  hepatized,  and  an  irregular  hectic  existed.  The 
disease  took  five  months  to  run  through  its  course,  but  the 
recovery  was  ultimately  perfect. 

This  case  is  decisive  as  to  the  question,  how  far  the  tympanitic 
resonance  in  pneumonia  is  to  be  referred  to  a  distended  stomach  : 
that  such  was  not  the  case  here  is  evident,  for  the  sound  onlv 
existed  in  the  upper  portions,  and  the  region  of  the  stomach  was 
never  t}mipanitic.  We  had  further  physical  signs  of  irritation  of 
the  pleura,  in  the  continuation  for  two  days,  of  the  friction  sound, 
audible  below  the  effusion  of  air. 

It  is  not,  however,  to  be  denied,  that  when  the  lower  lobe 
of  the  left  lung  becomes  solidified  from  any  cause,  an  accu- 
mulation of  air  in  the  stomach  will  produce  a  characteristic 
change  in  the  sound  on  percussion,  varying  with  the  amount, 
and  subsiding  with  the  disappearance  of  the  air  ;  but  this  sound 
is  altogether  different  from  that  of  pneumothorax  in  pneumonia. 
I  might  say,  and  stethoscopists  will  appreciate  the  distinction, 
that  the  one  is  a  tympanitic  dulness,  the  other  a  tympanitic 
clearness.* 

I  have  known  some  instances  in  which  this  clearness  from 
a  distended  stomach  was  mistaken  for  the  natural  sound  :  such 
an  error  can  only  happen  to  very  inexperienced  stethoscopists  ; 
the  clearness  and  distention  of  the  region  of  the  stomach,  the 
bronchial  respiration,  the  voice,  will,  independent  of  the  character 
of  the  sound,  suffice  to  prevent  the  error. 

Signs  refeerible  to  the  diminished  Volume  of  the  Lung. 

*  See  Appendix,  Note  B. 


296  PNEUMONIA. 

We  have  already  seen  that  between  pneumonia  and  empyema 
there  was  this  difference,  that  the  signs  of  accumulation  did 
not  occur  in  the  first  disease.*  In  most  cases  of  empyema  the 
side  is  enlarged,  but  the  increase  of  volume,  which  occurs  in 
pneumonia,  is  not  to  be  appreciated  during  life. 

But  in  the  advanced  stages  of  these  diseases,  a  curious  simi- 
larity in  physical  signs  may  be  observed  :  the  contraction  of  the 
chest  after  the  cure  of  empyema  has  been  long  known,  but  it  is 
not  generally  understood,  that  the  same  circumstance  may  occur 
in  chronic  pneumonia  ;  the  analogies  of  disease  would  lead  us  to 
anticipate  this  result,  but  I  am  not  aware  that  the  fact  has  been 
noticed  by  any  writer.f  We  may  observe  it  in  cases  where  the 
lung  has  been  long  indurated,  and  still  continuing  impervious, 
and  it  may  even  co-exist  with  a  gradual,  and  ultimately  perfect 
resolution  of  disease.  I  have  observed  this,  particularly  in  a 
case  of  asthenic  pneumonia,  which  was  under  my  daily  observa- 
tion for  nearly  three  months,  and  in  which  the  contraction  was 
as  great  as  in  any  case  of  empyema  that  I  have  seen.  In  this 
case  there  was  not  the  slightest  appearance  of  liquid  effusion 
into  the  cavity  of  the  pleura,  and  the  only  difference  between 
the  contraction  here,  and  that  of  empyema,  was,  that  it  seemed 
to  affect  the  whole  side  more  than  what  is  generally  found  in 
pleurisy. 

In  other  cases,  however,  the  contraction  is  very  similar  to 
that  of  empyema ;  it  occurs  in  the  lower  portion,  the  ribs  are 
approximated,  the  angle  of  the  scapula,  as  it  were,  tilted  out, 
and  the  sound  on  percussion  comparatively  dull,  with  feeble 
respiratory  murmur.  In  all  cases  of  this  contraction  which  I 
have  observed,  the  primary  disease  had  been  of  the  typhoid 
character,  and  the  contraction  seemed  to  result  from  that  slow- 
ness of  resolution,  so  remarkable  in  this  affection  : — 

[I  have  already  alluded  to  a  not  unfrequent  case  of  con- 
solidation of  the  lung  in  which  the  signs  of  the  earlier  stages  of 
pneumonia  being  wanting,  there  may  arise  a  difficulty  in  the 
differential   diagnosis    between    this    lesion   and    effusion    into 

*  I  am  satisfied  that  both  enlargement  and  subsequent  contraction  of  the  side  may 
occur  in  plastic  pneumonia.  In  the  case  of  a  young  gentleman  under  my  care,  the 
right  side  was  much  enlarged,  and  the  liver  displaced  during  the  illness,  while  after 
convalescence  it  became  equally  contracted.  See  also  the  case  of  Eliza  Helson — 
Appendix.    (Ed.) 

t  See  Walshe,  p.  354. 


PNEUMONIA.  297 

the  pleura;  whether  we  are  to  consider  such  as  cases  of  true 
pneumonia,  is  a  question  which  we  must  hereafter  examine. 

It  was  long  considered,  that  in  the  absence  of  enlargement  of 
the  side,  no  difficulty  could  arise,  this  sign  belonging  exclu- 
sively to  empyema ;  while  there  was  nothing  in  pulmonary 
consolidation  that  could  produce  it.  Subsequent  researches, 
however,  have  discovered  that  we  may  meet  with  the  signs  of 
eccentric  pressure  even  in  a  case  of  pneumonia. 

It  is  no  doubt  true,  that  in  the  greater  number  of  cases  of 
pneumonia,  no  enlargement  of  the  side,  or  other  signs  of  eccen- 
tric pressure,  sufficient  at  least  to  be  detected,  ever  occurs  ;  a 
fact  of  great  importance  in  practical  medicine.  But  that  even 
in  ordinary  hepatization  some  swelling  of  the  lung  takes  place 
is  probable  from  the  fact,  first  observed  by  Broussais,  though 
denied  by  Laennec,  that  depressions  corresponding  to  the  ribs 
are  to  be  seen  on  the  surface  of  the  solid  lung.  I  have  verified 
this  observation  of  Broussais  ;  but  to  produce  such  depressions 
a  very  small  amount  of  swelling  of  the  lung  is  necessary. 

More  recently,  Grisolle  has  advanced  the  opinion  that  inde- 
pendently of  pleuritic  effusion,  an  inflamed  lung  may  cause 
general  or  partial  dilatation  ;  in  one  of  his  patients,  slight 
bulging  of  the  infra-clavicular  region  (the  disease  occupied  the 
upper  lobe,  and  especially  its  anterior  part)  was  detected  on  the 
patient's  admission,  the  third  day  of  the  affection.  This  bulging 
gradually  increased  with  the  progress  of  hepatization.  M.  Gri- 
solle considers  himself  justified  in  referring  its  appearance  to 
the  inflammation  of  the  lung  ;  the  post  mortem  examination 
proved  the  absence  of  pleuritic  effusion.  In  another  instance, 
bulging  of  the  infra  and  post  clavicular  regions  was  observed  to 
subside  gradually  with  the  resolution  of  the  disease. 

Dr.  Walshe,  from  whom  I  quote,  properly  observes,  that 
neither  of  these  cases  proves  the  fact  of  general  expansion — as 
is  admitted  by  Grisolle — though,  as  far  as  they  go  in  establish- 
ing that  of  partial  expansion,  there  seems  no  plausible  objection 
to  the  cases,  but  thinks  that  we  must  have  more  evidence  before 
the  general  expansion  can  be  considered  as  established. 

But  the  question  of  general  enlargement,  as  occurring  at 
least  in  one  form  of  pneumonia  (the  plastic,  or  that  accompanied 
by  a  copious  fibrinous  exudation)  has  been  set  at  rest  by 
Professor    Smith,  in  a  communication    made   by   him   to   the 


298  PNEUMONIA. 

Pathological  Society  of  Dublin  in  1840.  A  man,  aged  fifty,  was 
admitted  into  the  Richmond  Hospital  complaining  of  dyspnoea, 
cough,  and  acute  pain  of  the  side.  His  expectoration  was  puru- 
lent. His  health  had  been  deranged  for  three  months  pre- 
viously, and  the  symptoms  under  which  he  had  laboured  had 
existed  in  a  mitigated  form ;  but  shortly  before  admission  he 
was  suddenly  attacked  with  acute  pain  in  the  side,  increase  of 
cough  with  dyspnoea,  and  purulent  expectoration.  The  entire  of 
the  affected  side  was  perfectly  dull  on  percussion,  with  extensive 
muco-crepitating  rale,  and  bronchial  respiration.  Over  the  oppo- 
site side  the  respiratory  murmur  was  distinct.  He  died  two 
days  after  his  admission  into  hospital.  On  inspection,  Professor 
Smith  was  struck  with  the  great  difference  between  the  two 
sides  of  the  chest,  the  right  side  being  fully  an  inch  and  a-half 
in  circumference  more  than  the  left,  and  the  hepatic  region  was 
extremely  full,  giving  the  appearance  as  of  enlargement  of  the 
liver.  The  right  pleural  cavity  was  found  to  be  completely 
obliterated ;  the  lung  solid  and  of  unusual  size  pressed  down  the 
diaphragm,  so  as  to  displace  the  liver,  and  also  intruded  upon 
the  left  lung.  Although  the  left  lung  was  emphysematous,  it 
was  not  more  than  half  as  large  as  the  right.  On  cutting  into 
the  right  lung  a  remarkable  modification  of  grey  hepatization 
was  everywhere  predominant,  and  on  the  cut  surfaces  were 
observed  a  countless  multitude  of  yellow  granular  bodies, 
each  circumscribed  in  a  distinct  cavity  lined  by  a  membrane. 
These  bodies  possessed  a  considerable  degree  of  firmness, 
their  external  coating  being  found  to  consist  of  coagulable 
lymph,  while  their  interior  was  soft  and  composed  of  pus  in 
various  states  of  fluidity.  It  was  easy  to  ascertain  that  the  cells 
in  which  these  globules  were  deposited  were  the  air  cells.  The 
granules  could  be  picked  out  of  them  with  the  point  of  a  needle ; 
but  in  picking  them  out  it  was  perceived  that  some  portions  of 
the  granule  were  more  adherent  than  the  rest.  These  points 
of  adhesion  presented  a  fine  pedicle  which  stretched  into  a  minute 
ramification  of  the  bronchia.  Professor  Smith  observed  that 
though  he  had  succeeded  in  tracing  the  projection  into  the 
ramifications,  he  believed  that  the  arrangement  was  general. 
The  air  cells  were,  in  fact,  enlarged,  and  filled  with  lymph  in  a 
state  of  considerable  solidity,  and  when  it  was  considered  that 
the  whole  substance  of  the  lung  was  thus  engaged,  it  would  be 


PNEUMONIA.  299 

easy  to  understand  how  the  lung  was  enlarged  in  every  direc- 
tion. It  was  obviously  twice  as  large  as  its  fellow,  and  the 
impressions  of  the  ribs,  on  the  surface  of  the  lung,  were  unusually 
deep. 

In  this  case,  the  most  conclusive  of  any  on  record  which  bear 
upon  the  point  at  issue,  we  see  a  general  enlargement  of  the 
lung,  causing  such  eccentric  pressure  as  to  dislocate  the  liver, 
and  extrude  the  mediastinum.  The  state  of  the  intercostal 
spaces  is  not  noted,  but  the  physical  signs  of  the  disease  cor- 
respond to  those  of  empyema,  with  the  exception  of  the  exist- 
ence of  general  muco-crepitating  rale. 

The  disease  was  probably  chronic,  though  the  patient's  death 
was  induced  by  an  exacerbation  of  the  affection.  It  will  be  seen 
that  the  disease  was  one  of  a  chronic  and  truly  plastic  pneu- 
monia, a  croup,  as  it  were,  of  the  cells  and  minute  tubes.  It 
was  essentially  a  disease  of  accumulation  and  an  engorgement, 
as  it  were  causing  an  accumulation  of  lymph  and  pus,  not  in 
the  pleurae,  but  in  the  air  cells  of  the  lung.  It  is  difficult  to 
say  why  this  affection  is  not  of  more  frequent  occurrence,  but  it 
appears  more  than  probable  that  many  of  the  cases  in  which  a 
granular  condition  is  exhibited  by  the  hepatized  lung,  are  exam- 
ples of  the  early  stage  of  the  affection,  in  which,  had  the  patient 
lived  long  enough,  the  simulation  of  empyema  by  the  increasing 
pressure  of  the  enlarged  organ  would  certainly  have  occurred. 

The  condition  of  lung  described  in  the  preceding  cases  has 
been  noticed  by  various  authors.  I  have  myself,  in  the  year 
1833,  recorded  a  case  in  which  the  granular  condition  of  the 
lung  was  observed,  while  at  the  same  time  a  suppurative  process 
had  dissected  the  lung  from  the  pleura,  so  that  the  pulmonary 
cells,  hanging  in  groups  like  bunches  of  grapes,  lay  bathed  in 
purulent  matter.  The  researches  of  Reynaud,  Andral,  Williams, 
and  others  may  be  also  referred  to  on  this  subject ;  and  more 
lately  Dr.  Blakiston  has  described  cases  which  he  terms  acute 
and  chronic  plastic  pneumonia,  in  which  granulations  in  great 
quantity,  easily  separable  from  matrixes,  existed  in  the  lungs ; 
but  neither  Dr.  Blakiston,  nor  other  writers  on  this  variety,  have 
connected  with  it  the  important  sign  of  dilatation  of  the  side. 

It  appears  to  me  extremely  probable  that  there  exist  two 
forms  of  sthenic  pneumonia,  just  as  we  see  two  forms  of 
bronchial    inflammation.      In    the    one    coagulable    lymph    is 


300  PNEUMONIA. 

secreted  on  the  internal  surface  of  the  cell,  which  is  admitted 
to  be  a  white  tissue,  and  which  there  takes  the  form,  while  it 
distends  its  containing  sac  ;  in  the  other,  either  all  the  structures 
are  simultaneously  engaged,  or  the  force  of  the  disease  is  thrown 
on  the  intervesicular  cellular  membrane.  In  these  latter  cases 
the  production  of  lymph,  and  its  accumulation  in  the  cells,  is 
either  wanting  or  takes  place  in  a  comparatively  trivial  degree. 
There  is  no  perceptible  enlargement  of  the  lung  during  life,  but 
that  some  augmentation  has  occurred  appears  probable  from  the 
existence  of  the  costal  depressions  on  the  surface  of  the  inflamed 
lung. 

I  have  already  stated  my  belief  in  the  correctness  of  Broussais' 
opinion,  that  the  tumefaction  of  the  lung  in  pneumonia,  although 
not  sufficient  to  be  discovered  by  measurement,  is  the  cause  of 
these  markings  in  many  cases ;  for  as  less  pressure  is  exercised 
in  the  intercostal  spaces  than  on  the  ribs,  depressions  are  pro- 
duced corresponding  to  the  ribs  themselves. 

Contraction  of  the  side  from  diminished  volume  of  the  lung  is 
a  phenomenon  more  frequent  in  chronic  than  in  acute  pneu- 
monia. I  have,  however,  witnessed  its  occurrence  during  the 
convalescence  from  some  forms  of  the  acute  disease  ;  an  example 
of  which  was  given  in  the  former  edition  of  this  work. 

In  this  case,  which  was  under  my  daily  observation  for  three 
months,  the  contraction  was  as  great  as  in  any  case  of  empyema 
that  I  have  ever  seen,  the  only  difference  being  that  it  seemed  to 
affect  the  whole  side  more  than  is  generally  found  in  pleurisy. 
In  other  cases,  however,  the  contraction  was  very  similar  to  that 
of  empyema,  occurring  in  the  lower  portion,  the  ribs  being 
approximated,  the  angle  of  the  scapula,  as  it  were,  tilted  out, 
and  the  sound  on  percussion  comparatively  dull  with  feeble 
respiratory  murmur. 

Dr.  Walshe  confirms  the  above  observation  by  a  case  of  ex- 
tensive pneumonia  of  the  left  side,  in  which  indisputable  de- 
pression of  the  latero-anterior  part  of  the  chest  gradually  took 
place  during  the  progress  of  recovery.  And  he  meets  the 
objections  of  Woillez  and  Grisolle,  who  maintain  that  such 
depression  can  only  originate  from  pleuritis.  "  Perhaps,  all 
things  considered,  the  most  efficient  agent  in  producing  de- 
pression of  the  chest  after  pleurisy  is  the  contraction  of  the 
plastic  matter  exuded  on  the  pleural  surfaces.     Why  should  not 


PNEUMONIA.  301 

the  same  contraction  (occurring  as  a  law  of  its  existence)  of 
exudation  poured  into  the  substance  of  the  lung  cause  similar 
alteration  in  the  form  of  the  thorax  ?  "  "It  appears  curious  that 
M.  Grisolle,  who  professes  to  have  seen  the  size  of  the  lung 
enlarged  by  interstitial  exudation  solely,  gradually  return  to  its 
natural  state,  should  maintain  depression  of  the  surface  to  be 
impossible.  What  is  to  prevent  the  tendency  to  diminution  of 
bulk  from  gradually  bringing  the  lung  to  a  less  volume  than  in 
health  ;  and  this  once  effected,  will  not  depression  of  the  parietes 
inevitably  follow  ?  "  My  own  opinion  is  that  atrophy  of  the  lung 
tissue  is  a  cause  of  depression  more  influential  than  is  com- 
monly supposed.  Were  the  contraction  of  plastic  exudation  the 
sole,  or  even  the  principal  cause  of  depression  of  the  side  after 
empyema,  it  would  be  difficult  to  understand  the  return  of 
expansion,  so  often  witnessed  in  young  persons  who  have  re- 
covered from  that  disease.  I  therefore  believe  that  this  de- 
pression is  in  such  cases  due  rather  to  non-expansion  of  the 
lung  than  to  the  presence  of  an  exudation  whose  tendency  would 
be  to  go  on  contracting. — Author's  Note  Book.] 

RECAPITULATION. 

I.  That  in  the  first  stage,  the  physical  signs  seem  often  to  be, 
puerile  or  exaggerated  respiration,  with  clearness  of  sound  on 
percussion,  preceding  the  crepitating  rale. 

II.  That  in  the  second  stage,  Laennec's  first,  the  signs  are 
the  crepitating  rale,  the  gradually  diminishing  respiratory  mur- 
mur, and  the  comparative  dulness  of  sound  on  percussion. 

III.  That  in  some  forms  of  the  disease  the  signs  of  the  third 
stage  (Laennec's  second),  namely,  dulness  on  percussion,  bronchial 
respiration,  and  bronchophony,  may  occur  without  being  preceded 
by  the  crepitating  rale  of  the  second. 

IV.  That  the  diminution  of  bronchial  respiration,  in  extensive 
solidification,  may  indicate  an  increase  of  the  disease ;  while  its 
return  may  indicate  returning  permeability,  produced  either  by 
local  resolution,  or  by  abscess  communicating  with  the  bronchial 
tubes. 

V.  That  perfect  dulness  may  be  suddenly  replaced  by  tym- 
panitic clearness  over  the  solidified  portion,  without  any  appre- 
ciable change  in  the  condition  of  the  part;  and  that  in  these 
cases  the  clearness  appears  and  disappears  in  a  sudden  manner. 


302  PNEUMONIA. 

VI.  That  in  the  fourth  stage  bronchial  respiration  is  generally 
combined  with  sharp  muco-crepitating  rale,  and  complete  dulness 
of  sound. 

VII.  That  the  signs  of  pneumonic  abscess  do  not  differ  from 
those  of  tubercular  cavities,  but  that  the  diagnosis  is  to  be 
drawn  from  their  history,  situation,  and  rapidity  of  formation. 

VIII.  That  the  formation  of  pneumonic  abscess  is  preceded 
by  more  complete  and  extensive  dulness  than  that  of  phthisical 
cavities. 

IX.  That  pneumonia  may  resolve  either  in  its  acute  or 
chronic  form  without  the  crepitus  of  resolution. 

X.  That  when  this  sign  exists,  it  may  be  combined  with,  pre- 
ceded or  followed  by  the  natural  respiratory  murmur. 

XI.  That  the  muco-crepitating  rale  in  the  fourth  stage  is 
to  be  distinguished  from  that  of  resolution  by  its  sharper  and 
more  viscid  character,  but  principally  by  its  combination  with 
bronchial  respiration,  great  dulness  of  sound,  and  the  signs  of 
extension  of  disease  in  other  parts  of  the  lung. 

XII.  That  notwithstanding  the  frequency  of  adhesions,  the 
friction  sound  is  comparatively  rarely  observed  in  pneumonia. 

XIII.  That  in  certain  forms  of  the  disease  appreciable  enlarge- 
ment of  the  side  may  occur,  with  eccentric  displacement  of  other 
organs. 

XIV.  That  while,  therefore,  in  a  large  majority  of  cases  the 
absence  of  the  signs  of  displacement  of  the  heart,  diaphragm,  or 
intercostals,  with  the  phenomena  of  voice,  are  sufficient,  taken 
along  with  the  previous  history  to  distinguish  between  universal 
solidity  of  the  lung  and  empyema,  the  diagnosis  is  not  equally 
certain  in  cases  where  an  extensive  fibrinous  deposit  takes  place 
in  the  lung,  producing  all  the  signs  of  accumulation. 

XV.  That  diminished  volume  of  the  lung  and  depression  of 
the  side  may  occur  under  certain  conditions,  more  especially  in 
the  slow  convalescence  from  asthenic  forms  of  pneumonia. 

XVI.  That  with  respect  to  the  circulating  system  two  remark- 
able signs  have  been  observed,  viz.,  a  bellows  sound  over  the 
heart  and  anterior  portion  of  the  chest,  and  a  throbbing  of  the 
lung  analogous  to  that  of  aneurism. 

XVII.  That  the  secretion  of  air  into  the  cavity  of  the  pleura 
is  pointed  out  by  the  sudden  appearance  of  tympanitic  resonance 
over  the  affected  portion  of  the  lung. 


PNEUMONIA.  303 

XVIII.  That  this  sound  has  an  essentially  different  character 
from  the  bruit  cle  pot  fete  of  caverns  or  of  solidity,  and  that  it 
also  differs  from  stomachal  clearness.* 


ACUTE    ASTHENIC    INFLAMMATION    OF    THE    LUNG. 

This  is  the  disease  to  which  the  term  typhoid  or  putrid  pneu- 
monia has  been  given ;  and  there  is  still  a  great  difficulty  in 
drawing  the  line  between  it  and  consolidation  of  the  lung  occur- 
ring in  the  course  of  and  clearly  secondary  to  typhus  fever ;  but 
this  much  is  certain,  that  in  many  cases  signs  and  symptoms  of 
pneumonic  inflammation  set  in  at  a  very  early  period  of  a  case, 
which,  whether  it  be  typhus  fever  or  not,  exhibits  two  apparently 
opposite  conditions,  the  one  great  activity  or  malignity  of  pul- 
monary inflammation,  and  the  other  the  symptoms  of  prostration 
in  a  marked  degree. 

We  have  had  abundant  opportunities  of  observing  this  disease 
in  Ireland,  and  its  frequency  may  in  part  be  explained  by  the 
tendency  of  so  many  local  inflammations  and  other  diseases  to 
assume  of  late  years  the  typhoid  condition.  We  cannot  say 
that  there  is  any  specific  typhoid  pneumonia,  but  we  find  that 
under  a  variety  of  depressing  circumstances,  conditions  of  the 
lung  more  or  less  analogous  may  be  induced,  presenting  the 
characters  of  the  disease  as  given  by  various  authors. 

The  occurrence  of  this  disease  as  affecting  great  numbers  in 
a  particular  locality  was  observed  in  this  city  some  years  since, 
and  its  history  is  full  of  interest.  The  persons  attacked  were 
young  and  healthy  men,  privates  in  the  constabulary  force,  who 
were  quartered  at  the  then  newly-erected  barracks  in  the  Phosnix 
Park.  It  may  be  mentioned,  as  bearing  on  the  question,  how 
far  the  typhoid  character  of  disease  in  Ireland  is  attributable 
to  deficient  nutriment  and  lodging,  that  the  disease  appeared  in 
a  large  body  of  young  men  who  were  well  fed  and  clothed,  and 
might  be  considered  as  possessing  the  greatest  strength  and 
vigour. 

It  is  a  remarkable  circumstance,  that  at  the  time  of  the  ap- 
pearance of  this  disease  many  cases  of  another  and  extraordinary 

*  The  introduction  of  new  matter  derived  from  Dr.  Stokes'  MS.  into  this  chapter 
has  necessitated  several  alterations  in  the  above  tummary  as  it  appeared  in  the  former 
edition.    (Ed.) 


304  PNEUMONIA. 

affection  was  observed  in  the  poorhouses  and  hospitals  in  and 
near  Dublin.  I  allude  to  the  cerebro-spinal  arachnitis,  of  which 
accounts  have  been  given  by  Drs.  Darby  and  Mayne,  and  it  is 
important  to  mention  that  several  cases  of  this  disease  occurred 
in  the  force  contemporaneously  with  those  of  the  pneumonia. 

The  general  characters  of  this  latter  disease  were  suddenness 
of  invasion  and  great  rapidity  of  progress.  The  lung  rapidly 
passed  into  hepatization,  yet  the  symptoms  were  not  those  of 
sthenic  pneumonia ;  the  pulse  was  often  rapid  and  weak,  and 
the  countenance  pallid  and  collapsed.  It  was  found  that  the 
patient  bore  any  reducing  treatment  badly,  and  the  resolution  of 
the  disease  was  singularly  slow  in  many  cases,  especially  in  those 
in  which  venesection  had  been  employed. 

The  character  of  the  disease  was  much  more  that  of  the 
diffuse  or  erysipelatous  than  the  more  sthenic  form,  suppuration 
rarely  occurred,  the  fatal  cases  appearing  to  run  a  course  too 
rapid  for  the  production  of  this  condition. 

The  principal  differences  between  this  disease  and  the  mani- 
festly secondary  affection  of  typhus  may  be  stated  to  be — 

I.  That  the  symptoms,  particularly  those  of  pain  and  dyspnoea, 
occur  at  a  much  earlier  period  of  the  case.  In  some  instances, 
indeed,  the  disease  sets  in  with  these  symptoms,  while  in  others 
they  appear  after  one  or  two  days  of  general  ailment. 

II.  That  the  whole  character  of  the  disease  seems  to  be  closely 
related  to  the  local  lesion,  that  is  to  say,  its  severity  increases 
with  that  of  the  pneumonia ;  while,  on  the  other  hand,  the 
mitigation  of  the  pulmonary  symptoms  is  attended  with  corre- 
sponding improvement  in  the  general  condition. 

III.  The  constitutional  symptoms  do  not  correspond  exactly 
to  those  of  typhus  fever ;  petechia?  may  be  absent,  while  the 
other  symptoms  are  principally  those  of  prostration.  The  patient 
complains  of  great  weakness,  the  countenance  is  generally  sunken, 
and  the  surface  may  be  cold ;  headache,  delirium,  and  vomiting 
are  often  frequent,  the  pulse  is  generally  rapid  and  feeble,  with 
weak  action  of  the  heart,  and  the  tongue  may  be  clean.  In  other 
cases,  the  skin  is  hot  and  dry,  with  tenderness  of  the  epigastrium, 
furred  tongue,  and  high-coloured  urine. 

It  is,  however,  certainly  true  that  in  many  of  these  cases  the 
constitutional  symptoms  singly  considered  have  the  closest 
resemblance  to  typhus  fever. 


PNEUMONIA.  305 

The  expectoration  is  by  no  means  so  characteristic  as  in 
ordinary  pneumonia ;  it  may  be  purely  catarrhal,  or  of  a  mixed 
kind,  consisting  of  catarrhal  and  pneumonic  sputa.  Dr.  Hudson 
has  noticed  the  occurrence  of  red  viscid  patches  floating  in  serum  ; 
and  I  have  seen  the  expectoration  consist  of  a  bloody  serum, 
with  shreddy  patches  floating  in  it.  This  occurred  in  a  case  in 
which  a  gangrenous  cavity  formed,  and  the  expectoration  became 
ultimately  sanious  and  foetid.  The  same  condition  has  also 
been  noticed  by  Dr.  Hudson,  and  in  a  similar  case. 

That  in  this  disease  a  true  inflammatory  process  is  present 
appears  plain  when  the  pathological  appearances  are  considered. 
The  pleura?  are  found  covered  with  coagulable  lymph,  red  and 
grey  hepatization  of  the  lung,  often  of  great  extent,  are  commonly 
observed,  and  we  have  noticed  also  the  granular  appearance  of 
the  cut  surface ;  this  appearance,  however,  may  not  be  so  well 
marked  as  in  ordinary  pneumonia.  The  lung  is  friable,  and  the 
bronchi  generally  of  a  deep  red  colour.  Finally,  as  Dr.  Hudson 
remarked,  the  physical  signs  may  be  rapidly  modified  by  local 
antiphlogistic  treatment  (as  by  cupping). 

On  the  other  hand,  the  deeper  colour  of  the  lungs,  occurrence 
of  petechial  spots  on  the  heart,  and  the  greater  liability  to 
gangrenous  action,  all  indicate  a  state  of  the  system  different 
from  that  in  ordinary  sthenic  pneumonia. 

Of  the  occurrence  of  fcetid  expectoration  and  breath,  coincident 
with  the  signs  of  a  cavity,  I  have  seen  one  remarkable  instance, 
which  occurred  in  the  Meath  Hospital.  This  case  has  been 
published  by  Dr.  Hudson  in  the  memoir  already  referred  to.  In 
another  case  given  by  the  same  gentleman  the  patient  recovered, 
although  he  had  presented  all  the  signs  of  a  gangrenous  cavity. 

Like  all  the  other  varieties  above  mentioned,  we  observe  re- 
markable differences  in  the  physical  signs  in  this  disease,  more 
especially  we  observe  that  the  signs  of  consolidation  may  appear 
without  having  been  preceded  by  the  crepitating  rale,  and  this  in 
a  manner  so  rapid,  and  over  so  large  a  surface,  as  to  closely 
resemble  those  of  pleuritic  effusion.  In  fact,  a  few  hours  only 
may  intervene  between  the  period  when  the  lung  was  clear  on 
percussion  and  without  rale,  and  that,  when  it  has  become 
absolutely  dull,  with  well-marked  bronchial  respiration  and  reso- 
nance of  the  voice. 

It  is  not  to  be  understood,  however,  that  in  all  cases  of  this 

x 


306  PNEUMONIA. 

disease  the  signs  are  developed  in  tins  unusual  manner  for  in 
many  the  crepitus  will  be  found  to  precede  the  dulness.  In  one 
remarkable  case  it  was  found  that  before  any  crepitus  was  heard 
there  was  great  feebleness  of  the  vesicular  murmur  all  over  the 
right  side  ;  in  fact,  it  was  nearly  absent  in  the  upper  and  anterior 
portions ;  but  on  the  following  day  these  parts  presented  the 
crepitating  rale,  the  right  lung  in  almost  its  entire  extent  became 
solid  before  death,  the  disease  appearing  to  advance  from  above 
downwards. 

In  the  difficulty  which  will  sometimes  arise  in  distinguishing 
this  form  of  hepatization  from  pleuritic  effusion,  in  consequence 
of  the  non-existence  of  previous  crepitus,  a  consideration  of  the 
following  points  may  assist  us. 

I.  That  in  this  country  typhoid  pneumonia  is  a  much  more 
common  affection  than  typhoid  pleurisy. 

II.  The  signs  of  consolidation  are  often  developed  from  above 
downwards,  so  that  while  the  dulness  and  bronchial  respiration 
exist  either  in  the  middle  or  the  upper  portion  of  the  lung,  or 
in  both,  the  lowest  may  yet  be  clear  on  percussion,  and  give  no 
sign  beyond  feebleness  of  respiration. 

III.  (Egophony  will  be  absent. 

IV.  In  many  cases,  at  least,  a  deep  inspiration  will  develop 
a  rale  over  the  dull  portion. 

V.  We  may  be  assisted  by  considering  the  general  characters 
of  the  disease,  and  the  appearance  of  the  expectoration. 

VI.  In  most  of  the  cases  of  this  disease  the  existence  of  the 
signs  of  bronchitis,  to  a  considerable  amount,  will  aid  in  the  diag- 
nosis. The  complication  with  bronchial  inflammation  is  much 
more  constant  and  important  in  acute  diseases  of  the  parenchyma 
of  the  lung  than  in  those  of  the  pleura,  at  least  in  the  early 
periods. 

In  some  of  the  most  remarkable  cases  of  this  disease  which 
have  been  observed  at  the  Meath  Hospital,  the  upper  lobes  of 
the  lung  were  the  parts  first  and  principally  engaged  ;  we  cannot 
even  offer  a  suggestion  to  explain  this  curious  circumstance. 
The  inflammatory  process  does  not  appear  to  have  the  same 
degree  of  tension  as  in  the  ordinary  cases,  and  resolution  is 
often  slow,  uncertain,  and  vacillating,  not  unfrequently  accom- 
panied by  slight  attacks  of  dry  pleurisy,  indicated  by  the  occur- 
rence of  friction  signs  before  alluded  to.     The  local  symptoms, 


PNEUMONIA.  307 

such  as  pain,  are  generally  better  developed  than  the  constitu- 
tional, which  are  sometimes  slight ;  prostration,  and  a  low,  but 
apparently  not  important  fever,  being  the  principal  phenomenon. 
I  incline  to  the  opinion  that  the  disease  seldom,  at  least  when 
it  has  been  recognised,  and  treated  at  a  sufficiently  early  period, 
runs  on  to  the  fourth  or  fifth  stages. 

It  happens  not  unfrequently,  when  the  disease  has  engaged 
the  upper  lobe,  and  that  the  patient  is  not  seen  until  after  the 
first  symptoms  have  subsided,  while  the  lung  remains  in  a  state 
of  semi-solidity,  that  an  erroneous  opinion  is  formed  as  to  the 
nature  of  the  disease.  The  dulness,  the  want  of  healthy  vesi- 
cular murmur,  and  the  existence  of  a  muco-crepitating  rale, 
all  closely  resemble  the  signs  of  tubercle,  and  it  is  at  once  con- 
cluded that  the  patient's  case  is  hopeless ;  in  a  few  days,  how- 
ever, the  physical  signs  disappear,  even  although  no  curative 
treatment  may  have  been  adopted,  and  a  perfect  recovery  takes 
place. 

A  similar  error  is  often  committed  in  cases  of  circumscribed, 
or  even  general  pleuritic  effusion,  and  it  mainly  arises  in  both 
instances  from  the  neglect  of  considering  the  physical  signs  in 
their  relation  to  time.  The  duration  of  the  illness  may  have 
been  but  a  few  days  ;  the  period  at  which  there  were  no  symp- 
toms or  signs  of  pulmonary  affection  may  be  quite  recent.  If 
the  physical  signs  proceeded  from  tubercle  they  would  indicate  a 
great  amount  of  disease,  an  amount  which  would  imply  a  long- 
continued  process,  and  which  would  be  probably  accompanied  by 
important  symptoms.  But  if  the  observer  did  not  allow  himself 
to  be  misled  by  the  similarity  of  the  signs  to  those  of  tubercle, 
but  corrected  his  observation  by  reference  to  the  actual  duration 
of  the  disease,  he  would  avoid  the  error  so  often  committed  of 
mistaking  a  recent,  and  even  spontaneously,  curable  disease,  for 
such  an  affection,  as  the  tubercular  degeneration  of  the  whole  or 
even  a  large  portion  of  the  one  lung. 

ACUTE    ASTHENIC    PNEUMONIA   WITH    INDURATION    OF    THE    LUNG. 

This  is  a  singular  form  of  disease  which  has  only  recently 
attracted  much  attention.  Induration,  as  contrasted  with  the 
soft  solidity  of  ordinary  solidification,  has  been  hitherto  held  to 
result  from  a  chronic  process;    there  is  no  doubt  that  under 

x2 


308  PNEUMONIA. 

certain  circumstances  an  acute  induration  of  the  lung  may  be 
produced. 

In  the  commencement  of  the  year  1841,  Dr.  Corrigan  brought 
before  the  Pathological  Society  of  Dublin  a  case  which  he  desig- 
nated as  a  rare  form  of  pneumonia.  The  symptoms  were 
decidedly  asthenic,  and  the  patient,  a  female,  had  been  largely 
blooded  before  coming  under  his  care  ;  so  great  was  the  debility 
that  stimulants  had  to  be  exhibited  from  the  first  period  of  her 
admission  into  hospital.  The  diseased  portion  of  the  lung 
was  of  a  deep  blue,  bordering  on  purple  ;  it  did  not  crepitate 
under  the  finger,  and  in  general  it  was  found  that  it  sank  in 
water ;  there  was  no  effusion  of  lymph  on  the  pleura,  and  no 
appearance  of  purulent  secretion.  Another  case  of  the  same 
kind  was  communicated  by  Dr.  Corrigan  during  the  same  ses- 
sion. The  patient,  a  lad  aged  fourteen,  was  six  days  ill  on 
admission.  His  surface  gave  the  sensation  of  the  calor  mordax  ; 
pulse  140,  and  the  respiration  sixty  in  the  minute ;  he  had 
cough  and  extreme  pain  in  the  side.  The  posterior  portions  of 
both  lungs  were  dull  on  percussion,  with  some  crepitus;  these 
signs  were  succeeded  by  extensive  bronchial  respiration  over  the 
dull  portions,  as  high  as  the  spines  of  the  scapulae,  with  bron- 
chitic  rales  over  the  remaining  portions  of  the  chest.  The  lung 
in  this  disease  presents  a  dark  blue  colour,  which,  according  to 
Dr.  Corrigan,  is  very  evanescent,  and  disappears  within  a  few 
hours  after  the  parts  have  been  removed.  The  diseased  lung 
was  firm,  heavy,  and  sank  in  water ;  when  grasped  feeling  like 
muscle  ;  there  was  no  trace  of  red  or  grey  hepatization. 

Dr.  Corrigan  observes  that  this  disease  is  remarkable  for  its 
bad  and  intractable  character,  and  from  its  being  accompanied 
by  that  state  of  the  vessels  characterised  as  the  state  of  passive 
congestion.  The  diseased  lung  differs  from  the  carnified  lung  in 
retaining  its  original  bulk.  In  carnified  lung  the  pressure  of  the 
liquid  expels  not  only  the  air,  but  also  the  blood,  and  there  is 
consequently  a  considerable  reduction  in  size.  All  these  cir- 
cumstances and  the  resistance  of  the  disease  to  treatment,  would 
go  to  establish  the  existence  of  a  peculiar  form  of  disease. 

I  have  now  witnessed  a  considerable  number  of  cases  con- 
firmatory of  these  opinions.  Shortly  after  the  period  of  Dr. 
Corrigan's  communication  I  submitted  to  the  Pathological 
Society  two  specimens  of  acute  induration  of  the  lung,  one  from 


PNEUMONIA.  309 

a  case  which  I  myself  witnessed,  the  other  occurring  in  the 
practice  of  Dr.  Lees.  In  my  case  the  patient  was  a  child,  and 
the  disease  was  found  totally  unamenable  to  treatment.  The 
lung  was  firm  and  solid,  grey,  exceedingly  tough,  and  not  exud- 
ing any  quantity  of  blood  on  being  cut.  There  was  no  lymph  on 
the  pleura,  and,  in  fact,  none  of  the  characters  of  ordinary  acute 
hepatization.  The  disease  had  lasted  about  a  fortnight,  when 
the  patient  sunk  apparently  from  exhaustion. 

In  Dr.  Lees'  case,  the  patient,  who  had  suffered  from  hepatic 
disease  in  India,  was  attacked  with  inflammation  of  the  lung, 
and  notwithstanding  the  production  of  full  mercurial  action,  the 
disease  proved  fatal  on  the  eighth  day.  The  lung  was  solid, 
exceedingly  heavy,  and  of  an  iron-grey  colour,  such  as  we  might 
find  in  a  case  of  chronic  pneumonia.  The  cut  surface  was  not 
granular,  and  the  lung,  so  far  from  being  friable,  required  great 
force  to  break  it  down.  There  was  no  trace  of  lymph  on  the 
pleura.  The  crepitus  which  ordinarily  precedes  pneumonia  did 
not  occur  in  this  case,  and  this  we  have  observed  in  several  other 
instances. 

Dr.  Corrigan  inclines  to  the  opinion  that  a  stasis  of  blood 
owing  to  local  debility  of  the  vessels  is  the  principal  pathological 
element  of  the  disease.  And  Dr.  Gordon,  in  a  recent  memoir 
on  this  form  of  pneumonia,  says,  "  The  physical  signs  are  very 
constant ;  there  is  a  dull  sound  on  percussion  over  the  affected 
portion  of  the  lung  or  lungs,  and  at  first  very  feeble  respiratory 
murmur,  which,  however,  maintains  somewhat  its  vesicular  cha- 
racter, but  soon  becomes  very  decidedly  bronchial.  The  peculiar 
crepitus  of  vesicular  pneumonia  is  never  audible.  If  the  patient 
recovers,  ■  the  progress  of  the  physical  signs  is  very  remarkable  ; 
sometimes  within  twenty-four  hours  the  extreme  bronchial 
respiration  and  bronchophony  are  replaced  by  a  feeble  or  even 
ordinary  vesicular  murmur,  proving  that  the  air  cells  merely 
suffered  obliteration  from  pressure,  which  being  removed,  they 
again  expanded." 

COMBINATIONS    OF    PNEUMONIA. 

Under  this  head,  we  shall  examine  some  of  the  cases  in  which 
acute  pneumonia  is  rendered,  if  not  latent,  at  least  obscure,|by 
the  co-existence  of  other  acute  diseases,  which  affect  either]  the 
entire  system  or  present  themselves  in  groups  of  local  irritations. 


310  PNEUMONIA. 

The  rule  that  the  existence  of  several  points  of  irritation  in  the 
whole  system  modifies  the  proper  symptoms  of  any  one  of 
them  is  of  course  found  to  he  true  in  lung  disease  as  well  as  in 
other  affections,  and  as  pneumonia  may  occur  as  a  complication 
in  a  great  number  of  acute  general  or  local  diseases,  so  we  have 
an  extensive  catalogue  of  cases,  the  symptoms  of  which,  so  far 
as  the  disease  of  the  lung  is  concerned,  are  extremely  various. 

It  may  occur  in  cases  of  fever,  delirium  tremens,  arthritis, 
gastro-enteritis,  erysipelas,  and  many  others,  in  all  of  which 
there  is  more  or  less  of  latency,  quoad,  the  proper  symptoms  of 
the  affection. 

But  so  far  as  the  physical  signs  are  concerned,  this  may  be 
said,  that  they  remain  if  not  wholly,  nearly  as  well  developed 
as  in  cases  of  the  simpler  forms  of  the  affection.  Indeed,  in 
these  cases  the  disease  is  only  overlooked  from  ignorance  of  the 
liability  to  it  which  exists,  and  from  the  neglecting  to  make  a 
physical  examination  of  the  lungs,  on  the  grounds  that  the 
prominent  symptoms  of  the  case  happen  not  to  be  those  of 
pneumonic  inflammation. 

THE    PNEUMONIC    COMPLICATION    OF    TYPHUS. 

The  pulmonic  complications  of  typhus  may  be  observed  under 
three  forms :  in  the  first,  bronchitis  exists  for  a  few  days  and 
passes  ultimately  into  a  pneumonia,  the  lower  part  of  one  side 
becoming  gradually  dull  with  a  humid  crepitus ;  in  the  second 
variety  we  observe  no  difference  in  the  mode  of  invasion  or  the 
physical  signs,  from  those  of  the  ordinary  disease ;  while  the 
third  presents  that  form  of  sudden  solidification  which  we  are 
now  to  consider,  namely,  the  asthenic  consolidations  of  the  lung 
occurring  in  typhus — and  manifestly  belonging  to  the  secondary 
phenomena  of  that  disease. 

Although  we  describe  this  lesion  under  the  general  head  of 
pneumonia,  and  though  in  the  first  edition  of  this  work  I  have 
designated  it  as  typhoid  pneumonia,  yet  it  may  be  questioned 
whether  this  is  in  reality  a  form  of  pneumonia,  or  is  not  rather 
the  filling  up  of  the  lung  by  the  typhic  deposit  in  a  non-concrete 
form  accompanied  by  more  or  less  congestion.  Analogy  would 
teach  us  that  in  such  a  condition  when  inflammation  takes  place 
it  is  of  the  same  kind  as  that  observed  in  the  secondary  gastro- 


PNEUMONIA.  oil 

intestinal  affection,  and  truly  of  a  reactive  nature,  deposit  having 
first  taken  place  in  the  tissue  of  the  organ.  These  cases  are 
perhaps  of  a  mixed  nature,  but  unquestionably  they  follow,  in 
many  instances,  the  course  of  the  secondary  diseases  of  typhus, 
and  the  inflammatory  conditions  which  follow  them  have  the 
characters  of  the  dothin-enteritis,  which,  when  arising  in  typhus, 
at  least  is  secondary  not  only  to  the  general,  but  also  to  the  local 
disease. 

The  chain  of  phenomena  may  be  arranged  as  follows,  fever 
{essential  typhus),  deposit  (with  or  without  accompanying  con- 
gestion), inflammation  (reactive,  low,  tending  to  gangrene). 

The  history  and  symptoms  of  these  affections  of  the  lungs  in 
typhus  are  more  easily  understood  by  adopting  this  view,  than 
by  the  supposition  of  an  inflammation  arising  in  a  lung  pre- 
viously unaltered. 

If  we  pass  in  review  the  circumstances  in  which  the  disease 
often  occurs,  and  compare  them  with  the  ordinary  conditions  of 
acute  primary  pneumonia,  we  cannot  help  admitting  that  they 
indicate  a  morbid  state  of  a  very  different  nature. 

In  the  first  place  the  signs  of  pulmonary  disease  are  preceded 
by  fever,  it  may  not  be  until  many  days  have  elapsed  that 
symptoms  of  lung  disease  set  in  ;  secondly,  this  fever  is  ob- 
viously an  essential  fever,  existing  without  or  with  petechia,  and 
it  may  be  without  or  with  other  complications ;  thirdly,  the 
disease  sets  in  as  it  were  spontaneously,  and  without  any 
external  exciting  cause ;  fourthly,  its  invasion,  though  often 
unaccompanied  by  new  symptoms  at  first,  is  sudden,  and  signs 
of  consolidation  are  among  its  very  earliest  physical  phenomena  ; 
fifthly,  well-formed  concrete  or  non-concrete  purulent  matter  is 
rarely  if  ever  produced  ;  sixthly,  there  is  a  tendency  to  gan- 
grene— in  some  cases  large  eschars  form  in  the  lung  with  great 
rapidity  ;  seventhly,  we  remark  a  greater  liability  to  bronchial 
complication  in  typhus  with  pneumonia  than  in  the  primary 
sthenic  inflammation ;  eighthly,  in  most  cases  the  condition  of 
the  heart  is  different,  it  is  either  not  excited  in  any  remarkable 
way,  or  it  may  exhibit  towards  the  close  of  the  case,  what  may 
be  called  the  typhous  excitement  of  the  heart.  Typhus  softening 
of  the  heart  is,  however,  so  far  from  being  peculiar  to  this  con- 
dition that  the  best  marked  cases  have  occurred,  rather  in  the 
bronchial,  than  the  pneumonic  complication  of  the  disease. 


312  PNEUMONIA. 

John  Peter  Frank  has  described  a  form  of  the  disease  to 
which  he  has  given  the  name  of  Peripneumonia  nervosa  :  he 
considers  it  to  be  a  combination  of  nervous  fever  with  inflam- 
mation of  the  lung.  The  disease  according  to  him  is  sometimes 
epidemic,  causing  the  most  terrible  ravages.  It  sets  in  with 
extreme  prostration,  pallor  of  the  face,  terror,  and  other 
symptoms  of  the  "  versatile  or  stupid  nervous  fever,"  rigors, 
followed  by  dyspnoea,  with  a  frequent  cough  and  scanty  ex- 
pectoration of  serous,  blood}7,  or  sanious  sputa  are  among  the 
first  symptoms  accompanied  by  a  severe  pungitive  pain  of  the 
chest,  which  is  exasperated  by  the  slightest  touch,  and  is  so 
severe  as  almost  to  suspend  respiration.  The  nervous  symptoms 
are  severe  pain  in  the  head,  particularly  in  the  occiput,  vertigo, 
furious  delirium,  continued  want  of  sleep,  subsultus  tendinum 
and  hiccough,  bilious  symptoms  supervene,  and  dark  coloured 
ptechise,  miliary  eruptions,  and  fatal  haemorrhages  may  occur. 
The  blood  is  in  general  without  cohesion,  and  the  pulse  either 
not  excited  or  frequent,  small,  and  very  variable  ;  and  the  patient 
may  suffer  from  excessive  thirst,  faintings,  and  aphtha?  of  the 
mouth. 

It  is  very  difficult  to  draw  a  line  between  the  disease  described 
by  Frank  and  typhus  fever  with  pulmonary  complication,  our 
knowledge  of  the  connexion  between  the  typhus  and  local 
disease  is  still  too  imperfect  to  enable  us  to  declare  whether  this 
disease  is  not  an  example  of  the  secondary  effect  of  typhus  deve- 
loped at  an  unusually  early  period,  a  state,  in  fact,  the  reverse  of 
what  commonly  happens,  namely  that  the  constitutional  precedes 
the  local  affection.  In  the  case  which  we  have  just  now  ex- 
amined, the  after  symptoms  of  typhus  did  not  appear,  so  that  it 
would  seem  to  establish  that  under  particular  circumstances 
inflammation  of  the  lung  may  induce  a  train  of  neurotic  symp- 
toms of  great  severity  which  are  purely  sympathetic. 

COMPLICATION  WITH  DELIRIUM  TREMENS. 

This  combination  is  observed  so  far  as  I  know  only  in  the 
cases  of  delirium  tremens  from  excess ;  there  is  no  reason  for 
believing  that  it  arises  in  the  more  purely  nervous  form  of  the 
disease  which  is  caused  by  want  of  stimulus,  and  even  in  the 
first  variety,  I  apprehend  that  it  is  a  rare  occurrence,  unless  the 


PNEUMONIA.  313 

patient  be  labouring  under  symptomatic  fever,  or  as  we  have 
sometimes  seen,  a  combination  of  the  symptomatic  fever  of 
delirium  tremens  with  typhus. 

In  almost  all  the  cases  of  the  disease  that  I  have  seen,  the  pneu- 
monia, though  a  very  important  element  in  the  case  was  but  one 
of  a  group  of  inflammations  ;  and  disease  cc-existed  in  the  brain, 
heart,  digestive  organs,  bronchi,  pulmonary  tissue,  and  pleurae. 
The  general  condition  was  more  or  less  typhoid,  and  the  symp- 
toms so  complicated  and  multifarious  as  to  be  incapable  of  being 
reduced  to  any  nosological  formulae.  The  nervous  symptoms 
were  seldom  so  well  developed,  as  in  simpler  cases  of  the  disease, 
but  delirium  sometimes  violent,  and  at  other  times  of  the  low 
and  muttering  character,  convulsion  and  tremor  were  often 
present ;  there  appears  to  be  less  of  sleeplessness  or  watchfulness 
than  in  ordinary  cases,  and  stupor  or  a  semi-comatose  sleep 
might  occur  not  followed  by  any  subsidence  of  the  symptoms. 

In  cases  such  as  I  have  described,  the  pathological  condition 
of  the  lung  resembles  that  of  the  asthenic  or  typhoid  forms  of 
disease  ;  this  may  arise  from  the  previously  depraved  state  of 
the  patient's  constitution.  I  once  saw,  however,  a  case  in  which 
violent  pneumonia  associated  with  other  inflammations  occurred 
in  a  man  of  a  good  constitution,  and  who  had  previously  been 
sober ;  he  drank  at  a  debauch  committed  on  his  arrival  in  town 
a  quantity  of  ardent  spirit,  which  appeared  almost  incredible. 

He  was  brought  into  hospital  in  a  profound  coma,  from  which 
he  could  not  be  roused  even  by  the  application  of  the  actual 
cautery.  Next  day  his  senses  returned,  and  he  remained  for 
several  hours  apparently  free  from  disease,  when  symptoms  of 
the  most  violent  inflammatory  fever,  soon  followed  by  the  local 
phenomena  of  many  visceral  inflammations  suddenly  exploded. 
The  disease  ran  a  rapid  course,  and  on  dissection  the  brain  and 
its  membranes,  the  spinal  cord,  the  lungs,  the  pleurae,  bronchi, 
the  pericardium,  and  endocardium,  the  stomach,  intestines,  liver, 
spleen,  kidneys,  and  bladder,  were  all  found  in  a  state  of  the 
most  intense  inflammation.  The  disease  in  the  lung  had  entered 
on  the  fourth  stage,  and  the  character  of  the  inflammation  was 
that  of  the  highest  degree  of  sthenic  disease  in  a  healthy 
subject. 

It  need  hardly  be  observed  that  in  most  of  these  cases  the 
lung  disease  is  more  or  less  latent,  or  only  becomes  manifest 


314  PNEUMONIA. 

when  it  has  attained  a  very  advanced  stage.  It  is  therefore  most 
necessary  in  the  management  of  a  case  of  delirium  tremens  from 
excess,  and  particularly  when  there  is  fever,  that  careful  and 
repeated  physical  examinations  both  of  the  lungs  and  heart 
« should  be  made  by  the  medical  attendant.* 

There  is  a  form  of  pneumonia  which  bears  a  close  resem- 
blance not  only  to  the  complication  of  pneumonia  with  delirium 
tremens,  but  also  to  the  latter  disease  in  its  uncomplicated  form. 
In  other  words,  pneumonia  may  be  attended  by  a  train  of  nervous 
symptoms  so  similar  to  those  of  delirium  tremens  as  to  lead 
easily  to  an  erroneous  diagnosis.  Of  this  the  following  case  is 
an  example. 

A  man,  set.  29,  was  admitted  March  1st,  1839,  with  symptoms 
which  were  supposed  to  be  those  of  delirium  tremens.  He  was 
not  violent,  but  was  obliged  to  be  confined  by  the  strait  waist- 
coat, in  consequence  of  his  continued  efforts  to  get  out  of  bed. 
He  had  considerable  tremor  and  subsultus ;  the  countenance 
was  wild  and  anxious ;  he  had  a  continual  muttering  delirium, 
yet  when  addressed  he  answered  in  a  perfectly  collected  and 

*  The  following  typical  case  by  Dr.  Banks  of  typhoid  pneumonia  with  delirium 
tremens  from  excess  deserves  to  be  noted  as  illustrating  the  latency  of  symptoms  and 
physical  signs  in  this  form  of  disease.  A  man  set.  forty  years  was  admitted  into 
hospital  on  the  10th  of  April,  1850.  He  stated  that  he  had  been  drinking  spirits 
freely  during  the  last  few  days  but  was  not  a  habitual  drunkard.  Four  days  since 
was  attacked  by  shivering,  sickness  of  stomach,  and  general  depression  followed  by 
loss  of  sleep.  He  had  slight  cough  with  some  dyspncea,  husky  voice,  anxious  counte- 
nance, was  uneasy  and  fidgety,  and  complained  of  a  stitch  in  the  right  side.  "  The 
respiration  was  natural  and  the  whole  of  the  thorax  resonant  on  percussion,  with  the 
exception  of  the  base  of  the  right  lung,  where  a  certain  amount  of  dulness,  some 
feebleness  of  respiration,  and  a  friction  sound  were  observed."  At  night  he  was 
sleepless  and  delirious  walking  about  the  ward,  and  "  on  the  following  morning  it  was 
observed  that  the  dulness  which  was  at  first  confined  to  the  very  base  of  the  lung 
had  extended  upwards.  No  crepitating  rale  could  be  heard,  but  the  greater  part  of 
the  right  side  was  dull  on  percussion  and  respiration  was  totally  inaudible."  He  passed 
the  11th  and  12th  without  much  change,  but  at  10  p.m.  the  delirium  passed  into  coma, 
•ending  in  death  at  5  A.M.  of  the  13th — the  third  day  after  admission. 

At  the  autopsy  "  the  greater  part  of  the  right  lung  was  found  in  a  state  of  solidifi- 
cation, and  in  some  places  had  passed  into  the  third  stage  of  pneumonia.  On  making 
a  section  of  this  lung  a  number  of  yellow  patches  were  observed  in  different  portions 
of  the  pulmonary  structure  which  broke  down  under  the  slightest  pressure.  Lymph 
had  been  effused  on  the  base  of  the  right  lung  and  also  on  the  adjoining  pleura."  Dr. 
Banks  observed  that  the  existence  of  pleuritic  friction  sound  rapidly  followed  by  ex- 
tensive dulness  without  crepitating  rale  might  have  led  to  the  mistake  of  supposing 
the  case  to  be  one  of  pleuritis  with  effusion.  The  characteristic  sputa,  the  extreme 
rapidity  of  the  diseased  phenomena,  and  the  knowledge  of  the  frequency  of  the  com- 
plication with  delirium  tremens  led  him  to  the  diagnosis  of  typhoid  pneumonia  which 
the  autopsy  proved  to  be  correct. — Dub.  Path.  Soc.  Transactions,  1850.    (Ed.) 


PNEUMONIA.  315 

rational  manner,  and  appeared  cheerful  and  contented  with  him- 
self and  those  around  him.  He  had  no  symptoms  of  sanguineous 
determination  to  the  head ;  there  was  no  flushing  congestion  of 
the  eyes  or  alteration  of  the  pupils ;  he  did  not  complain  of 
headache,  and  the  action  of  the  temporal  arteries  was  natural. 
He  had  no  thirst,  yet  his  tongue  was  red  and  dry,  but  not 
tremulous  ;  the  belly  was  not  painful,  but  hard,  as  if  the  muscles 
were  in  a  state  of  spasm.  The  pulse  was  140  and  exceedingly 
feeble ;  the  respirations  thirty-four  in  a  minute ;  he  coughed 
occasionally  and  expectorated  a  small  quantity  of  frothy  mucous 
which,  though  not  viscid,  had  a  decided  rusty  tinge. 

There  was  no  evidence  that  this  patient  had  been  indulging 
in  the  use  of  ardent  spirits  ;  and  he  was  able  to  give  a  consistent 
account  of  his  disease  for  a  short  time,  when  his  mind  wandered, 
and  he  became  unable  to  preserve  coherence.  He  stated  that  in 
returning  from  his  occupation,  which  was  that  of  a  coachman, 
he  was  suddenly  attacked  with  pain  in  the  right  side,  followed 
by  cough,  and  he  invariably  pointed  to  the  inferior  portion  of  the 
right  side  to  indicate  the  seat  of  pain.  He  never  varied  in  this 
statement,  which  he  continued  to  make  after  his  complete  recovery. 

We  found  the  physical  signs  of  pneumonia  in  the  third  stage 
accompanied  by  a  slight  friction  sound  over  the  postero-inferior 
portion  of  the  right  lung,  from  the  interscapular  region  down- 
wards. The  patient  was  treated  by  blisters,  ammonia,  and  the 
external  use  of  mercury.  The  nervous  symptoms  rapidly  sub- 
sided, and  the  resolution  of  the  pneumonia,  which  was  very 
extensive,  was  complete  in  about  a  fortnight  after  his  admission. 

It  should  be  mentioned  that  the  patient  was  never  inoculated, 
and  that  want  of  sleep  and  optical  illusions  were  present  during 
the  early  stage  of  the  disease. 

The  opinion  which  1  formed  of  this  case  was,  that  it  was  not 
delirium  tremens  combined  with  pneumonia,  but  rather  asthenic 
pneumonia  with  true  symptomatic  nervous  symptoms ;  and  this 
opinion  was  founded  on  the  following  grounds  : — 

I.  The  want  of  evidence  that  the  patient  had  committed 
excess. 

II.  The  fact  that  the  symptoms  set  in  with  pain  in  the  side. 

III.  The  manifest  existence  of  pneumonia. 

IV.  The  want  of  accordance  between  the  case  and  those  which 
we  have  already  observed  of  delirium  tremens,  in  this,  that  we 


\ 


316  PNEUMONIA. 

had  here  but  one  seat  of  inflammation,  while  in  the  compli- 
cated cases  of  delirium  tremens  we  commonly  find  evidence  of 
irritation  in  many  organs. 

The  treatment  and  complete  recovery  of  the  patient  warrant 
the  opinion  that  the  original  malady  was  pneumonia,  inducing  a 
train  of  violent  nervous  symptoms. 

But  even  in  cases  where  a  debauch  has  been  committed,  the 
symptoms  of  pneumonia  may  be  manifest,  and  be,  indeed,  the 
very  first  indications  of  illness.  We  have  seen  the  most  violent 
pain  and  other  symptoms  precede  the  delirium  tremens,  and  it 
commonly  happens  in  such  cases  that  the  use  of  copious  bleedings, 
without  reference  to  the  previous  circumstances  of  the  case,  pro- 
duces deplorable  results.  The  delirium  tremens  explodes  after 
the  symptoms  of  pneumonia  have  been  well  established.  The 
latter  disease  takes  the  typhoid  type,  and  the  patient  sinks  from 
nervous  prostration. 
\      This  combination  then  is  of  two  kinds  : — 

I.  Pneumonia,  generally  latent,  and  combined  with  other  local 
inflammations,  arising  in  the  course  of  delirium  tremens. 

II.  Pneumonia,  with  manifest  symptoms,  preceding  the  deli- 
rium tremens. 


ERYSIPELATOUS    COMBINATION. 

This,  which  is  one  of  the  most  insidious  and  dangerous  forms 
of  disease,  is  more  likely  to  occur  in  that  low  and  spreading 
form  of  erysipelas,  which  has  got  the  name  of  diffuse  inflamma- 
tion, than  in  the  more  sthenic  and  localised  varieties  of  the 
affection.  It  is  characterised  principally  by  rapidity  of  invasion, 
and  the  speedy  consolidation  of  the  lung. 

Anatomically  the  disease  differs  from  that  of  ordinary  pneu- 
monia in  this,  that  the  pleura  is  often  smeared  with  a  soft  and 
bloody  lymph,  and  the  solidified  portions,  though  soft  and  friable, 
are  not  so  vascular  as  in  ordinary  hepatization,  nor  does  the 
surface  of  the  incisiou  present  the  granular  aspect,  at  least  to 
the  same  degree.  I  have  seen  them  perfectly  smooth,  of  the 
palest  red  colour,  and  of  a  somewhat  sizy  appearance. 

This  disease,  I  believe,  may  arise  primarily  in  the  lung,  with- 
out any  external  appearance  of  erysipelas,  and  it  may  be  looked 
for  during  the  prevalence  of  an  epidemic  of  erysipelas,  or  where 


PNEUMONIA.  317 

the  disease  has  become  located  in  the  wards  of  an  hospital.  I 
can  say  little  as  to  the  physical  signs  of  its  earlier  stages,  but 
I  believe  that  consolidation  of  the  lung  will  be  often  the  first 
recognizable  morbid  condition.  This  afterwards  passes  into 
interstitial  suppuration.  In  one  case  of  diffuse  inflammation,  I 
observed  a  dry  friction  sound  over  a  large  portion  of  the  right 
pleura,  but  this  was  not  followed  by  signs  of  further  alteration. 


COMBINATION   WITH    PURULENT    SYNOVITIS   AND   PERIOSTITIS. 

We  owe  to  the  late  Dr.  Ephraim  M 'Dowel  of  this  city  any 
knowledge  which  we  possess  of  this  subject.  He  has  described 
a  peculiar  form  of  arthritis  attended  with  a  group  of  special 
symptoms,  and  eventuating  in  the  copious  production  of  purulent 
matter,  not  only  in  the  cavities  of  the  joints,  but  engaging  the 
periosteum  in  their  vicinity.  These  cases  do  not  appear  to  be 
examples  of  phlebitis,  although  in  their  progress,  the  viscera 
suffer  in  a  manner  very  similar  to  that  observed  in  venous 
inflammation.  It  was  found  that  in  many  of  these  cases,  symp- 
toms of  pulmonary  irritation  supervened,  as  shewn  by  cough, 
dyspnoea,  and  bronchial  effusion  ;  and  on  dissection,  recent  inflam- 
mation of  the  pleurae  with  adhesions  was  discovered ;  the  lymph 
being  sometimes  in  considerable  quantities  and  reticulated,  the 
bronchiae  inflamed,  and  the  substance  of  the  lung  congested,  or 
presenting  red  hepatization,  while  numerous  small  abscesses 
were  discovered,  more  or  less  contiguous  to  the  surface.  These 
cavities  were  sometimes  lined  by  a  thin  coating  of  lymph,  and  in 
one  case  the  entire  of  both  lungs  was  inflamed  and  condensed. 

These  cases  appear  to  be  not  merely  examples  of  purulent 
absorption  and  deposition  of  pus  in  the  lung,  but  rather  of  intense 
pleuro-pneumony,  with  the  singular  phenomenon  of  numerous 
small  abscesses.  No  physical  examination  of  the  lungs  in  these 
cases  is  recorded.  The  character  of  the  fever  and  the  constitu- 
tional symptoms  bore  a  striking  resemblance  to  those  which 
accompany  inflammation  of  the  lining  membrane  of  the  veins. 
In  some  instances,  vascularity  and  thickening  of  the  synovial 
membrane  and  periosteum  were  discovered,  and  the  latter  struc- 
ture was  frequently  extensively  detached  from  the  bone,  and  in 
one  instance  was  found  covered  with  reticulated  lymph  resem- 
bling that  seen  in  pericarditis. 


318  PNEUMONIA. 


PUERPERAL    COMBINATION. 


Of  this  form  I  have  seen  a  great  many  examples.  Yet  the 
works  on  obstetrical  science  are  very  deficient  in  accurate 
observations  on  the  subject.  The  cases  which  I  have  seen  are 
divisible  into  two  classes. 

First,  where  pneumonia  arises,  as  it  were,  spontaneously  soon 
after  parturition. 

Secondly,  where  it  has  been  preceded  by  symptoms  of  puer- 
peral fever,  with  or  without  the  manifest  signs  of  phlebitis. 

The  prognosis  in  the  latter  variety  must  be  most  unfavourable  ; 
and  particularly  so  if  the  disease  arises  within  the  first  eight 
days  after  parturition,  for  in  addition  to  the  constitutional 
affection,  we  have  to  deal  with  a  pneumonia  which  has  all  the 
intractable  character  of  the  diffuse  inflammations. 

In  the  first  variety  we  sometimes  observe  that  on  the  subsi- 
dence of  the  pneumonic  attack,  phlegmasia  dolens  of  the  lower 
extremities  becomes  developed.  The  rule  in  prognosis  seems 
to  be,  that  if  the  pneumonia  be  the  first  symptom  of  disease 
after  parturition,  we  may  have  more  hope  than  when  it  has  been 
preceded  by  the  fever  with  or  without  the  manifest  signs  of 
phlebitis. 

A  full  series  of  researches  on  the  puerperal  inflammations  of 
the  thoracic  viscera  is  still  a  desideratum  in  medicine. 


COMBINATION    WTITH    GASTRO-ENTERIC    AND    HEPATIC    DISEASE. 

I  am  not  aware  that  there  is  anything  worthy  of  special  notice 
in  this  form  of  complication,  so.  far  as  the  physical  signs  of 
disease  are  concerned.  The  symptoms  partake  of  the  character 
of  latency,  which  belongs  to  all  examples  of  local  disease,  when 
there  are  many  seats  of  irritation  co-existing,  and  this  applies 
not  only  to  the  symptoms  singly  considered,  but  to  their  group- 
ing, and  to  the  character  of  the  fever  which  attends  them.  The 
purely  inflammatory  fever  is  seldom  seen  in  this  combina- 
tion, at  least  in  this  country,  but  is  replaced  by  a  more  or  less 
typhoid  form,  with  or  without  the  presence  of  bilious  symptoms ; 
and  it  is  often  extremely  difficult,  if  not  impossible,  to  distin- 


PNEUMONIA.  319 

guish  these  cases,  in  which  both  the  pneumonia  and  enteric 
disease  are  but  the  result  of  a  general  malady,  and  those  in 
which  the  modifications  of  each  group  of  symptoms  is  owing  to 
the  mutual  reaction  of  the  disease. 

In  this  form  the  pain  is  often  trifling,  or  it  may  be  absent. 
The  expectoration  in  the  second  and  third  stages,  at  least,  is 
seldom  characteristic ;  nor  is  the  distress  of  respiration  com- 
monly observed  until  the  disease  has  engaged  a  large  portion  of 
the  lung,  or  until  some  bronchial  effusion  becomes  prominent. 
I  incline  to  think  that  the  activity  of  the  inflammatory  process 
in  the  lung  is  much  less  than  in  the  sthenic  pneumonia.  The 
consolidation  is  rarely  so  complete,  and  it  is  not  in  these  cases 
that  we  are  to  look,  at  least  generally,  for  the  well-marked  signs 
of  the  fourth  or  fifth  stages  of  the  disease. 

In  such  cases  the  arterial  reaction  is  comparatively  feeble, 
and  the  whole  character  of  the  disease  is  that  of  asthenia.  The 
tartar-emetic  treatment  is  seldom  applicable,  nor  can  depletions 
be  had  recourse  to  in  the  same  manner  that  we  may  employ  them 
in  the  simple  forms  of  the  disease. 

But  on  the  other  hand  we  have  seen  a  case  of  the  distinct 
combination  of  enteric  inflammation  with  pneumonia,  in  which 
the  symptoms  were  of  a  high  inflammatory  character,  requiring 
very  active  treatment.  The  combination  then  does  not  neces- 
sarily produce  the  asthenic  character. 


COMBINATION   WITH    EXANTHEMATA. 

Symptoms  and  signs  of  pneumonia  may  precede,  accompany, 
or  follow  measles,  scarlatina,  or  small-pox.  In  the  two  first  of 
these  the  characters  of  the  disease  are  commonly  more  active  or 
inflammatory,  while  the  pneumonia  which  is  associated  with 
variola  has  a  typhoid  character.  In  measles  the  disease  com- 
monly occurs  at  an  earlier  period  than  in  scarlatina,  and  in  the 
ordinary  forms  it  has  a  highly  sthenic  character,  occasionally 
running  on  to  the  formation  of  abscess.  In  scarlatina  it  is  more 
commonly  observed  after  the  disappearance  of  the  eruption,  and 
it  may  be  then  a  very  violent  and  intractable  affection.  It  is  by 
no  means  an  uncommon  complication  in  the  anasarcous  condi- 
tion which  follows  scarlatina,  a  condition  in  which,  at  least  so 


320  PNEUMONIA. 

long  as  fever  remains,  there  is  a  strong  tendency  to  the  repe- 
tition of  intense  and  varied  local  inflammations,  affecting  not 
only  the  parenchyma  of  organs,  hut  the  serous  memhranes 
also. 

COMPLICATION   WITH   GOUT. 

Our  information  on  this  subject  is  still  very  limited  ;  I  shall 
therefore  content  myself  with  simply  indicating  its  existence. 
I  have  seen  a  few  cases  in  which,  although  no  actual  gouty 
disease  of  the  articulations  existed,  yet  the  disease  occurred  in 
constitutions  which  were  essentially  gouty.  It  need  hardly  be 
observed  that  in  such  cases  the  principles  of  treatment  will 
differ  from  those  which  are  applicable  in  the  ordinary  forms  of 
the  disease. 

TREATMENT    OF    PNEUMONIA. 

Under  this  head  we  shall  consider  the  treatment  of  three 
important  conditions  of  the  disease,  namely — 

I.  The  acute  sthenic  pneumonia  in  its  early  stage. 

II.  Unresolved  hepatizations  resulting  from  acute  pneumonia, 
the  fever  and  advance  of  the  disease  having  ceased. 

III.  The  asthenic  or  typhoid  pneumonia. 

We  shall  then  describe  our  ordinary  practice  in  cases  of  typhus, 
or  other  acute  disease  with  secondary  pneumonia. 

It  is  obvious  that  to  lay  down  rules  for  the  treatment  of  each 
variety  or  complication  of  pneumonia  would  be  impossible,  and 
it  must  be  admitted,  so  far  as  we  know  at  present,  it  would 
appear  to  be  unnecessary.  As  met  by  the  practical  physician, 
they  may  be  divided  generally  into  two  great  categories,  dis- 
tinguished not  only  by  their  symptoms  and  pathology,  but  by 
the  results  of  treatment.  In  the  first  may  be  placed  the  cases  of 
acute  inflammatory  pneumonia  occurring  in  a  healthy  subject 
and  with  a  purely  symptomatic  fever.  While  in  the  second  we 
may  group  with  the  acute  asthenic  pneumonia,  a  vast  number  of 
cases  of  the  disease  complicating  typhus  feyer,  or  other  con- 
stitutional or  local  affections. 

It  may  be  laid  down  as  a  general  rule  that  in  this  second 
category  the  principles  of  treatment  are  different  from  those  that 
apply  to   the   first,  and  the  difference  may  be  thus  expressed, 


PNEUMONIA.  321 

that  while  in  the  first  class  general  and  local  antiphlogistic  treat- 
ment is  applicable,  in  the  second  this  treatment  must  be  adopted 
with  extreme  caution,  and  our  principal  reliance  must  be  placed 
on  counter-irritation,  mercurials,  stimulants,  and  tonics,  and  that 
the  greatest  attention  must  be  paid  to  supporting  the  strength 
of  the  patient,  who  in  many  cases  labours  under  a  constitutional 
disease  in  itself  as  formidable,  or  more  so,  than  the  local 
disease. 

ACUTE    STHENIC    PNEUMONIA. 

Let  us  suppose  a  case  of  this  disease  occurring  in  a  young  and 
healthy  man,  and  that  the  patient  is  seen  about  the  third  or 
fourth  day  of  the  disease,  when  we  may  suppose  the  fever  high, 
the  pain  of  the  chest  severe,  while  the  physical  signs  indicate 
that  the  disease  has  passed  into  its  second  or  third  stages,  the 
lower  portion  of  the  side  is  becoming  dull,  and  the  crepitating 
rale  is  spreading  upwards,  the  disease  has  not  been  modified  by 
previous  treatment,  the  skin  is  hot,  the  pulse  full  and  bounding, 
the  force  of  the  heart  considerable,  and  the  expectoration  rusty. 

The  first  question  to  be  discussed  would  be  the  propriety  of 
bleeding,  and,  I  believe,  that  under  the  circumstances  indicated, 
and  particularly  if  the  case  be  an  accidental  one,  and  not  occur- 
ring under  the  influence  of  any  epidemic  tendency,  venesection 
may  be  performed  with  safety  and  advantage  ;  but  our  experience 
is  quite  opposed  to  very  large  or  repeated  bleedings,  as  recom- 
mended by  Bouillaud.  We  believe  that  copious  depletion  is  not 
only  unnecessary,  but  mischievous,  and  it  must  never  be  for- 
gotten that  in  acute  as  well  as  chronic  diseases  the  great 
object  of  the  physician  should  be  to  cure  the  patient  at  the  least 
possible  expense  to  his  constitution. 

If  venesection  has  produced  a  favourable  alteration  in  the 
pulse,  if  it  has  permanently  diminished  the  force  of  the  heart, 
lessened  the  heat  of  the  skin,  and  relieved  the  dyspnoea,  the  mere 
circumstance  of  the  extension  of  physical  signs  ought  not  to 
induce  us  necessarily  to  repeat  the  blood-letting.  And  again, 
the  fact  that  while  the  constitutional  symptoms  are  reduced, 
still  the  physical  signs  remain  unchanged,  is  not  to  be  taken  as 
an  indication  for  further  general  depletion. 

Although  it  is  true  that  in  certain  cases  a  complete  and  rapid 
resolution  of  the  disease  both  as  to  symptoms  and  signs  follows 

Y 


322  PNEUMONIA. 

on  bold  bleeding  from  the  arm,  yet  such  a  case  is  comparatively 
rare,  and  a  sufficient  experience  enables  us  to  declare  that  the 
ordinary  effect  of  general  bleeding  in  acute  diseases  of  the  lung — 
particularly  pneumonia  and  pleurisy — is  less  the  removal  of  the 
affection  than  the  rendering  it  latent  so  far  as  its  vital  symptoms 
are  concerned.  It  would  be  well  if  this  proposition  were  more 
extensively  considered,  for  there  cannot  be  a  doubt  that  a  large 
portion  of  the  chronic  diseases  of  the  lung  are  the  result  of  acute 
affections  recognized  and  for  the  time  properly  treated  by  anti- 
phlogistic measures,  but  in  which  the  latent  condition  has  been 
mistaken  for  recovery,  and  the  disease  allowed  to  pass  on  into 
chronic  and  incurable  disorganization.  The  great  rule  appears 
to  be  that  in  these  cases  of  the  apparent  removal  of  disease  by 
antiphlogistic  treatment  physical  examination  must  be  had  re- 
course to,  to  determine  the  point  as  to  whether  the  cure  be  real 
or  fallacious. 

In  pneumonia  the  effect  of  early  bleeding  may  be  to  remove 
every  symptom,  yet  the  lung  may  remain  hepatized,  and  the 
result  be  a  slow  and  doubtful  resolution,  a  chronic  and  incurable 
hardening,  or  the  development  of  tubercle  in  the  diseased  lung. 
In  pleurisy,  too,  the  symptoms  may  in  like  manner  be  overcome, 
and  yet  the  effusion  remain  in  a  passive  state,  or  slowly  increase 
till  a  great  empyema  is  produced. 

From  all  this  we  learn,  that  under  these  circumstances  not 
only  may  the  original  disease  remain,  but  that  it  may  slowly 
progress,  or  take  on  new  pathological  characters. 

It  is  seldom  necessary  to  repeat  the  bleeding,  which  is  to  be 
considered  more  as  a  preparation  for  other  treatment  than  a 
means  for  removing  the  disease. 

The  next  step  will  be  the  use  of  local  bleeding,  which  of  all 
modes  of  treatment  has  the  most  marked  effect  on  the  disease. 
Cupping,  where  the  tenderness  of  the  side  permits  it,  is  pre- 
ferable to  the  use  of  leeches ;  but  either  of  these  methods  may 
be  used  and  repeated  again  and  again  according  to  circumstances. 
And  in  many  cases,  but  particularly  if  the  disease  be  asthenic, 
we  should  fully  support  the  strength  by  food  and  wine,  even  at 
a  time  when  we  are  using  local  depletion. 

We  obtain  great  advantage  from  the  use  of  poultices  to  the 
affected  side.  They  may  be  employed  at  all  periods  of  the 
disease,  and  their  efficacy  is  almost  always  manifest.     The  best 


PNEUMONIA.  323 

material  is  the  linseed  meal,  or  bran,  which  has  the  advantage  of 
greater  lightness,  and  it  is  more  easily  managed.  The  poultices 
should  be  large  and  warm,  and  covered  with  oiled  silk. 

I  do  not  know  any  period  of  the  disease  in  which  poulticing 
may  not  be  used  with  advantage,  even  in  cases  of  unresolved 
hepatizations.  When  the  fever  and  pain  have  subsided,  and 
the  pulse  is  quiet,  we  find  that  the  rapidity  of  the  resolution  is 
greatly  accelerated  by  their  employment. 

There  are  two  modes  of  internal  medication,  namely,  the  use 
of  tartar-emetic,  as  recommended  by  Laennec,  and  that  of  mer- 
cury with  or  without  opium,  the  selection  of  which  is  often  a 
subject  of  some  difficulty  to  the  practising  physician.  We  are 
not  to  believe,  however,  that  either  of  these  are  absolutely  re- 
quired in  the  treatment  of  pneumonia,  for  in  many  cases  the 
affection  can  be  conquered  without  their  aid. 

On  the  subject  of  Laennec's  use  of  the  tartar-emetic,  we  have 
nothing  to  add  to  what  has  been  already  stated.  And  our 
present  opinions  must  depend  less  on  recent  than  on  former 
experience,  for  it  is  a  remarkable  fact  that  of  late  years  we  have 
had  very  few  examples  of  the  simple  inflammatory  sthenic 
pneumonia  in  this  city.  But  when  such  cases  were  more  fre- 
quent we  did  find  that  the  efficacy  of  the  treatment  was  abund- 
antly proved,  and  that  we  could  verify  almost  every  one  of 
Laennec's  statements.  We  seldom  exhibited  more  than  six 
grains  in  the  course  of  the  twenty-four  hours,  and  our  results 
were  satisfactory. 

But  in  no  case  were  other  means  neglected,  and  general  and 
local  bleeding,  with  counter-irritation,  were  employed.  The  fol- 
lowing circumstances  were  found  to  be  favourable  to  the  use  of 
the  tartar-emetic  treatment. 

I.  The  disease  having  arisen  in  a  young  and  robust  subject. 

II.  The  disease  not  having  passed  its  earlier  stages. 

III.  The  fever  being  inflammatory  and  symptomatic. 

IV.  The  heart  acting  with  energy. 

V.  The  disease  being  uncomplicated  either  with  local  disease 
in  the  abdomen  or  with  the  various  constitutional  affections. 

Indeed,  the  only  proposition  of  Laennec's  that  we  had  to 
dissent  from  was  that  in  which  he  states  the  existence  of  the 
gastro -enteritis  of  fever  to  be  no  contra-indication  for  the  use  of 
the  remedy. 

y  2 


J- 


324  PNEUMONIA. 

But  in  the  great  majority  of  the  cases  met  in  the  Meath 
Hospital  for  the  last  fifteen  years  we  have  not  employed  the 
tartar-emetic  treatment.  More  or  less  of  a  typhoid  character 
attended  the  inflammation,  and  the  mercurial  treatment  was 
generally  adopted.  This  change  of  practice  arose,  however,  less 
from  any  direct  experience  of  the  injurious  effect  of  the  tartar- 
emetic  than  from  our  increasing  caution  as  to  any  proceeding 
calculated  to  lessen  the  strength  of  the  patients. 

The  mercurial  treatment  consisted  in  the  use  of  repeated 
moderate  doses  of  blue  pill  or  calomel,  or  a  combination  of 
them  ;  small  quantities  of  opium  or  Dover's  powders  were  added, 
and  the  remedy  continued  until  decided  mercurial  action  was 
produced.  The  inunction  of  mercurial  ointment,  and  the  dress- 
ing of  blistered  surfaces  with  the  mercurial  ointment  we  have 
found  valuable.  It  is  in  many  cases  unnecessary  to  push  the 
medicine  to  the  production  of  full  ptyalism.  It  often  happened 
that  resolution  took  place  with  scarcely  any  perceptible  mercurial 
action  either  on  the  gums  or  in  any  other  way.  Mercurial 
iarrhcea  sometimes  preceded  or  accompanied  the  resolution ; 
while  in  certain  cases  a  most  violent  and  long-continued  ptyalism 
ensued. 

We  have  in  several  cases  used  both  the  tartar-emetic  and 
mercurial  treatment  at  different  periods  of  the  same  case.  In 
some  instances,  where  the  tartar-emetic  failed,  or  that  the  cura- 
tive action  seemed  to  be  suspended,  the  use  of  mercury  has 
produced  a  most  rapid  improvement.  And,  on  the  other  hand, 
we  have  found  that  when,  after  a  certain  amount  of  mercury 
had  been  exhibited  without  manifest  change,  that  the  use  of 
the  tartar-emetic  was  followed  by  a  singularly  rapid  and  complete 
recovery.  Dr.  Hudson  has  published  a  case  which  strikingly 
corroborates  the  efficacy  of  tartar-emetic  given  after  mercur}'. 
Some  of  my  friends  employ  a  combination  of  these  remedies, 
but  of  this  mode  I  can  say  nothing  from  my  own  experience.* 

*  The  case  referred  to  in  the  text  was  published  in  the  eleventh  volume  of  the 
Dublin  Medical  Journal,  First  Series.  The  patient  had  suffered  an  attack  of  pneumonia 
a  month  previous  to  my  seeing  him,  for  which  he  had  been  actively  treated  with,  for 
a  time,  apparent  benefit.  For  a  week  before  I  saw  him  there  had  been  no  improve- 
ment, but  the  contrary.  He  had  then  cough,  with  sanguinolent  expectoration,  very 
marked  dyspnoea,  feeling  of  weight  and  oppression  in  the  side,  &c.  He  had  been 
salivated,  so  that  the  further  exhibition  of  mercury  was  out  of  the  question,  and  at  my 
suggestion  he  was  given  tartar-emetic  in  grain  doses  every  third  hour.  After  the 
first  dose  he  had  the  most  perfect  tolerance  of  the  mediane^  which  he  took  regu- 


PNEUMONIA.  325 

The  exhibition  of  mercury  in  very  large  doses  at  long  in- 
tervals, and  its  use  in  very  minute  quantities  frequently  repeated 
have  their  respective  advocates  in  Dr.  Graves  and  Dr.  Law. 

But  in  whichever  way  we  use  the  remedy,  we  should  consider 
it  only  as  an  adjuvant,  and  one  whose  employment  is  not  always 
necessary.  Its  true  action  seems  to  be  less  in  arresting  inflam- 
mation, than  in  accelerating  the  removal  of  the  products  of 
inflammation.  And  thus  the  production  of  mercurial  action 
appears,  in  a  great  number  of  cases,  to  be  rather  a  consequence 
than  a  cause  of  the  arrest  of  the  disease.  Whatever  may  be  its 
value,  it  is  not  to  be  considered  as  our  sheet-anchor,  nor  is  its 
exhibition  to  be  pressed  to  the  neglect  of  other  measures.  To 
this  I  shall  refer  when  we  speak  of  the  treatment  of  the  asthenic 
forms  of  the  disease. 

There  are  many  cases,  too,  in  which  the  use  of  mercury  must 
not  be  attempted,  or  at  least  adopted  with  extreme  caution  ;  of 
these  the  following  instances  may  be  taken  as  examples  out  of 
others  : — 

I.  When  the  disease  occurs  in  persons  who  have  recently 
suffered  from  acute  disease,  more  particularly  if  in  that  disease 
they  have  been  mercurialised. 

II.  When  the  scorbutic  diathesis  exists,  as  we  often  see  in 
certain  families ;  and  again,  where  signs  of  imperfect  haema- 
tosis  are  actually  existing,  as  shewn  by  spongy  or  bleeding 
gums,  ftetid  breath,  epistaxis,  or  splenic  congestions. 

larly  for  a  week.  On  the  third  day  the  commencement  of  resolution  was  indicated 
by  a  line  crepitus  in  the  solidified  part,  which  became  gradually  more  distinct  for 
a  few  days,  then  was  mixed  with  respiratory  murmur,  by  which  it  was  replaced 
and  resolution  perfected  in  the  course  of  a  fortnight. 

I  have  since  seen  many  examples  of  the  successful  treatment  of  unresolved  hepati- 
zation by  tartar-emetic.  In  two  of  these,  in-patients  under  my  care  in  the  Meath 
Hospital,  the  disease  was  of  long  standing — in  one  six  weeks,  in  the  other  three 
months — and  had  caused  general  dropsy,  a  consequence  of  this  form  of  hepatization 
noticed  by  Rokitansky,  who  says  :  "This  condition  may  exist  for  a  long  time,  and  is 
always  followed  by  cachexia,  and  especially  by  dropsical  symptoms,  and  it  often 
proves  fatal." 

In  these  cases  the  anasarca  rapidly  disappeared  with  the  hepatization  under  the 
antimonial  treatment.  According  to  Rokitansky  "  the  curative  process  in  indurated 
hepatization  is  somewhat  analogous  to  the  resolution  of  pneumonia  in  the  second 
stage,  for  an  exhalation  of  serous  fluid  takes  place  from  the  inner  wall  of  the  air  cells, 
and  acts  as  a  menstruum  which  gradually  corrodes  and  absorbs  the  indurated  granu- 
lations." This  view  is  in  accordance  with  Laennec's  theory  of  the  action  of  tartar- 
emetic,  namely,  that  it  "  increases  the  activity  of  the  interstitial  absorption,"  which 
it  probably  does  by  its  power  of  increasing  the  exhalation  from  the  capillaries  of 
the  lungs.    (See  Headland  on  the  Action  of  Medicines,  p.  371.)     (Ed.) 


f 


326  PNEUMONIA. 

III.  When  we  have  to  deal  with  persons  of  a  scrofulous  habit, 
or  even,  though  they  shew  no  marks  of  scrofula,  if  they  belong 
to  a  family  subject  to  the  disease.  We  must  also  be  especially 
cautious  in  using  the  mercurial  treatment  when  the  patient  has 
at  any  former  time  been  threatened  with  phthisis,  or  has  had 
any  near  relations  carried  off  by  that  disease.  In  such  cases 
nothing  but  the  resistance  to  all  other  treatment  will  justify  us 
in  resorting  to  mercury. 

I  believe  that  by  a  judicious  use  of  depletion,  counter-irrita- 
tion, poultices,  and  stimulants,  a  great  number  of  cases  of  acute 
pneumonia  may  be  successfully  treated,  without  our  having 
recourse  to  either  tartar-emetic  or  mercury  at  any  period.* 

On  the  other  hand  we  often  observe  that  while  the  fever  con- 
tinues high,  a  complete  resistance  to  mercurial  action  exists, 
and  precious  time  may  be  lost  in  the  attempt  to  salivate,  when  a 
direct  antiphlogistic  treatment  would  have  modified  the  disease, 
and  induced  the  ptyalism.  It  will  always  be  found  that  the 
facility  of  salivation  will  be  directly  as  the  reduction  of  the  fever. 

TREATMENT  OF  UNRESOLVED  HEPATIZATIONS. 

The  condition  now  indicated  is  one  which  we  are  frequently 
called  on  to  treat.  It  is  not  uncommon  in  cases  where  the 
recovery  has  been  erroneously  inferred  from  the  subsidence  of 
the  vital  symptoms  of  pneumonia. 

Its  discovery  is  often  accidental,  as  it  is  often  productive  of  no 
symptoms  beyond  dyspnoea  on  exertion,  or  a  difficulty  of  lying 
on  one  side. 

We  shall  generally  succeed  in  removing  the  obstruction  by 
adopting  the  following  course  :  — 

We  may  commence  with  one  or  two  cuppings  over  the  dull 
portion,  abstracting  from  six  to  twelve  ounces  of  blood  at  each 
operation ;  or  if  the  loss  of  blood  be  considered  unadvisable  we 
may  use  dry  cupping  with  great  advantage.     Poultices  are  then 

*  It  may  be  objected  that  the  opinions  stated  in  the  text,  are  at  variance  with  those 
which  I  formerly  expressed  on  the  use  of  mercury  in  threatened  phthisis,  and  the  views 
of  Dr.  Graves  as  given  in  his  Clinical  Medicine  appear  different.  But  the  questions  as 
to  the  use  of  mercury  in  incipient  phthisis  and  in  pneumonia  in  a  scrofulous  subject 
are  clearly  not  the  same.  When  we  speak  of  tubercle  I  shall  return  to  this  point,  and 
here  only  remark,  that,  as  late  experience  shews  me,  that  we  can  manifestly  treat 
many  cases  of  pneumonia  without  the  use  of  mercury — its  employment  in  a  decidedly 
scrofulous  patient  should  if  pos  sible  be  avoided.    (Author's  Note  Book.) 


PNEUMONIA.  327 

to  be  applied  for  one  or  two  days,  followed  by  the  use  of  blisters 
of  moderate  size,  so  that  they  may  be  applied  successively  over 
various  parts  of  the  dull  region.  The  parts  may  be  dressed  with 
mild  mercurial  ointment,  and  at  the  same  time  we  may  give 
small  doses  of  a  mercurial  with  Dover's  powders,  so  as  to 
produce  a  slight  degree  of  action,  which  if  it  can  be  kept  up 
conveniently  for  a  few  days  will  often  have  the  best  effect. 

Should  the  dulness  remain  obstinate,  or  be  only  partially 
removed,  the  use  of  iodine  internally  and  externally  is  to  be 
adopted ;  five  grains  of  the  iodide  of  potassium  may  be  given 
three  times  daily,  and  the  side  is  to  be  brushed  over  with  the 
tincture  of  iodine,  by  means  of  a  broad,  flat  camel's-hair  brush. 
This  is  to  be  repeated  every  day,  or  second,  or  third  day  accord- 
ing as  it  is  borne  by  the  patient. 

Great  attention  must  be  paid  to  position  in  this  case,  and  the 
patient  must  be  encouraged  to  avoid  lying  on  the  affected  side.  I 
have  reason  to  think  that,  where,  as  is  often  the  case,  the  solidity 
occupies  the  posterior  portions,  while  the  anterior  remains  free, 
that  advantage  would  be  derived  by  making  the  patient  lie  on 
his  face  for  such  periods  of  time  as  he  could  bear  without  incon- 
venience. 

The  seton  has  been  recommended  in  this  condition.  I  have 
not  used  it  for  many  years.  It  is  a  cruel  and  disgusting 
remedy,  and  one  the  efficacy  of  which  appears  very  doubtful. 
It  may  perhaps  be  more  applicable  in  this  condition  than  in 
phthisis,  in  which  its  employment  is  altogether  to  be  repre- 
hended. 

The  general  health  of  the  patient  should  be  carefully  attended 
to.  He  should  be  placed  in  pure  air,  and  be  allowed  to  take 
passive  exercise  out  of  doors.  His  diet  should  be  sufficiently 
nourishing,  and  a  moderate  quantity  of  wine  may  be  given  if  it 
does  not  excite  the  circulation. 

TREATMENT  OF  THE  FOUETH  AND  FIFTH  STAGES  OF  PNEUMONIA. 

We  have  had  a  considerable  number  of  examples  of  perfect 
recovery  after  the  extreme  interstitial  suppuration  of  the  lung,  or 
at  least  after  the  co-existence  of  the  proper  symptoms  and  signs 
of  this  condition.  And  the  treatment  has  not  been  different 
from  that  of  the  earlier  stages,  with  this  exception,  of  course, 


328  PNEUMONIA. 

that  general  bleeding  was  not  performed.  If  the  subject  be  of  a 
good  constitution,  and  if  signs  of  spreading  inflammation  are 
discoverable,  either  in  the  first  affected  or  in  the  opposite  lung, 
he  will  derive  great  advantage  from  cupping,  with  the  scarifi- 
cator, or  from  dry  cupping,  and  above  all  from  decided  blistering 
and  poultices  ;  mercury  should  be  employed  both  internally  and 
externally,  alternating  with  the  exhibition  of  carbonate  of 
ammonia,  in  doses  of  from  two  to  three  grains  ;  and  the  strength 
of  the  patient  may  be  supported  by  wine,  brandy,  and  broths. 

We  must  not  despair  of  our  patient,  or  refrain  from  the  use  of 
decided  measures,  because  we  find  that  interstitial  suppuration 
has  occurred.  The  only  difference  in  the  treatment  being, 
that  much  greater  attention  must  be  paid  to  supporting  the 
powers  of  life,  and  that  in  many  cases  we  should  use  stimulants 
freely. 

In  many  cases  resolution  will  be  rapid  and  complete  after  this 
treatment,  in  others  a  bronchial  flux  remains.  We  may  then 
make  use  of  the  decoctions  of  bark,  myrrh,  and  polygalse,  and 
the  addition,  to  each  of  these  remedies,  of  the  carbonate  of 
ammonia,  and  the  camphorated  tincture  of  opium  will  generally 
be  found  to  answer  well. 

As  might  be  expected  from  its  efficacy  in  cases  of  muco- 
purulent discharge  from  the  bronchi,  the  spirit  of  turpentine 
is  a  valuable  remedy  in  interstitial  suppuration,  particularly  in 
cases  in  which  the  patient  has  been  previously  treated  by 
mercury. 

In  the  treatment  of  abscess  of  the  lung,  to  allay  cough,  and  to 
support  the  patient's  strength  by  tonics  and  pure  air,  are  the 
chief  indications.  The  various  preparations  of  bark  with  the 
mineral  acids  are  useful,  and  when  the  discharge  becomes  foetid, 
we  may  give  the  chlorides  of  lime  and  soda  in  combination  with 
opium.* 

But  it  is  to  be  remembered  that  in  some  of  these  cases,  as  in 
those  recorded  by  Dr.  Graves,  recovery  took  place,  although  no 
treatment  of  a  special  nature  had  been  adopted.  In  others 
which  I  have  witnessed  the  treatment  was  either  purely  pallia- 
tive or  mildly  tonic.     In  young  persons  it  appears  very  probable 

*  It  is  scarcely  recessary  t~>  remark  on  the  superior  efficacy  of  the  sulphocarbolates 
of  lime  and  soda,  first  suggested  by  Dr.  Sansom  ;  especially  when  conjoined  with  the 
inhalation  of  the  vapour  of  carbolate  of  iodine,  or  of  oil  of  turpentine  as  recommended 
by  Skoda.     (Fd.) 


PNEUMONIA.  329 

that  the  efforts  of  nature  alone  are  sufficient  to  bring  about  a 
cure ;  while  in  adults  or  elderly  persons,  particularly  if  the 
patient  has  been  a  free  liver,  great  attention  must  be  paid  to 
supporting  the  strength,  and  in  some  cases  wine  may  be  liberally 
employed. 

TREATMENT  OF  TYPHOID  PNEUMONIA. 

From  what  has  been  said  it  will  be  unnecessary  to  dwell  long 
on  this  part  of  the  subject;  for  the  principles  which  should 
guide  us  must  be  evident  to  every  practical  man.  I  believe  that 
it  will  be  hardly  even  necessary  to  perform  venesection  in  this 
disease,  and  I  am  satisfied  that  in  most  cases  the  practice  is  full 
of  danger ;  at  the  same  time,  I  should  state  that  I  have  myself 
used  bleeding  cautiously,  and  have  known  instances  where  it  has 
been  employed  by  others  with  greater  boldness,  and  where  a 
recovery  has  followed,  but  for  many  years  I  have  avoided  the 
practice,  which  appears  to  me  to  be  almost  always  unnecessary, 
and  often  distinctly  injurious. 

We  may  employ  local  bleeding  in  conjunction  with  stimulants, 
the  use  of  the  latter  being  particularly  indicated  when  there  is 
prostration  with  a  weak  heart  and  typhoid  expression.  In  many 
cases  we  need  not  draw  blood  at  all,  but  may  trust  to  dry  . 
cupping  followed  by  counter-irritation  and  poulticing.  These 
measures,  with  the  use  of  mercurials,  ammonia,  and  the  diffusible 
stimuli,  will  effect  a  cure,  and  the  rapidity  of  the  resolution  will 
in  general  be  proportioned  to  the  degree  in  which  we  have  , 
economised  the  vital  forces  of  the  patient. 

To  conclude — the  greatest  practical  improvement  which 
modern  medicine  owes  to  clinical  study,  is  our  disuse  of  the 
lancet  in  a  vast  number  of  cases,  not  only  of  pneumonia  but  of 
other  diseases,  local  and  general ;  or  at  least  our  ceasing  to 
regard  its  employment  as  a  matter  of  course  in  diseases  of  an 
inflammatory  nature ;  the  day  of  prescribing  for  names  has 
gone  by,  and  a  more  philosophical  method  of  considering  and 
treating  disease  has  succeeded.  "We  have  returned  to  the  old 
system  of  husbanding  the  strength  of  the  patient,  and  of  con- 
sidering the  general,  as  much  at  least,  as  the  local  condition. 
We  have  learned  that  stimulants  are  often  the  best  antiphlo- 
gistics,    as    is    exemplified   in   the    subsidence    of  many  active 


•h 


330  PNEUMONIA. 

inflammations  arising  in  a  depressed  state  of  the  system,  when 
treated  by  wine,  brandy,  and  ammonia,  while  the  spontaneous 
recovery  of  many  cases  has  led  us  to  be  more  cautious  in 
attaching  too  great  a  value  to  particular  modes  of  treatment. 

There  is  a  circumstance  connected  with  the  use  of  mercury  in 
typhoid  pneumonia  which  it  is  important  to  notice  as  it  bears 
not  only  on  the  modus  operandi  of  mercury,  but  is  of  great 
value  in  prognosis.  I  allude  to  the  repeated  appearance  in  the 
course  of  the  case  of  abortive  attempts  at  mercurial  action.  A 
patient  who  has  been  using  calomel,  say  from  twenty-four  to 
thirty-six  hours,  will  have  slight  sponginess  of  the  gums,  and 
mercurial  foetor  of  the  breath  promising  a  full  and  as  is  gene- 
rally hoped,  a  sanatory  mercurial  action,  yet  in  a  short  time, 
sometimes  within  three  or  four  hours,  all  these  signs  will  dis- 
appear, although  the  use  of  the  medicine  has  been  continued  in 
the  meantime  ;  two,  three,  or  four  of  these  attempts  at  salivation 
will  occur  in  the  course  of  the  case,  and  nothing  can  be  more 
remarkable  than  the  sudden  disappearance  of  every  symptom  of 
mercurial  action.  In  some  cases  this  was  accompanied  by  a 
distinct  exacerbation  of  the  disease,  but  we  cannot  say  that  this 
was  observed  in  every  instance. 

With  regard  to  prognosis,  we  attach  great  importance  to  this 
symptom,  for,  with  a  very  few  exceptions,  the  cases  which  pre- 
sented it  proved  fatal.  It  is  yet  to  be  determined  whether  this 
arises  from  some  intensity  in  the  original  local  disease,  or  from 
the  springing  up  of  new  inflammations. 

I  have  not  yet  made  any  researches  with  the  view  of  deter- 
mining what  the  actual  condition  of  the  heart  is  in  this  disease, 
and  whether  the  rules,  as  to  the  use  of  stimulants,  drawn  from 
its  state  in  typhus  fever,  will  be  found  to  apply  in  typhoid 
pneumonia.  But  in  a  great  number  of  instances,  the  heart's 
action  is  certainly  weakened,  and  it  is  almost  certain  that  the 
recognition  of  this  state,  by  the  same  means  which  we  employ 
in  typhus  fever,  will  greatly  assist  us  in  determining  on  the  use 
of  stimulants,  and  the  period  when  they  should  be  had  recourse 
to.  If  the  impulse  be  greatly  diminished  or  absent,  if  the  first 
sound  be  lessened,  and  above  all  if  we  find  these  changes  pro- 
gressive, I  apprehend  that  there  should  be  no  question  as  to  the 
free  and  decided  use  of  stimulants. 

It  will  probably  be  found  that  the  cases  with  copious  bronchial 


PNEUMONIA.  331 

flux  will  more  especially  require  stimulants  than  those  without 
this  condition.* 

I  have  no  experience  in  the  treatment  by  large  doses  of 
quinine  as  recommended  by  Dr.  Corrigan.  I  must  therefore 
refer  the  reader  to  his  paper  on  this  subject  in  the  Dublin 
Hospital  Gazette.f 

*  On  this  subject  the  following  conclusions  of  Juergensen  deserve  consideration: — 
"  The  danger  in  croupous  pneumonia  threatens  principally  the  heart  of  the  patient. 
Death  results  from  insufficiency  of  the  heart. 
".And  now  for  the  proof  of  this  opinion. 

"  I.  The  exudation  in  pneumonia  produces  an  increased  resistance  in  the  pulmo- 
nary circulation,  and  consequently  increased  effort  on  the  part  of  the  right  ventricle. 

"  II.  The  changes  produced  in  and  near  the  lung  by  pneumonia  diminish  the  total 
amount  of  force  to  be  furnished  by  this  organ  for  the  movement  of  the  blood. 

"  III.  In  pneumonia  the  surface  over  which  blood  and  air  come  in  contact 
with  each  other  is  diminished  by  the  exudation,  and  this  fact  necessitates  increased 
labour  on  the  part  of  the  forces  which  impel  the  blood  and  air  whenever  an  abundant 
exchange  of  gases  is  required. 

"  IV.  The  fever  first  brings  to  expression  the  local  disturbances  produced  by  the 
pneumonia. 

"  V.  The  fever  induces  increased  labour  on  the  part  of  the  heart,  and  at  the  same 
time  inflicts  a  direct  injury  upon  it. 

"  From  all  sides  the  threads  run  together  to  a  central  point.    It  is  the  heart,  and     4— 
always  the  heart,  upon  which  the  burden  is  ultimately  thrown.     It  is,  therefore,  the 
duty  of  the  physician  to  enable  the  heart  during  pneumonia  to  perform  the  additional 
labour  made  necessary  by  the  disease  ;  this  duty  involves  two  sub-divisions — 
"  1.  Prophylaxis  against  exhaustion  of  the  heart. 
"  2.  Control  of  already  existing  exhaustion. 

"  The  fever  is  the  first  point  of  attack  for  treatment,"  &c.  (Ziemssen's  Cyclopedia, 
vol.  v.  pp.  153—156.) 

This  treatment,  according  to  Juergensen,  should  consist  in  the  cold  bath,  the  exhibi-    J_ 
tion  of  stimulants,  and  of  quinine,  which  he  gives  in  doses  ranging  from  thirty  to 
seventy-seven  grains  every  second  evening.     (Ed.) 

■f  The  following  strong  testimony  to  the  efficacy  of  this  mode  of  treatment  is  given 
by  Dr.  Gordon  : — "  Perhaps  one  of  the  best  marked  features  of  this  disease  is  its 
not  being  amenable  to  any  of  the  usual  modes  of  treatment ;  I  need  not  here  allude 
to  the  more  than  inefficacy  of  abstraction  of  blood  in  any  form  to  meet  its  require- 
ments. The  treatment  by  tartar-emetic  is  equally  inapplicable  ;  and  the  mercurial 
plan  of  treatment,  as  it  is  termed,  is  also  powerless  to  control  this  formidable  affec- 
tion. The  treatment  by  the  internal  use  of  oil  of  turpentine,  so  advantageous  in 
the  suppurative  stage  of  vesicular  pneumonia,  does  not  appear  to  have  any  influence 
on  this  form  of  disease.  Wine  and  the  usual  diffusible  stimulants  support  the 
patient's  strength  and  add  to  his  vital  energy,  and  so  are  of  use,  but  they  seem  to 
have  no  specific  power  over  the  disease,  such  as  is  evidently  exercised  by  the  sulphate 
of  quina.  During  the  last  eight  months  I  have  treated  with  quina  all  the  cases  of 
this  form  of  pneumonia  which  I  have  witnessed,  and  I  have  had  the  opportunity  of 
observing  several  cases  similarly  treated  by  Dr.  Corrigan  in  the  Hardwicke  Hospital. 
The  result  of  this  treatment  has  been  that  of  the  cases  which  came  under  observation 
before  effusion  had  taken  place  into  the  bronchial  tubes,  none  proved  fatal ;  while 
some  few  recovered,  even  after  the  lips  had  become  blue,  the  face  congested,  and 
mucous  rales  were  audible  in  the  bronchial  tubes." — On  Pneumonia,  Dublin  Quarterly 
Journal,  vol.  xxii.    (Ed.) 


332  PNEUMONIA. 


CHRONIC    PNEUMONIA. 


Considered  as  an  original  affection,  there  can  be  no  doubt  that 
simple  chronic  pneumonia  is  a  rare  disease ;  but  it  is  difficult  to 
define  the  exact  meaning  of  the  term  chronic  pneumonia,  or  to 
draw  the  line  of  distinction  between  it  and  that  low  irritation 
of  the  lung  which  is  followed  by  the  tubercular  infiltration.  It 
seems  not  unlikely  that  there  are  two  forms  of  the  disease,  the 
one  producing  the  iron-grey  and  indurated  lung,  and  the  other 
forming,  or  ultimately  passing  into,  tubercular  solidity. 

These  forms  of  disease  differ  remarkably  in  their  liability  to 
produce  suppuration.  In  the  scrofulous  affection,  suppuration, 
though  slow  in  its  occurrence,  is  almost  sure  to  supervene ; 
while  in  the  simple  form,  abscess  is  seldom  observed,  the  ter- 
mination being  in  that  hard  and  semi-cartilaginous  condition, 
the  "  induration  gris"  of  Andral. 

The  existence  of  this  disease  is  inferred  much  more  from  the 
appearance  of  certain  pathological  conditions  than  from  any 
observation  of  proper  symptoms.  Portions  of  the  lung  more 
or  less  extensive  are  found  indurated,  nearly  impermeable  to  air, 
and  of  an  iron-grey  colour.  This  condition  may  be  the  sole  patho- 
logic state,  or  exist  in  connexion  with  tubercle  or  other  diseases. 
Hasse  remarks  that  grey  induration  "  is  mostly  associated  with 
the  development  of  tubercle ;  and  in  the  few  marked  instances 
which  came  in  my  way,  I  was  unable  to  draw  the  precise  limits 
between  pneumonic  induration  and  grey  tubercular  infiltration. 
The  former  was  distinctly  recognizable  in  the  lower  half  of  the 
lung,  the  latter  in  the  upper  half;  at  the  apex  were  several  small 
cavities,  precisely  resembling  those  of  tubercular  phthisis.  There 
were  at  the  same  time  traces  of  the  tubercular  constitution  in 
other  organs.  The  transitions  and  combinations  of  the  two 
diseases  are  probably  numerous,  whilst  chronic  pneumonia  is 
sufficiently  rare  to  render  the  discrimination  in  a  given  case 
a  difficult  task." 

But  there  seems  to  be  little  •  analogy  between  this  state  of 
parts  and  that  in  pneumonia  properly  so  called,  which  is  essen- 
tially a  condition  of  change  and  of  activity,  advancing  towards 
suppuration  or  gangrene  on  the  one  hand,  or  resolution  on  the 
other.  It  is  possible,  however,  that  some  of  these  indurations 
owe  their  origin  to  unresolved  hepatizations,  and  that  softening 


PNEUMONIA.  833 

has  changed  into  a  grey  induration  ;  but  it  appears  probable  that 
this  change  having  occurred,  thei-e  is  a  suspension  of  further 
morbid  action  in  the  part,  and  the  disease  in  such  case  is  less 
chronic  pneumonia  than  a  particular  change  of  a  hepatization, 
which  was  essentially  the  result  of  acute  disease. 

Perhaps  no  better  definition  of  this  affection  could  be  given 
than  that  of  Dr.  Walshe :  "I  mean,"  he  says,  "by  chronic 
pneumonia  that  form  of  disease  in  which  an  impermeable  tissue 
is  infiltrated  with  toughly  solid  exudation  (in  the  state  of  indura- 
tion matter),  and  where  there  is  no  tendency  to  a  softening  pro- 
cess; these  are  its  main  characters." 

The  symptoms  of  this  form  of  disease  are  seldom  marked  or 
determinate ;  dyspnoea  is  not  usually  urgent,  cough  and  expec- 
toration are  variable  in  frequency,  quantity,  and  quality,  the 
latter  seldom  resembling  that  of  the  acute  primary  disease. 
There  is  occasionally  slight  haemoptysis.  The  fever  is  irregular 
in  its  type,  but  the  emaciation  is,  it  may  be  said,  a  constant  and 
progressive  symptom,  which,  with  the  physical  signs,  renders 
the  diagnosis  from  phthisis  a  task  of  difficulty,  more  especially 
when  the  upper  lobe  is  the  seat  of  disease. 

The  physical  signs  may  be  briefly  stated  to  be,  depression 
of  the  side,  marked  dulness  with  resistance,  weak  respiratory 
murmur,  with  more  or  less  of  a  bronchial  character,  occasional 
sub-crepitus  and  muco-crepitus,  sibilant  and  sonorous  rale. 

The  treatment  may  be  briefly  stated  to  be  that  adopted  for 
unresolved  hepatization,  as  already  described. 


APPENDIX   TO    ABOVE    CHAPTEK. 
Note  A. 

No  portion  of  Dr.  Stokes'  work  has  elicited  such  a  variety  of 
opinion  from  subsequent  writers  as  this. 

Eokitansky  thus  expresses  his  disbelief:  "  There  is  no  other 
and  earlier  stage  than  that  which  we  have  described  as  the  stage 
of  stasis,  for  the  condition  described  as  such  by  Stokes  is  in  no 
respect  inflammatory.  The  bright  red  colour  of  the  lungs  or  of 
portions  of  them  which  Stokes  regards  as  the  earliest  stage  of 


331  PNEUMONIA. 

inflammation  and  attributes  to  arterial  injection  is  dependent  on 
anaemia  which  is  frequently  very  highly  developed,"  &c* 

Skoda  adopting  Rokitansky's  view  says :  "  It  is  certainly  true 
that  loud  vesicular  respiration  occasionally  precedes  the  crepi- 
tating rale ;  but  this  is  no  reason  for  setting  up  an  especial 
first  stage  of  pneumonia,  this  symptom  being  even  less  constant 
than  crepitating  rale." 

On  the  other  hand,  Dr.  Walshe  says  :  "  My  opinion  coincides 
with  that  held  by  Dr.  Stokes.  The  vivid  arterial  tint  in  ques- 
tion is  seen  to  perfection  in  rapidly  fatal  cases  of  acute  miliary 
tuberculization,  in  persons  presenting  none  of  the  acknowledged 
characters  of  anaemia,  but  many  of  those  of  pulmonic  irritation. 
Besides  it  may  exist  in  one  lung  and  be  absent  in  the  other 
—a  fact  which  seems  to  me,  even  taken  alone,  to  settle  the 
question.     Its  characters  are  essentially  those  of  acute  active 

congestion."  t 

Dr.  Addison  expresses  his  assent,  having  recently  met  with  a 

case  in  which  for  other  reasons  he  anticipated  pneumonia — which 
afterwards  took  place — and  in  which  this  excited  state  of  the 
respiration  and  a  loud  but  rough  respiratory  murmur  in  the  lung 
about  to  be  affected  were  strongly  marked.  "  Further  observa- 
tion," he  adds,  "  is  still  required  to  establish  Dr.  Stokes'  position 
fully  and  satisfactorily." 

Dr.  Wilson  Fox  admits  that  "there  is  reason  to  believe  in 
the  probability  that  such  a  state  may  precede  the  subsequent 
changes  of  the  inflammatory  period,  and  the  auscultatory  signs 
of  harsh  respiration  which  have  been  described  by  Dr.  Stokes 
as  attending  it  have  been  recognized  by  many  and  different 
authors."  £ 

Dr.  Waters  says :  "Of  the  earliest  morbid  conditions  I  agree 
with  the  conclusions  arrived  at  by  Dr.  Stokes,  that  there  is  a 
stage  prior  to  that  of  engorgement  characterized  by  dryness, 
intense  arterial  injection,  and  consequently  a  bright  vermilion 
colour  of  the  pulmonary  membrane.  In  proof  of  the  probability 
of  this  condition  I  must  appeal  to  the  facts  furnished  by  auscul- 
tation, namely  the  existence  of  a  harsh  puerile  respiratory 
murmur  preceding  the  crepitating  rale." 

*  Pathological  Anatomy,  vol.  iv.  p.  75.    Syd.  Soc.  Ed. 

f  Diseases  of  the  Lungs,  p.  346.    4th  Ed. 

X  Reynolds'  System  of  Medicine,  vol.  iii.  p.  GG2. 


PNEUMONIA.  335 

Dr.  Waters  gives  two  cases  in  which  he  observed  this  murmur 
and  offers  an  elaborate  explanation  of  its  production.* 

Grisolle  gives  the  following  qualified  assent  to  Dr.  Stokes' 
views  : — f 

"  D'apres  M.  Stokes  l'engouement  inflammatoire  que  je 
viens  de  decrire  ne  devrait  point  constituer  le  premier  degre  de 
la  pneumonie,  puisque  suivent  cet  auteur  il  serait  consecutif  a 
une  autre  alteration.  Le  Medecin  de  Dublin  donne  comme 
marquant  la  premiere  periode  du  travail  inflammatoire  des 
poumons  un  etat  de  secheresse  de  durete  du  tissu  avec  une  injec- 
tion arterielle  intense,  ce  qui  lui  donne  une  coloration  vermeille 
eclatante  sans  aucune  effusion  de  sang  dans  les  cellules.  M. 
Stokes  pretend  avoir  trouve  cet  etat  au  voisinage  des  pneumonies 
arrivees  au  premier  et  au  deuxieme  degre  il  convient  d'ailleurs 
qu'on  l'observe  rarement,  ou  qu'il  passe  inapercu  etant  masque 
facilement  par  les  congestions  cadaveriques.  CependantM.  Stokes 
ne  me  parait  pas  avon  demontre  d'une  maniere  rigourouse  que 
l'engoument  inflammatoire  fut  reelement  un  etat  consecutif; 
pour  moi,  je  n'ai  encore  rien  observe  qui  justifie  son  opinion ; 
je  sais  bien  qu'en  theorie  elle  parait  fondee  car  il  est  rationnel  de 
supposer  que  le  premier  degre  de  Laennec  caracterise  par  un 
etat  de  secretion  ou  d'exhalation  morbide  dans  les  vesicules  pul- 
monaires  a  du  etre  precede  d'une  periode  d'irritation  pendant 
laquelle  le  tissue  simplement  congestionne  presente  au  contraire 
plus  de  secheresse  que  d'habitude.  Nous  verrons  plus  tard  que 
cette  opinion  semble  aussi  justifiee  par  l'etat  symptomatique. 
Toutefois  nous  n'avons  encore  a  ce  sujet  aucune  douee  certaine 

Je  n'ai  jamais  observe  au  debut  de  la  pneumonie  et 

comme  premier  phenomene  stethoscopique  la  respiration  puerile 
que  M.  Stokes  dit  avoir  rencontree  chez  plusiers  de  ses  malades. 
Toutefois  j'admets  quelle  peut  exister  dans  quelques  cas  rares, 
puisque,  comme  je  le  dirai  plus  tard  j'ai  moi  meme  rencontre  ce 
phenomene  plusieurs  fois  dans  les  points  des  poumons  qui  furent 
envahis  consecutivement.  La  faiblesse  du  bruit  respiratoire  ou 
le  respiration  puerile,  apres  avoir  persiste  pendant  deux,  six, 
douze  ou  vingt-quatre  heures,  sont  generalement  remplacees  par 
d'autres  phenomenes  stethoscopiques  et  presque  toujours  par  le 
rale  crepitant." 

*  Diseases  of  the  Chest,  pp.  31—37.    2nd  Edition, 
f  Traite'  pratique  de  la  Pneumonie,  pp.  9  and  232. 


336  PNEUMONIA. 

It  appears  that  while  the  accuracy  of  Dr.  Stokes'  ohservation 
is  admitted  by  these  writers,  none  of  them  have  adopted  his 
classification,  or  changed  that  of  Laennec  by  the  addition  of  a 
fiftlTstage.     (Ed.) 

Note  B. 

It  is  generally  admitted  that  Dr.  Graves'  case  of  displacement 
of  the  heart,  in  a  young  gentleman,  was  a  true  example  of 
pneumatosis  in  the  pleural  cavity  occurring  in  the  course  of  pleuro- 
pneumonia, a  conclusion  abundantly  confirmed  by  cases  since 
recorded  by  Dr.  W.  S.  Little,  Dr.  Keller,  and  Dr.  Walshe  ;  but 
I  believe  that  his  other  case — referred  to  by  Dr.  Stokes  — was  not 
of  this  character,  but  was  an  example  of  the  tympanitic  or 
amphoric  resonance  on  percussion  over  a  solidified  lung,  which 
was  observed  in  cases  first  recorded  by  me,  and  subsequently 
by  Drs.  Banks,  Walshe,  and  Hay  den,  and  more  recently  by 
Juergensen. 

As  some  confusion  still  exists  among  authors  with  regard 
to  the  conditions  under  which  this  phenomenon  occurs,  and 
its  explanation,  it  may  not  be  amiss  to  give  a  short  sum- 
mary of  the  observations  hitherto  made,  and  of  the  explanations 
offered. 

The  first,  in  order  of  time,  were  my  own. 

Case  I. — M.  M.,  a  female,  admitted  with  pneumonia  of  left 
lung.  On  the  morning  of  the  fifth  day,  the  upper  portion  of  the 
side,  previously  dull  on  percussion,  presented  a  muffled  tym- 
panitic clearness,  while  the  lower  third  continued  quite  dull.  On 
my  again  visiting  her  at  10  p.m.,  the  entire  side,  to  the  base  of 
the  lung,  presented,  on  percussion,  a  clearness  not  at  all  inferior 
to  that  of  the  other  side,  but  of  a  tympanitic  character.  On  the 
sixth  and  last  day  it  was  noted  that  the  same  tympanitic  clear- 
ness existed  fully  to  as  great  a  degree  as  in  pneumothorax. 
Autopsy  showed  the  lung  to  be  universally  adherent  to  the 
costal  pleura  ;  heavy,  and  solid  throughout,  with  exception 
of  part  of  the  inferior  lobe,  which  was  engorged,  but  still 
crepitous* 

Case  II. — C.  S.,  admitted  on  the  tenth  day  of  pneumonia  of 
left  lung.  On  percussion,  the  sound  on  the  right  side  was  clear; 
the  left  gave  anteriorly  a  sound  exactly  like  that  produced  by 

*  Dublin  Medical  Journal,  1st  series,  toI.  vii. 


PNEUMONIA.  337 

percussing  over  the  stomach  or  csecum,  while  posteriorly  the  side 
was  dull  over  the  spine  and  dorsum  of  the  scapula. 

During  the  last  two  days  of  life  the  tympanitic  sound 
became  gradually  more  muffled  and  less  clear,  while  the  signs 
of  crepitation  and  tubular  breathing  extended  from  above 
downwards. 

Autopsy  showed  the  lung  adherent  by  recently-formed  lymph, 
the  superior  lobe  solid  and  heavy,  presenting  a  marbled  appear- 
ance on  the  surface,  and  on  section,  grey,  softened,  granular,  and 
oozing  from  its  cut  surface  a  large  quantity  of  thin  grey  fluid. 
The  lower  lobe  much  engorged. 

Case  III. — A  young  woman  was  admitted  into  hospital  on  the 
sixth  day  of  pneumonia  of  the  upper  portion  of  the  right  lung 
and  a  small  portion  of  the  inferior  lobe  of  the  left.  She  appeared 
to  be  dying,  but  survived  for  two  days.  On  the  second  day  after 
admission,  the  right  side,  previously  quite  dull,  on  percussion, 
yielded  a  remarkably  clear  sound  of  a  tympanitic  character.  On 
autopsy  the  right  lung  was  found  to  be  adherent  to  the  costal 
pleura,  and  solid  throughout,  the  red  passing  in  spots  into  grey 
hepatization.* 

Some  years  after  the  occurrence  of  the  last  case,  I  was  called 
to  see,  in  consultation,  a  gentleman  in  whom  the  latency  of  the 
pulmonary  symptoms  with  the  highly  marked  icteroid  tinge  of 
the  surface  (so  well  described  and  explained  by  Hasse),  had  led 
his  medical  attendant  to  diagnose  hepatitis,  and  to  treat  the 
patient  accordingly.  I  was  of  opinion  that  the  entire  of  the 
right  lung  was  in  a  state  of  hepatization,  as  the  side  yielded,  on 
percussion,  a  sound  clearer  than  that  of  the  left  side,  but  of  a 
highly  tympanitic  character  ;  while,  on  auscultation,  no  inspi- 
ratory murmur  or  crepitus  was  audible.  As  my  friend  doubted 
the  correctness  of  my  diagnosis,  I  appealed  for  its  confirmation 
to  the  future  progress  of  the  case,  anticipating,  from  my  expe- 
rience of  similar  cases,  that  on  the  commencement  of  resolution 
the  side  would  become  as  dull  as  it  was  then  morbidly  clear. 
This  anticipation  was  realized  ;  at  our  next  meeting  the  entire 
side  was  dull  on  percussion,  while  the  stethoscopic  signs  of 
resolution  were  present,  and  my  friend  acknowledged  the  value  of 
a  sign  which  he  had  not  previously  thought  worthy  of  attention, 
but  which  he  afterwards  recognized  in  other  instances. 
*  Dublin  Medical  Journal,  1st  series,  vol.  xi. 
Z 


338  PNEUMONIA. 

In  1838,  Dr.  Williams,  in  his  "  Lectures  on  the  Physiology 
and  Diseases  of  the  Chest,"  London  Medical  Gazette,  March  31st, 
thus  alluded  to  the  phenomenon  : — "It  is  a  kind  of  tympanitic 
sound,  and  as  in  one  of  these  cases  there  was  also  a  sort  of 
amphoric  respiration  heard  in  this  spot,  I  concluded  the  case  to 
be  one  of  pneumothorax,  from  the  perforation  of  the  lung.  This 
patient,  whom  I  saw  with  my  friend,  Dr.  Roscoe,  surprised  me 
by  soon  getting  well,  and  losing  all  these  signs,  which  made  me 
reflect  more  on  the  matter ;  and  having  since  met  with  a  similar 
case,  which  proved  fatal,  I  have  satisfied  myself  as  to  the  cause 
of  the  phenomenon.  Dr.  Hudson,  of  Dublin,  has  also  recently 
described  cases  in  which  a  loud  tympanitic  sound  on  percussion 
was  presented  in  the  upper  part  of  the  chest  of  a  patient  affected 
with  pneumonia.  Now,  you  will  understand  how  this  sound  is 
produced,  if  you  listen  to  this  tracheal  sound,  which  I  got  by 
filliping  on  my  windpipe  above  the  sternum.  The  windpipe  also 
lies  under  the  sternum,  and  it  divides  into  the  two  great  bronchi, 
which  spread  between  one  and  two  inches  below  the  clavicles. 
Here,  however,  the  porous  lung  lies  over  these  tubes,  and  inter- 
cepts their  resonance  on  percussion  ;  but  let  this  portion  of  lung 
be  perfectly  condensed  by  a  liquid  effusion,  or  perfectly  con- 
solidated by  hepatization,  and  you  will  then  get  the  bottle-note 
of  the  tubes,  just  as  you  do  of  the  windpipe  where  no  lung  inter- 
venes. The  reason  why  this  phenomenon  does  not  occur  more 
frequently  is,  that  it  does  not  often  happen  that  the  compression 
of  solidification  of  the  upper  lobe  is  complete  enough ;  but,  since 
my  attention  has  been  drawn  to  it,  I  have  met  with  several  cases 
of  both  pleurisy  and  pneumonia,  in  which  it  existed  in  smaller 
degree  ;  and  I  had  occasion  to  notice  in  the  last  lecture  that  it 
sometimes  occurs  with  dilated  bronchi." 

Dr.  Stokes  regarded  tympanitic  resonance  in  pneumonia  as 
impossible,  and  inconsistent  with  the  received  doctrine  of  per- 
cussion, unless  when  caused  by  pneumothorax,  or  by  transmission 
of  the  sound  of  a  distended  stomach. 

On  these  causes,  Dr.  Walshe  remarks  (having  previously  stated 
that  he  had  observed  two  positive  examples  of  temporary  tym- 
panitic note  over  pneumonic  consolidation  at  the  right  base)  : — 
"  True  tympanitic  resonance  is  excessively  rare  over  pneumonic 
consolidation,  and  I  have  scarcely  ever  observed  it  at  the  upper 
part  of  the  chest,  where  pleural  fluid  had  accumulated  below. 


PNEUMONIA.  339 

When  such  resonance  occurs  at  the  base  of  the  chest,  great 
distention  of  the  stomach  or  colon  might  be  suggested  in  expla- 
nation ;  but,  in  point  of  fact,  the  stomach  and  colon  are  rarely- 
distended  enough  for  the  conversion  of  their  common  amphoric 
into  tympanitic  quality ;  and  in  the  only  two  positive  instances 
I  have  observed  of  pneumonic  tympanitic  sound,  the  consolidation 
was  on  the  right  side  above  the  liver.  I  am  satisfied  the 
phenomenon  does  not  depend  on  temporary  secretion  of  air  by  the 
pleural  sac."* 

Skoda  appears  to  regard  the  phenomena  as  due  entirely  to 
diminished  quantity  of  air  in  the  lung.  He  says :  "  The  sound 
is,  moreover,  in  many  cases  remarkably  tympanitic,  even  when 
the  diminution  of  the  quantity  of  air  in  the  lung  is  the  effect  of 
an  increase  in  its  fluid  or  solid  constituents ;  and  this,  too, 
whether  the  lung  retains  its  normal  volume  or  becomes  larger 
than  natural.  When  the  lung  is  much  reduced  in  volume 
by  compression,  but  still  contains  air,  its  sound  is  invariably 
tympanitic. "f  Skoda,  however,  as  Dr.  Walshe  remarks,  no- 
where defines  the  meaning  of  the  term  tympanitic,  as  used  by 
him. 

In  March,  1853,  Dr.  Banks  presented  to  the  Pathological 
Society  of  Dublin  a  case  of  pneumonia,  in  which  this  phenomenon, 
was  observed.  In  the  report  it  is  stated  that  on  the  second  day 
after  the  patient's  admission  into  hospital,  the  whole  of  the 
anterior-superior  portion  of  the  side,  previously  dull  on  percussion, 
presented  a  remarkably  tympanitic  resonance,  best  heard  by  a 
light,  smart  percussion.  The  sign  continued  up  to  the  death  of 
the  patient,  on  the  fourth  evening  after  admission. 

"  On  opening  the  chest,"  says  Dr.  Banks,  "I  found  that  the 
right  lung  had  been  the  seat  of  universal  solidification.  It  oc- 
cupied a  very  great  extent  of  the  chest ;  it  crossed  the  mesial 
line,  covered  the  heart,  and  overlapped  a  portion  of  the  opposite 
lung ;  it  was  solid  from  its  apex  to  its  base,  with  the  exception 
of  the  lower  edge  of  the  inferior  lobe,  which  was  emphysema- 
tous. There  was  no  purulent  infiltration.  The  left  lung  was 
healthy." 

Dr.  Walshe  mentions  a  case  of  acute  tuberculization  and  con- 
solidation, in  which  amphoric  resonance  was  observed  over  a  solid 

*  On  Diseases  of  the  Lung?,  p.  73. 
f  Translation  by  Mark'iam,  p.  13. 

z2 


340  PNEUMONIA. 

portion  lying  over  the  main  bronchial  tube,  forty-eight  hours 
before  death,  but  not  at  the  autopsy.* 

A  most  important  contribution  to  this  subject  is  the  paper 
"  On  Typhoid  Pneumonia  associated  with  Muffled  Tympanitic 
Kesonance,"  by  Dr.  Hayden.f 

In  the  case  of  James  Osborne,  on  the  sixth  day  after  admission, 
the  report  states,  that  "  from  base  of  thorax  to  right  nipple  there 
is  complete  dulness,  with  crepitus ;  from  nipple  to  clavicle  the 
percussion  is  of  a  mixed  and  very  singular  character — it  is  that 
of  dulness,  qualified  by  a  metallic  resonance,  and  communicates 
the  sensation  of  a  solid,  but  resonant,  body  under  percussion. 
Over  the  region  which  presents  this  remarkable  modification  of 
dulness,  respiration  is  bronchial,  accompanied  by  crepitus  on  full 
inspiration. 

On  the  teuth  day  the  right  side  was  observed  to  be  more  pro- 
minent in  front  than  the  left,  with  less  respiratory  movement ; 
and  over  the  anterior  surface,  and  extending  slightly  to  the  left 
of  the  mesial  line,  the  percussion  sound  was  tympanitic,  and  of 
a  somewhat  metallic  character.  Over  entire  posterior  right  side 
percussion  was  perfectly  dull,  with  fine  crepitus,  over  resonant 
region ;  in  front  respiration  is  bronchial,  as  it  has  been  for  the 
last  three  days. 

The  patient  died  on  the  eleventh  morning,  and  the  following 
is  a  summary  of  the  observations  made  on  autopsy,  three  hours 
after : — 

1st.  The  right  side  was  remarkably  prominent,  and  still  yielded 
tympanitic  resonance,  but  a  shade  less  marked  than  before 
•death. 

2nd.  The  body  being  immersed  in  water,  face  upwards,  and 
the  right  side  punctured,  the  pleura  was  found  to  be  adherent, 
and  no  air  escaped,  until  after  separation  of  its  surfaces  the  lung 
was  punctured,  when  bubbles  of  air  freely  escaped. 

3rd.  The  chest  being  laid  open  in  the  usual  manner,  the  right 
lung  was  fully  distended,  so  as  to  keep  that  side  of  the  chest  in 
a  state  of  maximum  distention  ;  its  colour  was  dark  grey,  and  its 
anterior  edge  was  thickened,  and  overlapped  the  pericardium. 
The  superior  and  middle  lobes  yielded  on  percussion  a  somewhat 
muffled  metallic  ring.     The  percussion  note  of  the  same  portion 

*  On  Diseases  of  the  Lungs,  p.  75. 
f  Dublin  Quarterly  Journal,  vol.  xli. 


PNEUMONIA.  341 

was  similar  when  the  lung  was  removed  from  the  body,  while 
percussion  of  the  inferior  lobe  yielded  a  perfectly  dull  sound. 

On  section,  the  cut  surface  was  light-grey  in  colour,  somewhat 
darker  at  the  base ;  no  fluid  escaped  from  it,  but,  on  pressure 
with  the  flat  surface  of  the  knife,  thin  purulent  matter  streamed 
out.     Placed  in  water,  the  lung  sunk  at  once. 

Dr.  Hayden  gives  two  other  cases  of  typhoid  pneumonia,  in 
one  of  which,  the  upper  lobe  of  the  left  being  engaged,  this 
phenomenon  was  observed,  while  in  the  other,  the  upper  portion 
of  the  right  being  engaged,  it  was  entirely  absent. 

The  conclusions  (says  Dr.  Hayden)  deducible  from  these  cases, 
as  regards  the  phenomenon  of  muffled  tympanitic  resonance,  are 
both  negative  and  positive. 

NEGATIVE. 

1st.  The  phenomenon  is  not  due  to  transmitted  resonance 
from  a  healthy  through  a  solidified  portion  of  lung  substance. 
(a.)  Because  in  Case  No.  II.,  in  which  it  was  best  pronounced, 

the  entire  lung  was  solid. 
(b.)  Because  in  Case  No.  III.  it  did  not  exist,  although  the 

inferior  and  posterior  portion  of  the  lung  was  physically 

healthy. 
2nd.  It  was  not  the  result  of  gastric  resonance  transmitted 
through  a  solid  lung. 

(a.)  Because  it   existed  in   Case  No.   I.,   in  which  only  the 

superior  portion  of  the  left  lung  was  hepatized,  the  in- 
ferior lobe  being  in  a  healthy  condition. 
(b.)  Because  in  Case  No.  II.  it  existed  only  in  the  superior 

portion  of  the  right  lung,  notwithstanding  that  the  entire 

organ  was  solid ;  and  it  likewise  existed  in  the  isolated 

lung,  as  proved  by  post-mortem  test. 
3rd.  It  was  not  due  to  pneumothorax, 
(a.)  Because  in  Case  No.  II.  it  existed  up  to  death ;  and  after 

death,  lung  was  found  universally  adherent  to  chest,  and 

no  air  existed  in  the  pleura. 


POSITIVE. 


1st.  The  phenomenon  was  intrinsic  in  the  lung,  and  had  its 
seat  in  that  portion  of  the  organ  in  which  it  was  manifested. 


342  PNEUMONIA. 

(a.)  Because  percussion  of  the  lung  removed  from  the  body 
afforded  proof  of  its  existence  in  the  isolated  organ,  and 
even  in  a  thin  layer  of  it  resting  on  a  solid  body. 
(&.)  Because  percussion  showed  dulness  in  that  portion  of  the 
lung,  after  removal  from  the  body,  over  which   dulness 
existed  during  the  patient's  illness. 
2nd.  The  resonance  of  the  solidified  lung  was  associated  with 
the  presence  of  air  in  its  tissue. 

(a.)  Because  air  freely  escaped  from  an  opening  made  with  the 
finger,  under  water,  in  that  portion  of  the  lung  which 
yielded  tympanitic  resonance. 
3rd.  Simple  pneumothorax,  whether  pneumonic  or  pleuritic,  is 
characterized  by  absence  of  respiratory  sound,  co-extensive  with 
tympanitic  resonance,  and  by  displacement   of  the  heart  if  the 
aeriform  effusion  be  abundant,  as  in  the  cases  of  Graves  and  Little. 
4th.  The  resonant  or  tympanitic  dulness  of  pneumonia,  due  to 
air  implicated  in  the  tissue  of  the  lung,  is  distinguished  from 
pneumothorax  by  the  qualified  or  muffled  character  of  the  reso- 
nance, and  by  the  presence  of  bronchial  respiration  and  of  crepitus, 
as  in  Dr.  Hudson's  cases  and  in  mine.'" 

Of  more  recent  writers  on  pneumonia,  Niemeyer  follows  Skoda. 
Waters  does  not  allude  to  the  phenomenon.  Sturges  mentions  it 
as  one  of  the  occasional  misleading  abnormalities  of  the  stage  of 
solidification  still  awaiting  explanation,  when  "  the  solid  lung, 
instead  of  yielding  to  percussion  the  usual  dull  wooden  note, 
gives  a  resonance  which  suggests  the  neighbourhood  of  an  empty 

cavity Cavernous  respiration  will  often  concur  with  this 

metallic  note,  while  the  conclusions  to  which  such  signs  point 
may  be  yet  further  strengthened  by  the  existence  of  very  perfect 
pectoriloquy.  Whatever  may  be  the  true  explanation  of  these 
signs,  it  is  quite  certain  that  they  may  be  met  with  in  lung  that 
is  simply  consolidated."  * 

Lastly,  Juergensen  contributes  the  following  important  obser- 
vations! : — "  Baumler,  to  whom  we  are  indebted  for  a  very  read- 
able article  on  this  subject,  thinks  that  Williams's  tracheal  tone 
cannot  occur  in  infiltrations  of  the  lower  lobe.  This  is  contrary 
to  my  experience,  which  is  based  upon  two  cases,  one  of  which 
recovered,  and  the  other  proved  fatal." 

*  On  Pneumonia,  p.  49. 

f  Art.  Pneumonia,  Ziemssen's  Cyclopedia,  vol.  v.  p.  79. 


PNEUMONIA.  343 

"  A  few  words  in  regard  to  the  latter  case,  in  which  the  evi- 
dence was  conclusive.     It  was  one  of  pneumonia  of  the  lower 
lobe  of  the  left  lung,  occurring  during  the  course  of  the  secondary 
fever  in  a  patient  with  srnall-pox,  in  the  middle  of  his  twentieth 
year.     When  the  plessimeter  was  placed  at  the  level  of  the  sixth 
to   seventh  ribs,  exactly  midway  between  the  spinal  column  and 
the  posterior  axillary  line,  and  was  struck  with  a  strong  and  short 
blow,  an  exquisitely  tympanitic  note  was  heard,  which  quite  un- 
mistakably changed  its  note  of  vibration  whenever  the  mouth  was 
opened  or   closed.       We  suspected  a  cavity  from  pathological 
causes,  such  as  abscess  or  gangrene,  and  were  astonished  when 
the  autopsy  revealed  no  other  lesion  than  a  solid  infiltration  in 
the  stage  of  yellow  hepatization.     The  case  was    observed   by 
Bartels  and  myself  in  the  Medical  Clinic  of  Kiel.     Afterwards, 
I  saw  another  similar  case  in  the  Kiel  Polyclinic,  and  showed  it 
to  my  assistants.     It  was  a  pneumonia  of  the  right  inferior  lobe, 
which  run  throughout  a  normal  course. 

"lam  very  willing  to  admit  that  these  cases  are  rare  ;  for,  out 
of  the  very  large  number  of  cases  of  pneumonia  seen  by  me 
during  many  years,  and  carefully  examined  in  regard  to  this  point, 
the  above  are  the  only  instances  in  which  the  evidence  was 
entirely  clear.  Another  reason  why  a  perfectly  pure  tympanitic 
note,  unless  it  be  traceable  to  Williams's  tracheal  tone,  cannot 
usually  be  obtained  in  croupous  pneumonia,  may  be,  that  in  the 
different  parts  of  the  lung  percussed  at  the  same  time  the  sound 
is  controlled  sometimes  by  the  elastic  membrane,  and  sometimes 
by  the  columns  of  air  inclosed  in  the  bronchi,  and  that  the  waves 
thus  produced  belong  to  different  systems,  and  have  different 
rates  of  vibration." 

When  I  first  offered  an  explanation  of  this  phenomenon,  I  did 
not  attach  due  importance  to  the  condition  of  the  parietes  of 
the  chest,  which,  in  Dr.  Banks'  and  Dr.  Hayden's  cases,  were 
observed  to  be  rendered  tense  by  the  tumefaction  of  the  affected 
lung.  Attention  was  first  directed  to  it  by  Dr.  Williams,  whose 
opinion  is  controverted  by  Skoda.*  Its  importance  was,  however, 
recognised  by  Dr.  Graves,  who  first,  so  far  as  I  am  aware,  ob- 
served the  occurrence  of  dilatation  of  the  side  and  tympanitic 
resonance  over  the  displaced  lung  in  a  case  of  pericarditis  with 
effusion  in  a  young  person.      "In  this  case  (says  Dr.  Graves) 

*  Markham's  Translation,  pp.  5  and  14. 


344  PNEUMONIA. 

there  was  an  evident  dilatation  of  the  left  chest  exactly  corres- 
ponding to  the  distended  pericardium,  which,  pushing  before  it 
the  flexible  parietes,  formed  a  well-marked  and  evident  promi- 
nence. This  likewise  rendered  the  parietes  of  the  superior  por- 
tions of  the  left  side  of  the  chest  more  tense  than  natural,  an 
occurrence  sure,  for  reasons  well  explained  by  Dr.  Williams,  to 
occasion  increased  resonance  on  percussion."  * 

A  similar  case  was  published  by  Dr.  R.  Todd,  in  the  Medical 
Times  of  December  18th,  1852.  On  the  eleventh  day  after  ad- 
mission— the  symptoms  and  signs  of  increasing  effusion  in  the 
pericardium  being  present — "  a  new  sign,"  says  Dr.  Todd, 
"  attracted  our  attention,  and  puzzled  us  not  a  little.  We  found 
great  resonance  of  the  lower  half  of  the  left  side  behind  :  in  fact, 
it  had  become  tympanitic.  The  chest  was  also  tympanitic  on 
percussion  at  the  left  side,  in  front,  and  in  the  lateral  region." 

In  a  paper  "On  the  Signs  of  Accumulation  in  some  Thoracic 
Diseases,"  in  The  Dublin  Quarterly  Journal  of  1856,  I  offered 
the  following  observations  on  the  occasional  occurrence  of  general 
dilatation  of  the  side  in  pericarditis  and  pneumonia,  and  its 
accompanying  phenomenon,  increased  or  tj'mpanitic  clearness  on 
percussion,  as  it  is  defined  by  Dr.  Walshe  : — "  The  note  clear; 
the  duration  considerable ;  the  resistance  of  the  walls  tense, 
drum-like,  highly  elastic."  This  is  the  percussion  sound  of  the 
upper  portion  of  the  chest  in  the  commencing  stage  of  pleuritis 
with  effusion,  before  the  quantity  of  fluid  is  become  so  consider- 
able as  to  interfere  with  chest  vibration,  and  so  cause  the  sound 
to  become  amphoric  or  tubular.  It  resembles  the  sound  on  per- 
cussion in  the  bronchitis  of  the  young,  and  in  some  cases  of 
emphysema  with  dilatation,  in  which  the  parietes  are  rendered 
tense,  partly  by  the  pressure  from  within,  and  partly  by  the 
heightened  action  of  the  intercostals. 

I  believe  that  the  conflicting  observations  on  this  point  are  to 
be  reconciled  by  taking  into  account  the  existence  of  different 
forms  of  pneumonia,  in  one  of  which,  at  least — that,  namely, 
attended  with  plastic  exudation  into  the  lung — well-marked  si<ms 
of  accumulation  are  present.  The  following  are  the  grounds 
for  this  opinion  : — 

First— The  remarkable  case  presented  to  the  Pathological 
Society  of  Dublin,  by  Professor  Smith,  which,  we  may  say,  bears 

*  Clinical  Medicine,  vol.  ii.  p.  286. 


PNEUMONIA.  345 

much  the  same  relation  to  the  diagnosis  of  pneumonia  as  that  of 
Dr.  Graves,  already  quoted,  does  to  pericarditis.  In  this  patient 
the  external  signs  of  enlargement  of  the  lung  were,  dilatation  of 
the  side  to  the  extent  of  an  inch  and  a-half,  and  downward  pro- 
trusion of  the  liver.  On  post-mortem  examination  it  was  found 
that  the  diaphragm  was  pushed  down,  and  the  opposite  lung- 
compressed,  and  the  surface  of  the  lung  indented  hy  the  rihs  to 
an  unusual  depth;  the  increase  of  hulk  being  owing  to  the  depo- 
sition of  lymph  in  the  air-cells  of  the  lung,  constituting  that 
form  of  disease  since  described  by  Dr.  Blakiston  under  the  term 
"  plastic  pneumonia."  "  This  case,"  as  Professor  Smith  observes, 
"  places  the  fact,  denied  by  many  authors,  of  actual  enlargement 
of  the  lung,  beyond  doubt." 

Second — The  occurrence,  under  my  own  observation,  at 
different  times,  more  especially  during  the  past  year,  of  cases  in 
which  positive  dilatation  of  the  side,  ascertained  by  measure- 
ment, existed,  with  other  signs  of  accumulation,  and  in  which 
other  characters  of  the  disease  resembled  those  of  plastic  pneu- 
monia :  such  as  absence  of  the  crepitus  of  the  first  stage,  absence 
of  the  rusty  expectoration  of  pneumonia,*  and  rapid  solidification, 
with  remarkable  chronicity  of  disease — all  the  cases  extending 
over  many  weeks,  several  over  months.  (In  this  particular  they 
resembled  Professor  Smith's  case,  which  was  of  three  months' 
duration.)  In  three  young  persons,  in  whom  the  disease  occurred 
in  the  left  lung,  this  side  measured  from  half  to  three-fourths  of 
an  inch  more  than  the  right ;  and  in  two  of  these,  in  whom  it 
was  confined  to  the  upper  lobe,  the  heart  was  sensibly  displaced 
downwards,  and  to  the  right,  as  in  emphysema  of  the  same  part. 
In  one  of  these,  a  young  lady,  aged  ten,  the  dilatation  and  dis- 
placement were  witnessed  by  her  medical  attendant,  Dr.  Travers, 
as  well  as  by  myself. 

In  three  fatal  cases  both  lungs  were  engaged — two  of  these 
were  gentlemen  of  previously-dissipated  habits  and  broken  con- 
stitution ;  unfortunately,  no  opportunity  was  afforded  of  ascer- 
taining the  truth  of  the  diagnosis  by  post-mortem  examination  ; 
but,  in  the  third,  which  was  under  the  care  of  Dr.  Aquilla  Smith, 
this  was  done. 

Eliza  Helson,  aged  nine,  had  measles  six  weeks  since,  after 
which  cough  and  dyspnoea  supervened,  and  have  since  continued. 
*  This  absence  was  also  remarked  in  Dr.  Hayden's  second  case. 


346  PNEUMONIA. 

When  examined,  after  admission  into  Sir  P.  Dim's  Hospital 
(February  19th),  she  presented  the  dusky  face,  with  dark  flush, 
and  the  pungent  heat  of  skin  of  pneumonia  ;  her  breathing  was 
oppressed,  but  not  laborious,  36  in  the  minute  ;  pulse  108, 
small  and  feeble.  On  inspection  of  the  chest  both  sides  seemed 
to  expand  equally  during  the  inspiration,  but  the  right, 
posteriorly,  was  evidently  rounder  and  fuller  than  the  left ;  and 
being  carefully  measured  by  Dr.  Smith,  Dr.  K.  M'Dermott,  and 
myself,  was  found  to  be  fully  an  inch  larger.  Both  over  the 
rounded  part  and  over  the  mammary  region,  it  gave  a  tympanitic 
sound  on  percussion,  so  clear,  that  it  was  remarked  at  the  time 
how  easily  one  previously  unacquainted  with  this  modification  of 
the  percussion  sound,  might  mistake  the  natural  resonance  of  the 
left  side  for  comparative  dulness,  from  its  contrast  to  the  abnormal 
clearness  of  the  right.  Over  the  lower  third,  posteriorly  and 
laterally,  there  was  a  loose  muco-crepitus,  mixed  with  feeble 
bronchial  respiration,  while  superiorly  the  bronchial  respiration 
was  pure  and  unmixed  with  rale  ;  over  the  spine  of  the  scapula 
and  under  the  clavicles,  respiration  was  puerile.  Gradually  the 
breathing  became  more  hurried,  the  pulse  more  rapid,  the  cough 
more  frequent,  and  the  expectoration  more  purulent  and  copious. 
Each  time  that  the  chest  was  examined  the  measurement  of  the 
side  was  found  to  be  less,  while,  on  percussion,  it  sounded  duller 
and  more  amphoric,  and  the  muco-crepitus  became  looser  and 
mixed  with  gurgling.  Ten  days  after  her  admission  the  measure- 
ment of  the  sides  was  equal,  and  the  signs  of  cavity  in  the  lower 
part  of  the  side  (cavernous  respiration  and  garqouillent)  fully 
established.  She  continued  much  in  the  same  state  for  three 
weeks  longer;  when,  on  the  22nd  of  March,  she  was  suddenly 
seized  with  acute  pain  in  the  side  and  great  increase  of  dyspnoea, 
and  died  on  the  following  day. 

On  dissection,  the  diagnosis  made  during  life,  of  plastic  pneu- 
monia and  abscess  in  the  lung,  with  recent  opening  into  the  pleura, 
was  found  to  be  correct ;  the  appearance  of  the  upper  and  middle 
lobes  was  exactly  similar  to  that  in  Professor  Smith's  preparation 
and  drawing ;  the  deposit,  which  studded  every  portion  of  these 
lobes,  was  contained  in  cysts,  varying  in  size  from  a  pin's  head 
to  a  horse-bean.  On  this  substance  being  submitted  to  exami- 
nation, under  the  microscope,  by  Dr.  M'Dermott,  it  was  found  to 
consist  of  fibrinous  exudation,  without  any  trace  of  tubercle. 


PNEUMONIA.  347 

The  entire  lower  lobe  was  converted  into  an  abscess,  lined  by  a 
smooth  pyogenic  membrane,  and  communicating  by  a  small  rent 
with  the  cavity  of  the  pleura.  It  should  have  been  mentioned, 
that  three  weeks  before  death  signs  of  solidification  had  appeared 
in  the  upper  part  of  the  left  side,  where  some  of  the  same  deposit 
was  found  in  a  crude  state. 

In  one  of  the  other  fatal  cases  the  course  of  the  disease  was, 
in  some  respects,  similar  to  the  above.  .  .  .  Solidification, 
first  of  the  lower  lobe  of  the  left  lung,  with  tympanitic  resonance, 
then  of  the  upper  lobe  of  the  right,  ending  in  the  formation  of  a 
large  abscess  in  the  former  situation.  In  the  third  case  the 
disease  also  commenced  in  the  left  lung,  then  attacked  the  right, 
the  chest  becoming  dilated  and  rounded,  as  in  emphysema, 
and  everywhere  preternaturally  clear  on  percussion  ;  respiration 
being  effected  entirely  upwards,  and  by  the  diaphragm  ;  the  heart 
was  carried  down,  and  pulsated  under  the  lower  edge  of  the 
sternum.  It  is  worthy  of  remark,  that  both  these  patients  had 
extensive  and  obstinate  diphtherite  of  the  mouth  and  pharynx — 
an  indication,  perhaps,  of  the  blood  crasis  which  determined  this 
peculiar  form  of  pneumonia.* 

From  a  review  of  the  cases  which  I  have  from  time  to  time 
observed,  as  well  as  of  those  published  by  others,  I  would  offer 
the  following  conclusions  : — 

I.  That  three  varieties  of  tympanitic  sound  have  been  observed, 
differing  in  degree,  but  not  always  distinguished  from  each  other ; 
namely  : — 

(a).  The  absolutely  clear  resonance  of  pneumothorax,  yielded 
in  some  rare  cases  by  a  lung  entirely  solidified. 

(b).  The  muffled  tympanitic,  or  amphoric,  sound  yielded  by  a 
lung  partially  hepatized,  or  compressed  by  a  moderate  amount  of 
fluid  in  the  pleura,  or  a  proportionally  large  amount  in  the  peri- 
cardium.— (Skoda's  tympanitic  sound  ;  Bruit  Scodiquc  of  the 
French.) 

(c).  The  tubular  or  tracheal  sound  yielded  by  the  upper  por- 
tion of  the  chest  in  more  copious  pleural  effusion,  or  in  some 
cases  of  consolidation  of  the  upper  lobe  from  pneumonia  or 
phthisis. — (Williams  :  see  remarkable  case,  reported  by  Walshe, 
p.  75,  4th  ed.) 

*  It  may  be  observed  that  all  these  cases  occurred  during  a  limited  epidemic 
period.  Neither  previously,  nor  during  twenty-five  subsequent  years,  have  I  met 
with  any  similar  example  of  plastic  pneumonia. 


348  PNEUMONIA. 

II.  That  tins  sign  is  not  peculiar  to  the  first  stage  and  that  of 
resolution,  as  erroneously  stated  by  Guttman,*  but,  on  the  con- 
trary, has  been  invariably  observed  to  occur  during  the  stage  of 
hepatization,  disappearing  more  or  less  completely  on  the  com- 
mencement of  resolution,  and  declining  during  the  stage  of  grey 
softening,  thus  rendering  it  probable  that  an  amount  of  uniformity 
of  consistence  is  requisite  for  the  transmission  of  the  vibrations 
of  the  parietes  to  the  bronchus  and  its  divisions,  to  produce  this 
resonance,  changes  of  media  being  well  known  to  interrupt 
sonorous  vibrations. 

III.  That  its  disappearance  and  the  change  to  dulness  on  the 
commencement  of  resolution  may  be  due  in  part  to  the  filling  up 
of  the  minute  bronchi  by  serous  exudation,  their  permeability 
being  regarded  by  Dr.  Walshe  as  necessary  for  the  production  of 
a  tubular  sound. 

*  Handbook  of  Physical  Diagnosis,  p.  99. 


349 


SECTION  V. 


GANGRENE    OF    THE    LUNG. 


[This  chapter  consists  of  two  parts  :  the  first,  a  reprint  of  the  brief  chapter  in 
the  first  edition  of  this  work  ;  the  second,  of  a  more  elaborate  memoir  in  the 
Dublin  Quarterly  Journal  of  February,  1S50.] 

Part  I. 

I  have  placed  this  disease  after  pneumonia  independent  of 
any  theoretical  considerations.  Its  close  connexion  with  pneu- 
monia and  congestion  of  the  lung,  however,  will  justify  an 
arrangement  adopted  principally  for  convenience. 

I  shall  not  discuss  the  nature  of  this  affection,  but  content 
myself  with  giving  an  abstract  of  a  few  cases  which  have  fallen 
under  my  own  observation. 

Case  I. — A  middle-aged  man  was  attacked  with  symptoms 
of  pneumonia,  in  consequence  of  a  contused  injury  of  the  right 
side ;  from  these  he  partially  recovered,  when  he  was  thrown 
from  a  car,  and  received  a  second  injury  on  the  same  side. 
Cough,  with  a  dark  coloured  and  offensive  expectoration,  and 
occasional  haemoptysis,  set  in.  He  was  admitted  into  hospital 
in  the  seventh  week  of  his  illness,  with  extreme  prostration ; 
the  countenance  was  of  a  leaden  hue ;  the  respiration  seventy- 
two  in  a  minute ;  breath  foetid ;  the  cough  constant,  with 
expectoration  of  a  yellowish-white  purulent  matter.  By  the 
stethoscope  a  large  cavity  was  detected  in  the  right  lung. 
The  patient  died  on  the  fourth  day  after  admission. 

Inspection. — A  vast  gangrenous  abscess  occupied  the  whole 
posterior  part  of  the  right  lung  :  the  cavity  was  eight  inches  in 
length,  four  in  breadth,  and  two  in  depth ;  this  contained  a 
large,  moist,  and  soft  slough  of  an  extreme  foetor,  and  the  upper 
part  of  the  cavity  was  lined  with  a  distinct  layer  of  coagulable 
lymph. 

This  cavity  had  extensive  communication  with  the  bronchial 
tubes.     Having  placed  it  under  water,  we  found,  by  inserting  a 


350  GANGRENE    OF    THE    LUNG. 

blow-pipe  into  the  pulmonary  artery,  that  air  in  great  quantity 
could  be  made  to  rise  from  the  surface  of  the  cavity ;  the  left 
lung  was  extensively  inflamed. 

Case  II. — A  man,  aged  28,  of  a  full  habit,  laboured  for  a 
year  under  palpitation,  cough,  and  pains  of  the  sides ;  he  was 
admitted  into  hospital,  stating  that  on  the  day  before  he  had  had 
rigor  with  great  increase  of  pain.  He  had  frequent  cough  with 
dark  coloured  expectoration  ;  the  pulse  was  rapid ;  he  lay  on  the 
right  side  ;  the  breath  had  the  characteristic  fcetor  of  gangrene, 
and  there  was  a  cadaverous  smell  from  the  whole  body  ;  coun- 
tenance of  a  leaden  hue  ;  lips  livid ;  the  right  side  sounded 
dull,  and  a  cavity  was  detected  in  the  mammary  region.  In 
five  days  after  admission  he  was  attacked  with  severe  inflamma- 
tion of  the  left  lung  ;  copious  hemoptysis  followed ;  and  he 
died  on  the  ninth  day  after  admission. 

Inspection. — The  right  lung  was  solid  and  strongly  adhe- 
rent ;  the  upper  lobe  presented  the  third  and  fourth  stages  of 
inflammation.  At  about  four  inches  from  the  summit  an  anfrac- 
tuous cavity  existed,  having  three  prolongations  extending  in 
different  directions  ;  most  of  this  cavity  was  filled  with  a  sub- 
stance resembling  putrid  flax,  of  an  exceedingly  fcetid  odour. 
This  cavity  was  evidently  chronic,  as  its  walls  were  firm,  and 
lined  with  a  cartilaginous  membrane.  Many  of  the  bronchial 
tubes  were  dilated ;  the  lower  half  of  the  left  lung  was  in  a  state 
of  deliquescent  sphacelus,  the  affected  part  being  surrounded  by 
a  band  of  hepatization,  beyond  which  the  tissue  was  healthy  and 
crepitating. 

Case  III. — A  man,  aged  26,  who  had  been  previously 
healthy,  and  not  subject  to  cough,  while  intoxicated  and  very 
warm,  bathed  and  remained  for  a  considerable  time  in  the  water ; 
on  coming  out  he  felt  very  cold  ;  he  again  indulged  in  drinking, 
and  became  a  second  time  intoxicated  ;  he  partly  undressed, 
and  lay  for  the  whole  day  on  the  left  side,  on  a  cold  and 
damp  floor  ;  on  the  following  day  he  was  attacked  with  violent 
symptoms  of  pleuro-pneumonia,  and  in  about  three  weeks  coughed 
up  some  dark-coloured  fluid  blood ;  he  then  became  hectic, 
and  was  admitted  on  the  1st  of  September.  He  was  greatly 
emaciated,  had  extreme  prostration  of  strength,  and  coughed 
up  large  quantities  of  a  foetid  greenish  matter  ;  the  breath  was 
extremely  fcetid,  and  the  skin  hot :  the  supero-anterior  portion 


GANGRENE    OF    THE    LUNG.  351 

of  the  left  side  sounded  dull,  while  between  the  third  and  fifth 
ribs  a  cavity  could  be  easily  detected. 

This  patient  was  treated  by  the  chloride  of  lime,  with  wine 
and  opium.  The  most  rapid  and  marked  amendment  followed  ; 
in  a  few  days  the  foetor  of  breath  and  expectoration  had  disap- 
peared ;  no  inconvenience  whatever  was  experienced  from  the 
remedy.  We  also  directed  the  covering  of  the  bed  to  be  sprinkled 
with  a  solution  of  the  salt.  The  remedy  being  omitted,  in  two 
days  the  foetor  returned,  and  fever  began  to  appear ;  but  these 
symptoms  again  subsided  with  rapidity  on  his  resuming  the 
medicine.  The  patient  was  ultimately  discharged,  greatly  im- 
proved in  strength  and  flesh  ;  he,  however,  some  time  afterwards 
relapsed,  and  died  in  the  county. 

Case  IV. — A  labourer,  aged  about  thirty-two,  habitually  in- 
temperate, while  intoxicated  fell  into  a  canal,  and  after  sitting 
for  some  time  in  his  wet  clothes,  was  seized  with  a  rigor ;  on  the 
next  day  he  had  cough,  pain  in  the  side,  and  difficulty  of 
breathing,  and  was  admitted  into  the  Meath  Hospital  on  the  third 
day  after  the  accident.  He  presented  the  usual  symptoms  of 
typhoid  pneumonia,  the  anterior  and  lateral  portions  of  the  right 
side  sounding  dull,  with  absence  of  respiration.  In  the  course 
of  the  day,  tlte  dulness  extended  over  the  whole  of  the  right  side, 
witliout  any  'preceding  crepitus  being  observed.  On  the  next  da}* 
the  prostration  was  extreme,  and  the  breath  slightly  foetid  ;  the 
foetor  increased  remarkably  towards  evening,  and  a  copious 
expectoration  of  dark-coloured  sanious  fluid  took  place.  The 
foetor  was  much  increased  after  coughing ;  the  countenance  be- 
came sunk ;  but  the  peculiar  leaden  hue  was  never  observed. 
On  the  next  day  the  signs  of  a  cavity  were  detected,  and  the 
patient  died  on  the  following  evening. 

Inspection. — The  right  lung  was  generally  adherent ;  exter- 
nally it  appeared  solid,  but  there  existed  a  large  cavity  in  the 
anterior  portion,  extending  backwards  and  downwards ;  this 
cavity  occupied  the  lower  lobe ;  it  was  not  lined  by  any  false 
membrane,  but  contained  a  quantity  of  sanious  fluid,  similar  to 
what  had  been  expectorated.  Its  walls  were  formed  by  the  pul- 
monary tissue,  which  was  solid,  softened,  and  of  a  dirty  reddish 
colour,  but  not  presenting  the  granular  appearance  of  ordinary 
pneumonia. 

On  comparing  these  cases,  they  will  be  found  more  or  less 


352  GANGRENE    OF    THE    LUNG. 

analogous ;  and  they  all  present  inflammation  preceding  and 
accompanying  the  disease.  It  is  yet  to  be  determined  whether 
the  occurrence  of  gangrene  depends  on  the  suddenness  and  com- 
pleteness of  congestion,  or  on  the  general  morbid  state  of  the 
patient.  No  doubt  both  causes  influence  its  production.  In  all 
the  cases  which  I  have  seen,  the  patients  were  long  addicted  to 
the  use  of  spirits.  "With  respect  to  the  violence  of  congestion, 
the  exciting  causes  of  the  disease  would  favour  such  an  occur- 
rence. In  the  first  case,  the  patient  received  two  contused 
injuries  of  the  chest ;  and  I  have  known  of  others  in  which 
gangrene  followed  this  accident.  In  the  third  and  fourth  cases 
the  circumstances  are  just  such  as  would  produce  intense  con- 
gestion ;  and  the  fourth  is  also  an  example  of  the  typhoid 
pneumonia  which  I  have  described  as  producing  solidity  without 
preceding  crepitating  rale. 

Notwithstanding  the  general  similarity  of  my  cases,  their 
history  presents  some  interesting  points  of  difference  which  may 
be  thus  enumerated  : — 

1st  Case. — Enormous  gangrenous  abscess  succeeding  to  con- 
tused injury  of  the  chest. 

2nd  Case. — Chronic  circumscribed  gangrene,  with  an  isolated 
slough  in  one  lung,  succeeded  by  acute  sphacelus  in  the  other. 

3rd  Case. — Gangrenous  cavity  occurring  under  circumstances 
calculated  to  produce  extreme  congestion  of  the  lung. 

4th  Case. — Acute  gangrenous  abscess,  supervening  on  t}-phoid 
pneumonia. 

I  have  not  found  any  peculiar  physical  signs  in  the  gangrenous 
abscess  of  the  lung.  I  believe  that  the  only  pathognomonic 
symptom  is  the  extraordinary  and  disgusting  odour  of  the  breath 
and  expectoration,  making  the  patient  loathsome  to  himself  and 
all  around  him  ;  the  stench,  however,  is  not  constant,  for  during 
the  progress  of  a  case  it  may  disappear  more  than  once.  In 
some  cases  the  expectoration  is  foetid,  while  the  breath  is  free 
from  odour,  and  it  will  be  often  necessary  that  the  patient  be 
made  to  cough  in  order  to  produce  the  stench. 


GANGRENE    OF    THE    LUNG.  353 

Part  II. 

Under  the  term  gangrene  may  be  included  all  cases  in  which 
a  putrefactive  process,  accompanied  by  death  of  a  portion  of  the 
lung,  takes  place.  The  disease  is  met  with  in  the  acute  and 
chronic  forms,  and  also  in  that  of  continually  recurring  acute 
attacks ;  it  may  he  a  primary  idiopathic  affection,  or  arise  in  the 
course  of  some  constitutional  disease,  or  be  the  result  of  a 
previous  acute  or  chronic  disease  within  the  chest.  Under 
whatever  form  it  occurs,  it  is  one  of  the  most  terrible  and  un- 
manageable of  the  diseases  of  the  lungs. 

The  following  are  some  of  the  forms  of  this  disease  : — 

1.  A  gangrenous  eschar  rapidly  produced  from  causes  which, 
under  ordinary  circumstances,  would  cause  simple  pneumonia  or 
pleurisy. 

2.  Gangrene  of  the  lung  occurring  as  a  consequence  of  diffuse 
or  erysipelatous  inflammation. 

3.  Arising  from  long  exposure  of  the  surface  to  cold. 

4.  Occurring  in  the  consolidation  of  the  lung  observed  in 
bad  cases  of  typhus  fever. 

5.  Induced  by  contused  injuries  of  the  chest. 

6.  Repeated  distinct  attacks  of  acute  gangrenous  disease,  with 
severe  symptoms  of  irritation  and  high  fever.  The  attacks,  with 
the  exception  of  the  first,  not  having  any  apparent  exciting  cause, 
and  continuing  to  recur  for  a  great  length  of  time. 

7.  Chronic  gangrenous  cavity  with  great  diminution  of 
volume. 

8.  Recent  sphacelus  of  one  lung  supervening  on  a  chronic 
gangrene  of  the  opposite  lung. 

9.  The  result  of  pressure  of  the  nutrient  vessels  and  nerves  of 
the  lung  by  aneurismal  or  cancerous  tumours. 

There  are  other  forms  of  the  affection,  but  the  above  are  those 
which  have  come  under  my  observation.* 

The  general  symptoms  have  a  close  similarity  in  the  various 
forms  of  the  affection,  consisting  in  cough,  with  an  extreme  and 
perfectly  peculiar  fcetor  of  the  breath.  There  is  generally  copious 
expectoration  of  a  sanious  or  muco-purulent  character ;  but 
neither  with  this  nor  with  the  breath  is  the  fcetor  constantly 
associated,  for  it  is  found  to  appear  and  to  subside  in  singularly 

*  See  Appendix. 
A  A 


354  GANGRENE    OF    THE    LUNG. 

short  spaces  of  time.  This  foetor  is  of  all  stenches  the  most 
terrible.  It  is  commonly  perceived  during  a  fit  of  coughing, 
and  appears  to  be  produced  rapidly  by  the  use  of  stimulating 
food  or  drinks.  It  may  subside  for  a  great  length  of  time, 
and  be  again  produced  without  our  being  able  to  explain  the 
cause  of  its  re-appearance.  The  system  seems  to  suffer  from 
the  effects  of  a  septic  poison,  and  a  weakened  and  leuco- 
phlegmatic  condition  is  observed  in  most  of  the  chronic  cases  of 
the  disease. 

We  would,  however,  fall  into  error  if  we  were  to  consider  all 
cases  of  cough,  with  foetid  breath  and  expectoration,  as  cases  of 
true  gangrene  of  the  lung.  Dr.  Graves  has  shown  that  these 
symptoms  may  come  on  in  chronic  bronchitis.*  Dr.  Williams 
describes  cases  of  foetid  abscess  of  the  lung  with  recovery,  a  disease 
which  I  have  also  observed  in  the  pneumonia  following  measles. 
I  have  more  than  once  observed  a  distinct  gangrenous  odour  on 
the  breath  of  a  lady  who  had  recently  suffered  from  slight 
bronchial  haemorrhage.  And  in  cases  where  an  empyema  opens 
through  the  lung  the  discharge  has  sometimes  an  extreme 
degree  of  foetor.  In  such  cases  there  is  no  sphacelus  of  the 
tissues,  and  we  have  only  putrefaction  of  a  secreted  fluid  occur- 
ring after  it  has  occupied  its  containing  cavity. 

We  may  here  pause,  even  at  the  risk  of  digression,  to  inquire, 
why  it  is  that  this  change  does  not  more  often  occur,  both  in 
bronchial  effusions  and  also  in  the  fluid  contents  of  an  empyema  ? 
In  the  case  of  an  empyema  with  closed  sac,  we  may  presume 
that  the  want  of  contact  with  air  is  the  cause  of  absence  of 
putrefaction  ;  but  in  copious  bronchial  effusions,  in  the  fluid 
contents  of  open  tuberculous  abscesses,  and,  above  all,  in  the 
case  of  empyema  and  pneumothorax  with  pulmonary  fistula,  the 
preservation  from  a  septic  state  of  the  secreted  matters  is  one  of 
the  most  singular  of  pathological  phenomena. 

In  the  case  of  empyema  with  pulmonary  fistula  we  may  have 
many  pints  of  a  highly  annualized  fluid,  mixed  with  floating 
fragments  and  shreds  of  lymph,  kept  at  a  high  temperature  and 
in  contact  with  atmospheric  air,  which  is  more  or  less  renewed 
at  every  inspiration.  And  yet  this  fluid  remains  for  months,  or 
even  more  than  a  year,  without  putrefying;  when,  if  it  were 
withdrawn  and  kept  at  the  same  temperature  and  in  contact  with 

*  Clinical  Medicine,  2nd  ed.,  vol.  ii.  p.  52. 


GANGRENE    OF    THE    LUNG.  355 

air  outside  the  body,  it  would  run  rapidly  into  decomposition. 
We  can  only  explain  this  by  assuming  that  actual  organic  con- 
nexion is  unnecessary  for  a  certain  degree  of  inherent  vitality,  or 
that  there  is  a  vital  irradiation  from  surrounding  parts.  The 
organization  of  effused  lymph,  and  its  transformation  into  fat,  or 
cancerous,  or  bony  structures,  seem  to  favour  these  views. 

It  is  many  years  since  I  saw  a  case  which,  as  bearing  on  these 
points,  is  worthy  to  be  placed  on  record.  A  gentleman  past 
middle  age  had  for  some  months  laboured  under  the  ordinary 
form  of  tuberculous  phthisis.  In  the  course  of  some  months 
empyema  and  pneumothorax  with  fistula  occurred  with  the  usual 
symptoms,  and  he  remained  for  a  great  length  of  time  with  the 
usual  symptoms  and  signs  of  this  condition :  there  were  no 
evidences  of  putrefaction.  The  liquid  effusion  slowly  increased 
until  the  pressure  was  so  great  as  to  cause  extreme  distress,  and 
the  operation  of  paracentesis  was  performed  by  Mr.  Porter, 
merely  as  a  palliative  measure.  As  is  usual,  however,  in  such 
cases,  there  was  but  little  relief  given.  The  fluid  drawn  off  was 
of  the  ordinary  sero-purulent  tint,  and  had  not  the  slightest  un- 
pleasant odour.  The  liquid  effusion  again  accumulated,  and  a 
fluctuating  tumour  appeared  at  the  situation  of  the  cicatrix  of 
the  puncture.  This  was  opened  by  a  lancet,  and  a  great  quantity 
of  matter  given  exit  to,  still  free  from  fcetor.  Soon  after  this 
the  patient  complained  of  great  internal  distress  ;  his  strength 
rapidly  sank,  he  began  to  cough  up  foetid  matter,  and  his  breath 
had  an  intense  gangrenous  stench.  He  died  in  a  few  days  after 
the  second  operation.  On  dissection  a  quantity  of  dark-coloured 
and  putrid  fluid  was  found  in  the  pleural  cavity ;  the  serous 
membrane  had  passed  into  a  state  of  universal  sphacelus,  and 
hung  in  blackened  shreds  ;  the  periosteum  was  also  mortified, 
and  the  ribs  appeared  in  a  state  of  necrosis.  The  fistula  was 
easily  found,  passing  into  a  tuberculous  cavern  in  the  antero- 
superior  portion  of  the  lung. 

It  would  appear  that,  in  this  case,  gangrenous  action  spread 
from  the  wound  to  the  pleura,  which  was  then  deprived  of  its 
vitality ;  and,  consequently,  the  fluid  in  the  cavity  passed  rapidly 
into  putrefaction.  We  cannot  suppose  that  this  change  was 
produced  by  the  admission  of  air,  as,  for  many  months  before 
the  operations,  air  had  been  freely  entering  through  the  pul- 
monary fistula. 

a  a2 


356  GANGRENE    OF    THE    LUNG. 

I  formerly  entertained  the  opinion  that  this  disease  was  most 
frequently  met  with  in  persons  addicted  to  the  abuse  of  spiritu- 
ous liquors ;  but  I  have  since  seen  many  instances  where  it 
occurred  in  the  most  temperate  individuals.  I  have  not  met 
with  any  examples  of  the  disease  in  the  child. 

One  of  the  most  singular  and  not  unfrequent  characters  of  the 
disease  is  the  extreme  severity  of  the  pain  which  attends  its 
invasion.  We  observe  this  not  only  in  patients  who  have  expe- 
rienced but  a  single  attack,  but  in  another  form,  which  I  shall 
just  now  describe,  and  which  I  have  noticed  as  the  ninth  in  the 
catalogue  of  forms  of  this  disease,  given  at  the  commencement 
of  this  paper.  This  pain  is  more  severe  than  that  in  ordinary 
acute  pleuritis,  and  the  extent  of  serous  inflammation  is  by  no 
means  commensurate  with  the  amount  of  suffering.  In  the 
recurrent  form  of  the  affection,  I  have  seen  each  attack  accom- 
panied by  this  agonizing  pain,  and  this  at  a  time  when  the 
patient  was  reduced  to  almost  the  last  stage  of  exhaustion. 

In  my  work  on  diseases  of  the  chest  I  have  noticed  some 
forms  of  gangrene  of  the  lung.  Since  then  I  have  met  with 
several  cases  presenting  the  disease  under  conditions,  which 
may  be  described  as  follows  : — 

I.  Gangrenous  eschar,  in  typhoid  pneumonia. 

II.  Circumscribed  sphacelus,  in  cases  of  diffuse  inflam- 
mation. 

III.  Chronic  gangrene,  producing  dexiocardia. 

IV.  Frequently  recurring  attacks  of  gangrenous  disease  of 
the  lung. 

Of  the  first  of  these  my  friend  Dr.  Hudson  has  given  a  good 
example,  which  was  observed  in  our  wards,  and  I  therefore  need 
not  here  do  more  than  refer  to  his  paper.*  The  second  form 
may  be  illustrated  by  the  following  case  : — 

A  3'oung  female  was  attacked  with  a  low  form  of  spreading 
erysipelas,  which  extended  from  the  legs  upwards  to  the  trunk  ; 
the  respiration  became  impeded,  and  the  right  lung  soon  pre- 
sented the  signs  of  consolidation  in  its  posterior  and  inferior 
portions,  without  the  usual  signs  of  progressive  pneumonia. 
Bronchial  effusion  soon  set  in,  and  the  patient  sank.  There 
was  but  little  pain,  nor  was  there  ever  foetor  of  breath  or  ex- 
ectoration.     On  dissection,  the  lower  lobe  of  the  right  lung  was 

*  On  Typhoid  Pneumonia.    Dublin  Journal,  First  Series,  vol.  vii.  p.  372. 


GANGKENE    OF    THE    LUNG.  357 

found  solid,  of  a  yellowish-grey  colour,  soft,  impermeable, 
leaving  a  smooth  surface  under  the  scalpel,  from  which  a  sero- 
purulent  fluid  could  be  expressed.  Within  about  an  inch  of  the 
outer  surface,  and  towards  the  lower  portion,  we  found  a  cavity 
completely  filled  with  sanious  pus,  having  the  most  extreme 
foetor.  There  was  no  bronchial  communication,  nor  any  air  in 
the  cavity,  the  sides  of  which  were  formed  by  the  condensed 
lung,  and  presented  a  broken  and  shreddy  surface.  This  cavity 
was  well-defined,  and  could  have  contained  a  large  walnut. 

This  case  is  of  importance,  as  exhibiting  a  true  gangrenous 
cavity,  although  there  was  no  communication  with  the  external 
air. 

Gangrenous  Cavity  in  the  upper  portion  of  the  Right  Lung,  with 
Dexioeardia  from  the  diminished  volume  of  the  organ. 

I  have  met  with  but  one  example  of  this  hitherto  undescribed 
form.  The  patient  was  an  old  man,  who  had  for  many  months 
laboured  under  cough,  emaciation,  and  fetid  expectoration.  He 
presented,  on  admission  to  hospital,  the  ordinary  signs  of  a 
circumscribed  cavity  below  the  right  clavicle ;  gurgling  and 
cavernous  respiration  being  distinct.  The  heart  was  found 
pulsating  to  the  right  of  the  sternum ;  and  though  its  action 
was  feeble,  there  was  no  difficulty  in  recognizing  it,  owing  to  the 
emaciation  of  the  patient.  On  dissection,  a  gangrenous  cavity, 
nearly  the  size  of  a  goose-egg,  was  found  in  the  supero-anterior 
portion  of  the  upper  lobe,  communicating  with  the  bronchial 
tubes,  and  exhaling  an  abominable  odour.  There  was  another 
appearance  which  I  had  never  before  seen.  We  found,  scattered 
over  the  anterior  surface  of  the  lung,  superficial  sloughs  between 
the  lung  and  pleura,  not  communicating  with  the  bronchial 
tubes.  They  were  about  a  third  of  an  inch  in  depth,  and  about 
an  inch  in  length  ;  their  form,  an  elongated  oval.  In  one  of 
these,  the  blood-vessels,  still  pervious,  were  found  to  traverse 
the  cavity  ;  while  in  another,  which  lay  on  the  anterior  face  of 
the  middle  lobe,  a  large  mass  of  nearly  detached  and  putrid 
cellular  structure  was  discovered.  On  the  side,  the  superficial 
eschars  resembled  at  first  view  the  ordinary  markings  of  the  ribs 
on  the  lung.  The  heart  lay  completely  to  the  right  of  the 
mesian  line. 


358  GANGRENE    OF    THE   LUNG. 

We  may  then  add  gangrene  of  the  lung  to  the  list  of  causes 
of  dexiocardia  from  diminished  volume  of  the  right  lung. 

Frequently  recurring  attacks  of  local  Gangrenous  Disease, 
accompanied  on  each  occasion  by  severe  constitutional  Dis- 
turbance. 

Of  this  extraordinary  form  I  have  seen  two  well-marked 
examples  ;  and  I  am  not  aware  that  its  symptoms  and  history 
have  as  yet  been  described  in  any  work  on  pulmonary  diseases. 
In  one  instance,  which  occurred  in  a  female  of  middle  age,  the 
disease  proved  fatal  after  a  continuance  of  many  months.  The 
other  example  was  in  the  case  of  a  young  man  who,  after  a  long 
struggle  with  the  affection,  seemed  to  have  recovered  perfectly. 
He  left  this  country,  and  remained  in  the  South  of  Europe,  free, 
as  I  understand,  from  any  symptoms  of  his  former  malady ;  but 
was  attacked  in  the  ensuing  summer  with  symptoms  of  acute 
pneumonia,  under  which  he  sank. 

This  form  of  the  disease  may  be  described  as  consisting  in  a 
succession  of  distinct  attacks,  with  high  fever  and  general  con- 
stitutional disturbance,  followed  by  copious  expectoration,  which 
exhales  the  most  intense  fcetor,  with  or  without  blood.  The 
breath  becomes  foetid,  and  the  patient's  condition,  during,  as  it 
were,  the  paroxysm  of  the  disease,  is  distressing  in  the  highest 
degree.  In  both  these  cases  intervals  of  apparently  complete 
recovery  were  observed.  The  pulse,  which  had  presented  all  the 
characters  of  inflammatory  fever,  would  become  tranquil,  the 
respiration  quiet,  the  cough  would  almost  wholly  subside,  and 
the  appearance  of  the  patient  improve  so  much  as  to  lead  to  the 
belief  of  perfect  recovery  ;  when  another  attack,  like  that  which 
had  preceded  it,  would  set  in,  and  run  a  course  precisely  similar 
to  that  of  the  last  invasion  of  the  disease.  The  physical  pheno- 
mena in  both  these  cases  Avere  in  the  early  stage  of  the  disease 
singularly  obscure,  and,  in  their  character  and  extent,  quite  in- 
commensurate with  the  violence  of  the  symptoms,  and  the 
severity  and  danger  of  the  disease.  To  this  subject  I  shall 
recur. 

The  first  case  was  that  of  a  lady,  past  thirty-five  years  of  age. 
She  had  never  before  been  subject  to  pulmonary  disease,  when, 
after  a  long  exposure  to  a  cold  sea-fog,  she  was  attacked  with 


GANGRENE    OF    THE    LUNG.  359 

symptoms  of  bronchitis,  accompanied  by  the  sensation  of  pain 
and  oppression  referrible  to  the  lower  portion  of  the  left  side. 
Within  a  week  of  the  attack  she  expectorated  some  foetid  matter, 
after  which  she  appeared  to  improve.     She  bore  a  long  journey 
to  Dublin  without  any  inconvenience,  and  I  saw  her  within  a 
month  of  her  recovery  from  the  first  attack.     Her  circulation 
was  then  tranquil,   her  cough  very  trifling,  with  mucous  ex- 
pectoration, which  was  free  from  any  fcetor,   as  was   also  her 
breath  ;  in  fact,  she  had  no  appearance  of  disease,  beyond  the 
slightest  possible  cachectic  hue.     The  chest  sounded  everywhere 
perfectly  clear,    and   there    was    no    stethoscopic   indication    of 
disease  beyond  a  slight  and  diffused  mucous  rattle  in  the  inferior 
portion  of  the  left  lung,  which  was  clear  on  percussion.     She 
appeared  to  improve  for  about  a  fortnight,  when,  without  any 
apparent  exciting  cause,  she  was  attacked  with  most  agonizing 
pain    in  the   situation  first  affected.     The   pulse   became    full, 
rapid,  and  resisting ;  the  skin  burning  hot ;  the  cough  constant  ; 
the  breath  extremely  foetid ;  and  she  expectorated  great  quan- 
tities •  of   muco-purulent   fluid,    often    tinged   with    blood,    and 
exhaling  the  most  extreme  foetor.     Notwithstanding  the  violence 
of  the  symptoms,  physical  examination  gave  but  slight  results ; 
there  were  no  signs  of  dry  pleurisy,  no  appreciable  dulness,  and 
the  only  change  was  an  increase  in  the  amount  of  the  mucous 
rattle.     The  symptoms  continued  with  great  severity  for  about  a 
week,  and  then  subsided  ;  moderate  local  bleeding,  and  opiates, 
being  the  principal  means  employed.     She  had  then  an  interval 
of  ease  and  apparent  recovery,  when  another  attack  succeeded, 
precisely  similar   in  every  character  to  its    predecessor.     This 
attack  came  on  without  any  apparent  exciting  cause,   and  thus 
the  disease    continued  for  many  months ;   the  attacks  slightly 
varying  in  severity,  but   agreeing  in  the  general  characters  of 
agonizing  pain,  high  fever,  and  foetid  expectoration.     No  treat- 
ment  that  was   adopted    seemed   in   the   least   to  control  the 
disease ;  yet,  in  its  intervals,  the  patient  continued  able  to  use 
nourishment,   to    sleep  well,  and   to  take  equestrian  exercise. 
The  intervals  of  the  attacks  became  less,   and  a  permanently 
febrile  state  was  established,  notwithstanding  which  the  remit- 
tent character  of  the  local  disease  continued  manifest.     I  have 
never  witnessed  more  acute  suffering  from  mere  pain  than  this 
lady  experienced  during  each  attack  of  this  terrible  disease  ;  and 


360  GANGRENE    OF    THE    LUNG. 

yet  it  was  not  till  within  two  or  three  months  of  her  death  that 
any  important  change  in  the  condition  of  the  lung  could  be 
detected.  The  lowest  portion  became  gradually  dull ;  and  this 
change  advanced  upwards  with  extreme  slowness.  The  mucous 
rale  gradually  passed  into  obscure  gurgling,  but  it  was  not  until 
within  a  few  weeks  of  the  patient's  death  that  signs  of  a  cavern 
were  established.  The  attacks  continued  with  unmitigated 
violence  up  to  a  period  not  more  than  a  few  days  before  death, 
and  the  sufferings  from  the  pain  were,  if  possible,  greater  as  the 
patient's  strength  gave  way. 

At  no  time  did  physical  examination  indicate  disease  over  a 
space  of  more  than  about  four  fingers  in  breadth  and  three  in 
depth  in  the  postero-inferior  portion  of  the  lung. 

There  was  no  post  mortem  examination. 

In  the  second  case  the  exciting  cause  was  also  a  long  exposure 
to  cold,  but  under  different  circumstances.  The  patient,  a 
young  man  of  fair  complexion  and  soft  fibre,  while  bathing  in 
the  sea  on  a  cold  and  windy  day,  was  carried  to  a  considerable 
distance  from  shore  by  a  tide-current ;  and  it  is  believed  that  he 
was  nearly  an  hour  in  the  water  before  he  reached  a  landing- 
place,  when,  as  might  be  expected,  he  was  in  a  state  of  extreme 
exhaustion  and  collapse.  He  remained  in  a  weak  state  for  some 
days,  with  a  slight  cough,  and  then  suddenly  expectorated  some 
foetid  matter.  The  disease  in  this  case  ran  a  course  very  similar 
to  that  in  the  former  instance,  except  that  it  was  not  accom- 
panied by  the  extreme  and  unaccountable  pain,  and  that  almost 
every  attack  of  the  fever  and  foetid  expectoration  was  accompanied 
by  haemoptysis.  Like  the  first  case,  there  were  the  singular 
intermissions,  with  complete  absence  of  foetor,  and  apparent 
return  to  health,  and  the  attacks  would  come  on  without  any 
exciting  cause.  It  also  presented  the,  singular  want  of  coinci- 
dence between  the  symptoms  and  physical  signs.  At  first, 
indeed,  there  were  evidences  of  a  congested  state  of  the  lower 
lobe,  but  these  soon  subsided,  and  then  for  many  months  the 
physical  phenomena  remained  almost  perfectly  normal,  except 
that  during  the  attacks  a  sonoro-mucous  rattle  was  developed  in 
the  lower  portion  of  the  lung.  The  attacks  gradually  lessened 
in  severity,  and  occurred  at  longer  intervals,  and,  after  a  period 
cf  about  five  months,  the  patient  was  so  far  recovered  as  to  be 
able  to  leave  this  country  for  the  south  of  Europe.     He  regained 


GANGRENE    OF    THE    LUNG.  361 

his  strength  and  appearance  during  a  winter  passed  in  Rome, 
but,  as  I  before  stated,  died  of  pneumonia,  as  was  reported  in 
the  ensuing  summer. 

I  am  anxious  here  to  draw  attention  to  a  circumstance  of  very 
great  importance  in  practice  ;  namely,  the  singular  obscurity  of 
physical  signs  in  the  earlier  periods  of  this  disease.  This  was 
exemplified  in  the  two  cases  which  have  been  just  now  given  ; 
and  I  have  had  examples  of  the  same  difficulty  in  many  other 
instances. 

From  considering  all  the  facts  of  these  cases  it  appears  very 
probable  that  in  the  earlier  periods  of  this  disease  there  is  no 
solution  of  continuity,  nor  much  consolidation  of  the  lung. 
This,  of  course,  does  not  apply  to  that  form  described  by  Dr. 
Graves,  where  a  lung  previously  hepatized  from  pneumonia 
takes  on  a  gangrenous  action  ;  a  most  important  variety,  which 
we  shall  presently  examine.  Nor  is  it  applicable  to  some  of 
the  cases  of  haemoptysical  gangrene,  established  by  Dr.  Law. 
But  in  many  of  the  cases  of  gangrene  occurring  in  a  lung  not 
previously  diseased,  or  in  what  may  be  termed  primary  gan- 
grene, we  see  the  disproportion  between  the  existing  physical 
signs,  and  the  violence  and  importance  of  the  disease,  in  a  very 
remarkable  degree. 

Is  this  a  disease  commencing  in  points  with  intervening 
healthy  tissue  ?  If  it  were  so  we  should  expect  to  meet  all  the 
difficulties  which  attend  the  detection  of  analogous  changes, 
such  as  the  first  stage  of  tubercle  or  isolated  cancers.  Yet  there 
must  be  something  more,  for  the  great  phenomena  of  the  disease 
are  high  febrile  reaction  and  copious  secretion  of  a  foetid  matter. 
I  am  of  opinion  that  the  portion  of  the  organ  which  suffers 
death  must  be  at  first  very  insignificant,  but  that  the  surface 
which  secretes  the  putrid  fluid  is  extensive.  It  seems  almost 
certain,  too,  that  this  fluid  is  originally  poured  out  in  a  putrid 
condition,  and  the  disease  at  first  is  essentially  one  of  secretion. 

Professor  Wood,  of  Philadelphia,  in  his  Treatise  on  the 
Practice  of  Medicine,  states,  that  after  the  expectoration  of 
foetid  matter,  a  cavity  must  be  held  to  have  formed,  and  that 
we  can  detect  it  by  the  usual  means.  My  experience  leads 
me  to  an  opposite  opinion  on  both  these  points.  I  have  known 
the  expectoration  of  putrid  matter  to  occur  within  so  short  a 
time  after  the  operation  of  the  exciting  cause  as  thirty-six  or 


362  GANGBEXE    OF    THE    LUNG. 

forty- eight  hours,  that  it  is  difficult  to  conceive  the  formation 
of  a  cavity  so  rapidly ;  and  I  repeat  that  months  may  elapse 
with  the  best-marked  symptoms,  and  yet  no  physical  sign  of  a 
cavity  be  discoverable. 

From  what  has  been  stated  we  thus  draw  one  practical  con- 
clusion. It  is,  that  in  any  case  ivhere  a  sudden  foetid  expectora- 
tion has  occurred,  we  are  not  justified  in  pronouncing  the  lungs 
healthy,  or  the  patient  in  a  safe  position,  because  physical 
examination,  even  the  most  accurate,  fails  to  detect  disease. 

This  aphorism  I  would  most  earnestly  impress  on  the  minds 
of  all  who  may  have  to  deal  with  cases  of  this  description. 

This  peculiarity  in  many  cases  of  gangrene  of  the  lung  did 
not  escape  Laennec.  In  speaking  of  the  physical  signs  he  says  : 
"  I  have  been  several  times  assured  that  the  crepitous  ronchus 
did  not  exist  until  after  the  production  of  the  eschar,  thereby 
indicating  the  formation  of  the  inflammatory  circle,  which  was 
to  operate  its  detachment."  He  further  observes,  that  "  the 
invasion  is  usually  characterized  by  symptoms  of  slight  pneu- 
monia ;  but  this  is  attended  by  a  degree  of  prostration  of 
strength,  or  anxiety  quite  disproportioned  to  the  severity  of  the 
local  symptoms,  and  to  the  small  extent  of  space  over  which  the 
respiratory  murmur  and  sound  on  percussion  are  wanting."  I 
quote  from  Forbes's  Translation. 

Of  the  two  next  forms  of  gangrene  which  I  shall  notice  here  I 
have  not  myself  met  any  example.  In  the  first,  which  has  been 
described  by  Dr.  Graves,  gangrenous  action  seizes  on  a  lung 
which  had  been  for  some  weeks  previously  in  a  state  of  unre- 
solved hepatization ;  *  while,  in  the  form  described  by  Dr.  Law, 
the  putrefaction  of  the  effused  blood  in  pulmonary  apoplexy 
appears  to  be  the  first  cause  of  the  disease. 

Of  gangrene  attacking  hepatized  lung,  Dr.  Graves  gives  a 
remarkable  instance  in  his  Clinical  Medicine.  The  patient  was 
an  old  man  who  had  been  attacked  with  symptoms  of  pleuro- 
pneumonia, and  was  admitted  with  the  usual  physical  signs  of 
consolidated  lung  and  pneumonia.  Under  a  moderate  anti- 
phlogistic treatment,  and  the  use  of  calomel  and  opium,  the 
progress  of  the  disease  was  checked,  the  pain  ceased,  and  the 
respiration  became  less  frequent,  but  still  continued  at  the  rate 
of  thirty  in  a  minute,  while  the  stethoscope  indicated  no 
*  Quere,  is  not  case  two  an  example  of  such  ?     (Ed.) 


GANGRENE    OF    THE    LUNG.  363 

tendency  to  resolution.  In  this  state  the  patient  continued 
for  a  week,  when  he  was  attacked  with  symptoms  of  laryngitis, 
with  copious  muco-purulent  expectoration.  This  was  speedily 
followed  by  extreme  prostration,  the  countenance  became 
sunk  and  livid,  the  breath  exceedingly  foetid,  and  the  expec- 
toration greenish,  ichorous,  and  intolerably  foetid.  The  patient 
died  within  forty  hours  after  the  commencement  of  the  last 
attack. 

In  addition  to  the  gangrene  of  the  lung  the  posterior 
surface  of  the  larynx  was  found  destroyed  by  gangrenous 
sloughing.* 

The  putrefaction  of  blood  previously  effused  into  the  substance 
of  the  lung,  as  in  cases  of  pulmonary  apoplexy,  has  been  con- 
sidered by  Dr.  Law  as  constituting  an  important  variety  of 
pulmonary  gangrene.  I  have  not  seen  any  cases  of  the  change 
from  one  of  these  diseases  into  the  other;  and  I  apprehend 
that  the  occurrence  must  be  rare.  I  would  say  further,  that 
where  a  clot  of  blood  effused  into  the  lung  putrifies,  this  change 
is  in  itself  a  proof  of  a  gangrenous  disposition  pre-existing  ;  and 
I  feel  satisfied  that  the  haemorrhages  in  cases  of  gangrene  have 
no  relation  to  pulmonary  apoplexy. 

That  an  effusion  of  blood  into  the  lung  does  not  more  often 
end  in  putrefaction  of  the  fluid  is  certainly  an  extraordinary 
fact ;  but  not  more  so  than  the  rarity  of  putrefaction  in  abscesses, 
tubercular  cavities,  or  empyema  and  pneumothorax.  That  it 
is  rare,  appears  from  the  fact  that  neither  Laennec,  nor  many 
other  writers  on  pulmonary  apoplexy,  mention  gangrene  as  a 

*  In  his  observations  on  this  case  Dr.  Graves  inquires,  "  How  are  we  to  account 
for  this  sudden  supervention  of  gangrene  ?  There  was  nothing  in  the  nature  of  the 
pneumonic  inflammation  to  dispose  it  to  terminate  in  this  way.  It  had  lasted  for 
three  weeks,  and  had  arrived  at  a  stage  in  which  inflammation  very  rarely  assumes 
the  gangrenous  character.  To  what  then  are  we  to  attribute  it?  Partly  to  the 
debility  of  the  man's  constitution,  and  partly  to  an  erysipelatous  tendency  in  the  air, 
which  was  at  the  time  prevalent.  Except  there  was  something  to  dispose  the 
lungs  to  gangrenous  disease,  as  an  enfeebled  habit  and  vitiated  quality  of  atmosphere, 
we  could  not,  under  the  existing  circumstances,  have  expected  such  a  termination. 
That  this  view  of  the  subject  is  correct,  is  shewn  by  the  simultaneous  occurrence  of 
gangrene  in  another  part  which  had  not  been  previously  diseased  or  subject  to 
inflammation,  except  shortly  before  the  man's  death— I  allude  to  the  larynx. 

"  What  I  wish  to  impress  on  you  is,  that  though  the  inflammation  of  the  lungs 
ended  suddenly  in  gangrene,  it  was  not  in  consequence  of  the  inflammation  having 
in  itself  any  such  tendency,  but  in  consequence  of  the  change  produced  in  the  man's 
constitution  by  atmospheric  influence,  and  which  was  favoured  by  his  advanced  age 
and  great  debility." 


364  GANGRENE    OF    THE    LUNG. 

result  of  the  disease ;  which,  besides,  is  in  many  instances 
connected  with  disease  of  the  heart,  producing  either  an  active 
or  passive  congestion  of  the  lung.  The  production  of  gangrene, 
however,  seems  in  no  way  connected  with  lesion  of  the  heart. 
We  may  also  refer  to  the  rarity  of  putrefaction  of  bloody  effusions 
in  the  brain  and  in  other  parts  of  the  system,  even  where  the 
quantity  of  blood  effused  is  enormous,  as  in  cases  of  long- 
existing  diffuse  anourisms. 

I  do  not  wish  to  be  understood  as  denying  the  possibility  of 
the  passing  of  a  pulmonary  apoplectic  clot  into  putrefaction  ; 
but  that  the  accidental  putrefaction  of  blood  effused  in  the  lungs 
is  to  be  reckoned  as  even  an  ordinary  cause  of  pulmonary  gan- 
grene, I  feel  great  reluctance  to  admit.* 

Mr.  OTerrall,  adopting  generally  the  views  of  Dr.  Law,  goes 
a  step  further,  and  describes  a  non-putrefactive  gangrene  of  the 
sanguineous  clot,  and  also  states  that  the  clot  may  undergo  the 
process  of  puriform  softening ;  a  condition  in  itself  not  gan- 
grenous, so  far  as  the  clot  is  concerned,  but  which  may  be 
attended  with  sloughing  of  the  surrounding  tissues.  Without 
denying  the  accuracy  of  these  observations,  I  apprehend  that 
Mr.  O'Ferrall's  distinctions  are,  perhaps,  too  finely  drawn  ;  and 
it  is,  at  all  events,  clear  that,  in  the  present  state  of  our  know- 
ledge, there  is  no  practical  benefit  to  be  derived  by  the  attempt 
to  distinguish  between  the  ordinary  forms  of  gangrene,  and 
that  in  which  sloughing  of  the  pulmonary  tissue  complicates 
or  succeeds  to  the  puriform  softening,  as  described  by  Mr. 
O'Ferrall. 

The  researches  of  these  gentlemen,  however,  are  of  great  value, 
as  still  further  corroborating  the  opinion  already  announced  by 

*  How  otherwise  do  contused  injuries  lead  to  gangrene?  According  to  Hertz  "it 
may  be  found  to  occur  from  severe  contusions  of  the  thorax — for  instance,  injuries  to 
the  shoulder.  The  elasticity  of  the  chtst  wall  allows  the  contusion  to  act  on  the 
lung  and  thus  to  produce  effusion  of  blood  followed  by  gangrenous  sloughs."  (Art. 
Gangrene,  Ziemssen's  Cyclopedia,  vol.  v.  p.  412.) 

In  a  case  which  was  recently  under  my  care,  and  which  was  also  seen  by  my  friend 
Dr.  James  Little,  the  patient,  a  gentleman  aged  35,  while  engaged  in  the  amusement 
of  throwing  a  heavy  stone  from  his  shoulder,  was  seized  with  haemoptysis,  which 
recurred  repeatedly  at  intervals,  and  was  replaced  by  a  grumous  purulent  expectora- 
tion, which,  as  well  as  the  breath,  had  a  strongly  fcetid  odour.  The  signs  of 
pneumonic  consolidation  were  succeeded  by  those  of  cavity  in  the  upper  portion  of 
the  right  lung,  and  after  a  few  weeks  by  those  of  pneumothorax,  the  occurrence  of 
perforation  being  indicated  by  sudden  severe  pleuritic  pain.  The  disease  ended 
fatally  ten  weeks  after  the  attack  of  haemoptysis.    (En.) 


GANGRENE    OF    THE    LUNG.  365 

Laennec,  that  gangrene  of  the  lung  does  not  necessarily  imply  a 
previously  intense  inflammation.* 

There  is  a  great  difficulty  in  drawing  the  line  between  what 
has  been  termed  foetid  abscess  of  the  lung  and  true  gangrene. 
Are  they  cases  of  original  gangrenous  action,  or  examples  merely 
of  putrefaction  of  the  fluid  contents  of  a  pulmonary  abscess  ? 
Are  they  examples  of  gangrenous  action  speedily  formed,  and  as 
speedily  arrested  ?  for  we  know  that  many  such  cases  have 
eventuated  in  recover}*.  Further  investigation  alone  will  suffice 
to  clear  up  these  points.  With  the  sudden  formation  of  gan- 
grenous action  every  practical  man  is  familiar,  but  its  sudden 
cessation  is  a  circumstance  not  yet  sufficiently  recognized ;  yet 
we  may  observe  this  singular  phenomena  in  certain  cases  of 
typhus  fever,  when  the  occurrence  of  local  gangrene  is  manifestly 
under  the  operation  of  a  law  which  regulates  the  general  morbific 
state  arising  in  the  progress  of  that  condition,  and  suddenly 
ceasing  with  its  termination. 

We  may  see  a  patient  presenting  every  day  new  bed-sores  in 
every  part  of  the  body,  where  even  the  slightest  pressure  has 
been  exercised ;  a  condition  so  apt  for  the  gangrenous  state, 
that  the  mark  of  the  hand  may  be  imprinted  in  mortification  on 
the  face  if  the  patient  has  lain  but  for  an  hour  with  the  cheek 
supported  by  the  hand.  Every  day  new  cutaneous  gangrenes 
are  formed  up  to  a  certain  period,  when,  as  if  this  tendency,  like 
the  other  secondary  effects  of  fever,  was  under  a  law  of  periodicity, 
not  only  are  no  new  gangrenes  produced,  but  those  already 
formed  at  once  take  on  a  healthy  action.  May  not  the  same 
condition  occur  in  local  disease  of  the  lung  ?  How  many  of 
these  diseases,  supposed  to  be  idiopathic,  are  really  secondary 
to  an  unrecognized  morbid  state  of  the  entire  system. 

Practically,  however,  we  may  form  this  conclusion,  that,  in 
any  case  of  foetid  expectoration,  the  earlier  we  discover  the 
physical  signs  of  cavity,  or  of  manifest  local  disease,  preceding 
the  cavity,  the  better  should  our  prognosis  be. 

*  See  Dr.  Law's  paper,  Transactions  of  the  Association  of  the  King  and  Queen's 
College  of  Physicians,  New  Series,  vol.  i.  Also  Mr.  O'Ferrall's  Observations  in  the 
Transactions  of  the  Pathological  Society,  Dublin  Journal  of  Medical  Science,  First, 
Series,  vol.  xix.  p.  121. 

The  converse  of  this  does  not  hold  good.  On  this  Juergensen  remarks,  "  Rindfleisch 
states  that  an  exudation  which  contains  much  blood  is  apt  to  produce  gangrene.  This 
fact  may  be  explained  by  Cohnheim's  observation,  that  the  number  of  red  corpuscles 
in  an  exudation  increases  with  the  intensity  of  the  inflammation."  (On  Croupous 
Pneumonia,  Ziemssen's  Cyclop.,  vol.  v.  p.  49.)     (Ed.) 


3G6  GANGRENE    OF    THE    LUNG. 

It  would  be  difficult,  and,  in  some  cases,  perhaps,  impossible, 
to  make  an  accurate  diagnosis  between  foetid  abscess  of  the  lung 
and  gangrene ;  especially  when  the  case  is  seen  for  the  first 
time,  and  the  foetid  expectoration  established.  If  the  manifest 
signs  of  the  cavity  appear  at  a  very  early  period  of  the  case,  say 
within  a  week  or  ten  days  of  the  first  invasion  of  disease,  we 
ought  to  lean  to  the  more  favourable  opinion  of  abscess.  It  must 
be  remembered,  however,  that  this  is  the  more  rare  condition, 
and  that,  as  in  the  case  of  typhoid  consolidation,  a  gangrenous 
eschar  may  form  rapidly,  and  present  the  signs  of  cavity. 

An  important  case,  illustrative  of  these  remarks,  is  given  by 
Dr.  Hudson.  The  patient  had  been  attacked  with  pneumonic 
symptoms  ten  days  before  he  came  under  observation.  The 
lower  lobe  of  the  right  lung  was  solidified,  while  cavernous 
respiration  and  pectoriloquism  existed  at  the  angle  of  the  scapula. 
Next  day  the  breath  and  expectoration  were  foetid,  and  all  the 
signs  of  a  cavity  very  distinct.  In  about  twenty-four  hours  the 
foetor  ceased,  and  the  seventh  day  after  his  admission  to  hospital 
the  signs  of  cavity  had  disappeared. 

We  have  in  this  case  two  circumstances  leading  to  the  diag- 
nosis of  foetid  abscess  rather  than  of  true  gangrene ;  first,  the 
early  formation  of  a  cavity,  and  secondly,  the  existence  of  well- 
marked  physical  signs  of  extensive  recent  solidification. 

Of  a  similar  nature  is  the  example  recorded  by  Dr.  Williams 
in  the  Cyclopaedia  of  Practical  Medicine. 

In  addition  to  such  cases  of  foetid  abscess  there  are  two  other 
examples  of  disease  which  may  be  mistaken  for  gangrene  of  the 
lung  :  one  the  perforation  of  the  pleura  by  an  empyema,  and  the 
evacuation  of  the  fluid  through  the  lung;  and  the  other,  that 
which  is  commonly  described  as  the  opening  of  an  hepatic 
abscess  into  the  bronchial  tubes.  It  does  not  invariably  occur, 
however,  in  either  of  these  diseases,  that  the  fluid  evacuated  is 
putrid,  so  that  where  this  character  is  absent  it  is  not  likely 
that  the  case  would  be  confounded  with  gangrene.  W"e  only 
know  that  in  certain  cases  belonging  to  either  of  these  categories 
the  patient  at  some  period,  either  earlier  or  later  in  the  disease, 
expectorates  for  a  considerable  time  a  quantity  of  the  most 
offensive  matter,  has  a  foetid  breath,  and  presents  symptoms 
which  may  be  attributed  to  the  presence  of  a  septic  poison  acting 
on  the  economy. 


GANGRENE    OF   THE    LUNG.  367 

If  we  compare  these  two  cases  with  regard  to  the  facility  of 
diagnosis,  we  shall  find  much  less  difficulty  in  the  first  than  in 
the  second  example.  Indeed,  our  knowledge  as  to  this  last  class 
of  cases  is  still  extremely  imperfect,  as  will  be  seen  when  we  treat 
of  perforations  of  the  lung. 

The  diagnosis  of  the  first  is  in  general  not  difficult,  and  rests 
upon  three  considerations  : — 

I.  The  early  symptoms,  which  are  those  of  pleuritis  with 
effusion. 

II.  The  physical  signs  observable  before  the  occurrence  of 
any  foetid  expectoration,  which  are  indicative  of  a  manifest  and 
extensive  lesion. 

III.  The  coincidence  of  the  phenomena  of  pneumothorax, 
complicating  those  of  empyema,  coincident  with  the  occurrence 
of  foetid  expectoration. 

In  such  cases  we  are  not  yet  able  to  say  whether  the  putres- 
cence of  the  empyematous  fluid  existed  before  the  perforation  of 
the  pleura,  or  occurred  subsequently  to  the  admission  of  air, 
but  it  appears  that  in  some  instances  the  signs  of  putrescence 
have  rapidly  followed  those  of  the  perforation  of  the  pleura. 

Of  this  condition  I  saw  a  remarkable  instance  some  years  ago 
(which  will  be  found  narrated  in  the  chapter  on  diseases  of  the 
pleura). 

Our  knowledge  of  the  second  class  of  cases  is  still  so  limited 
that  we  can  do  little  more  than  indicate  their  general  character. 
A  patient  suffers,  or  is  supposed  to  suffer  from  acute  hepatitis, 
followed  by  constitutional  symptoms  indicating  suppuration. 
After  a  time  he  begins  to  expectorate  purulent  matter,  which 
may  or  may  not  be  putrid.  These  cases  have  been  hitherto  sup- 
posed to  be  examples  of  perforation  of  the  diaphragm  and  lung, 
and  direct  evacuation  of  the  hepatic  pus ;  but  there  is  reason  to 
doubt  the  existence  of  this  triple  lesion  in  many  instances,  and 
it  seems  probable  that  we  may  often  refer  the  phenomena  to 

vicarious  secretion,  independent  of  any  solution  of  continuity. 

In  such  a  case,  no  matter  how  great  the  foetor,  we  should  be 

extremely   slow    in    assuming    the    existence    of  a   pulmonary 

gangrene. 

The   attention   of  the   physician    in    such    cases    should   be 

directed  to  the  following  points  :  — 

I.  The  pre-existence  of  symptoms  of  hepatic  disease. 


368  GANGRENE    OF    THE    LUNG. 

II.  The  fact  that  though  the  symptoms  are  those  of  confirmed 
gangrenous  abscess,  the  physical  signs  of  such  a  condition  are 
wanting. 

III.  The  rarity  of  hemoptysis  in  these  cases,  as  compared 
with  those  of  ordinary  gangrene  of  the  lung. 

It  may  be  stated  that  in  these  three  cases  of  pneumonic  abscess, 
empyema  opening  into  the  lung,  or  hepatic  abscess,  with  or 
without  a  perforation  of  the  lung,  we  are  utterly  in  the  dark  as 
to  the  causes  which  determine  putrescence  in  some,  and  its 
absence  in  other  examples  of  these  diseases. 

If,  on  the  other  hand,  we  have  been  able  to  observe  the  case 
from  its  commencement,  and  traced  the  symptoms  and  signs  of 
a  pneumonia  to  its  suppurative  stage,  we  might  then,  on  the 
occurrence  of  fcetor,  diagnose  putrid  abscess.  I  have  never  seen 
any  case  of  true  primary  gangrene  of  the  lung  preceded  by  the 
signs  of  the  successive  stages  of  pneumonia. 

In  most  of  these  cases  it  is  only  with  reference  to  prognosis 
that  the  determination  of  the  question  is  of  importance,  for  the 
treatment  of  the  disease  in  either  case  should  not  materially 
differ. 

An  important  case  of  gangrene  of  the  lung,  and  purulent 
deposits,  is  mentioned  by  Dr.  Inman,  in  the  Reports  of  the 
Liverpool  Pathological  Society.*  The  patient,  a  female  of  rather 
intemperate  habits,  had  been  liable  to  chronic  cough.  She  was 
attacked  with  what  was  probably  diffuse  inflammation  of  the 
vulva,  which  soon  took  on  a  gangrenous  character.  She  died  in 
three  weeks,  and  it  was  found  that  the  lower  lobe  of  the  right 
lung  contained  three  gangrenous  cavities  which  did  not  com- 
municate with  the  bronchial  tubes. 

The  left  lung  contained  many  small  circumscribed  deposits  of 
yellowish  purulent  matter,  not  gangrenous. 

Can  we  interpret  the  phenomena  in  this  case  by  supposing 
the  absorption  of  gangrenous  matter,  and  recent  gangrene  of  the 
lung  thus  induced  '?  The  fact  of  the  co-existence  of  the  disease 
with  purulent  deposits  would  seem  to  strengthen  this  supposi- 
tion, to  which  Dr.  Inman  appears  to  incline. f 

The  following  conclusions  appear  justifiable  from  the  present 
state  of  our  knowledge  on  this  subject. 

*  Dublin  Medical  Journal,  First  Series,  vol.  xxvi. 
t  See  Appendix. 


GANGKENE    OF    THE    LUNG.  369 

1.  The  gangrene  of  the  lung  is  met  with  under  a  variety  of 
forms,  differing  from  one  another  not  only  in  the  duration  and 
violence  of  the  symptoms,  but  also  in  their  relations  to  various 
local  and  constitutional  diseases. 

2.  That  in  a  great  proportion  of  the  cases  the  disease  is 
attended  with  putrefactive  action  engaging  the  necrosed  portion 
of  the  lung,  and  affecting  its  secretions. 

3.  That  in  the  progress  of  a  case  we  may  observe  the  septic 
action  singularly  variable.  It  is  increased  by  over-stimulation  of 
the  system. 

4.  That  we  cannot  explain  the  symptoms  in  many  cases  of 
this  disease,  without  assuming,  either  that  a  spot  of  mortifica- 
tion, so  small  as  to  be  undiscoverable  by  physical  means,  causes 
severe  symptoms,  and  is  attended  with  super- secretion  ;  or  that 
a  process  of  putrefactive  secretion  precedes,  in  many  cases,  the 
death  of  the  lung. 

5.  That  pain  of  the  most  extreme  kind  may  attend  this 
disease  ;  and,  in  the  remittent  form,  appear  on  each  access  of 
the  affection  with  unmitigated  violence. 

6.  That  the  contact  with  air  is  not  necessary  for  the  formation 
of  a  gangrenous  eschar  or  cavity. 

7.  That  haemoptysis  commonly  attends  each  access  of  the 
remittent  disease. 

8.  That  in  the  earlier  periods  of  this  disease,  auscultation 
and  percussion  often  fail  in  detecting  any  signs  of  organic 
change  ;  or  if  such  is  discovered,  it  appears  incommensurate 
with  the  gravity  of  the  symptoms. 

9.  That  in  many  cases  the  evidences  of  congestion  and  paren- 
chymatous infiltration  seem  to  follow,  rather  than  precede,  the 
symptoms  of  gangrene. 

10.  That  dexiocardia,  from  diminished  volume  of  the  lung, 
may  occur  in  gangrene  of  the  right  lung. 

11.  That  gangrene  may  attack  a  lung  previously  hepatized 
from  ordinary  inflammation,  or  in  a  chronic  tubercular  con- 
dition. 

12.  That  from  the  pre-existence  of  signs  and  symptoms  of 
the  stages  of  pneumonia,  or  from  the  early  appearance  of  signs 
of  excavation,  we  may  be  able  to  distinguish  between  foetid 
abscess  of  the  lung  and  gangrene. 

13.  That  in  certain  cases  of  chronic  bronchitis  the  breath  and 

B    B 


370  GANGRENE    OF    THE    LUNG. 

expectoration  may  become  foetid,  and  yet  no  gangrene  appear  to 
have  formed. 

14.  That  the  diseases  with  which  gangrene  may  be  found 
complicated  are  divisible  into  general  and  local  affections  ;  but 
that  its  occurrence  in  the  class  of  general  diseases,  termed  putrid 
or  asthenic,  is  much  more  rare  than  might  be  expected. 

15.  That  it  is  rarely  observed  in  the  typhus  fever  of  this 
country,  even  where  the  secondary  bronchial  affection  is  intense  ; 
but  that  in  typhoid  pneumonia  it  may  be  occasionally  observed. 

16.  That  it  may  be  directly  induced  by  the  pressure  of  a 
tumour  on  the  nutrient  vessels  and  nerves  of  the  lung,  so  that 
in  cases  of  cancerous  or  aneurismal  tumour,  the  patient  may 
die,  not  from  the  extension  of  the  original  disease,  but  from  its 
inducing  a  rapid  mortification  of  some  portion  of  the  lung. 

17.  That  the  disease,  though  always  of  a  formidable  character, 
is  not  necessarily  fatal. 


APPENDIX. 


Of  other  forms  of  the  affection  the  following  are  worthy  of 
notice  : — 

I.  Gangrene  of  the  lung  consequent  on  bed  sores  in  fever. 

II.  Gangrene  due  to  purulent  infection  from  caries  of  the 
temporal  bone. 

III.  Gangrene  due  to  putrefaction  set  up  in  the  brochi  either — 

(a)  From  fistulous  communication  with  the  oesophagus. 

(b)  From  the  entrance  of  food  particles  during  the  artificial 
feeding  of  lunatics  or  paralyzed  persons. 

(c)  From  the  putrefaction  of  the  contents  of  a  bronchiec- 
tasis and  extension  of  infection  and  inflammation  to  sur- 
rounding lung. 

IV.  Due  to  the  lowered  state  of  the  general  nutrition  in 
insanity  and  cerebral  disease,  and  the  cachexia  of  Bright 's 
disease,  and  of  diabetes,  or  of  chronic  alcoholism. 

V.  Due  to  embolism  and  haemorrhagic  infarction. 

VI.  Due  to  prolonged  exposure  to  cold  and  moisture  while 
under  the  influence  of  alcohol. 


GANGRENE    OF    THE    LUNG.  371 

I.  Cases  of  this  category  are  noticed  by  Dr.  Murchison, 
chiefly  in  patients  who  had  previously  suffered  from  starvation, 
and  by  Dr.  Graves,  who  regards  the  pulmonary  gangrene  as 
secondary  to  that  of  the  sacrum,  and  adds  the  important  remark 
that  although  gangrene  of  external  parts  in  fever  sometimes 
occurs  in  those  not  liable  to  pressure,  that  he  "  never  knew  such 
parts  to  become  gangrenous  except  after  some  other  portion  of 
the  integument  had  mortified  evidently  in  consequence  of  pres- 
sure." 

On  this  secondary  infection  Niemeyer  observes  that  "the 
transition  of  necrosis  into  gangrene  is  materially  promoted 
if  a  ferment  (a  bit  of  putrid  material)  come  in  contact  with 
the  mortified  part.  This  explains  why  circumscribed  gan- 
grene of  the  lungs  is  common  in  metastatic  infarction  caused 
by  an  embolus  from  some  region  where  putrefaction  is  going 
on."* 

II.  In  cases  of  gangrene  following  caries  of  the  temporal 
bone,  Traube,  quoted  by  Hertz,  twice  observed  clots  adhering 
to  the  wall  of  the  corresponding  internal  jugular  vein  along  with 
hemorrhagic  infarction  of  the  lungs.  A  similar  case  was  reported 
to  the  Pathological  Society  of  Dublin  in  December,  1854,  by 
Dr.  B.  G.  McDowel. 

A  boy,  aged  thirteen,  was  admitted  into  the  Whitworth  Hos- 
pital on  the  3rd  and  died  on  the  5th.  He  had  for  ten  years  had 
otorrhoea.  A  fortnight  since  had  been  struck  on  the  ear.  Four 
days  after  had  headache  and  vomiting  ;  then  appeared  stupid, 
raved  occasionally,  and  screamed  at  night.  The  otorrhoea  had 
ceased. 

"  On  opening  up  the  right  lateral  sinus  a  round  opening  was 
found  leading  from  the  interior  of  the  mastoid  portion  of  the 
temporal  bone,  which  was  excavated  by  caries,  into  the  cavity  of 
the  sinus.  A  soft  coagulum  occupied  the  venous  channel  .  .  . 
On  the  surface  of  the  lungs  were  numerous  gangrenous  spots, 
over  each  of  which  the  pleura  was  elevated,  forming  a  dark 
bulla,"  &c. 

A  similar  case  was  reported  by  Dr.  J.  S.  Hughes  on  the  12th 
of  April,  1856. 

A  girl,  aged  eleven,  was  subject  to  deafness  and  otorrhoea  for 
nearly  two  years.     Five  week^  before  her  death  she  was  seized 

*  Text  Book  of  Medicine,  vol.  i.  p.  203. 
B    B  2 


372  GANGKENE    OF    THE    LUNG. 

with  severe  pain  in  the  ear,  rigors,  and  fever,  followed  by 
convulsions  and  severe  pain  in  the  head.  For  a  fortnight 
before  her  admission  into  Jervis  Street  Hospital  there  had 
been  no  discharge  from  the  ear.  Two  days  before  death  she 
had  dry  cough,  rapid  respiration,  and  strong  fcetor  from  the 
breath. 

Among  the  morbid  appearances  in  the  head  the  petrous  por- 
tion of  the  temporal  bone  was  found  carious  and  cribriform,  the 
groove  for  the  lateral  sinus  carious  and  covered  with  purulent 
matter,  the  sinus  filled  with  coagulated  blood. 

"  When  the  thorax  was  opened  some  foetid  air  escaped,  and 
the  right  cavity  of  the  pleura  was  found  to  contain  purulent 
matter.  The  edge  of  the  lower  lobe  and  the  lower  border  of  the 
upper  lobe  each  presented  two  small  spots  of  gangrene  covered 
by  cribriform  pleura,  and  the  left  lung  contained  a  large  gan- 
grenous abscess." 

III.  (a)  In  an  illustrative  case  of  this  lesion  presented  to  the 
Pathological  Society  by  Mr.  J.  Hamilton,  January  12th,  1860, 
a  communication  was  found  between  the  oesophagus  imme- 
diately above  a  scirrhous  stricture  and  a  large  gangrenous  abscess 
in  the  adjoining  portion  of  the  left  lung. 

On  this  occasion  Professor  K.  Smith  stated  "  that  he  had 
seen  not  less  than  five  cases  previous  to  the  present,  this  being 
the  sixth,  wherein  abscess  of  the  lung,  generally  of  a  gangrenous 
character,  co-existed  with  ulcerated  stricture  of  the  oesophagus  ; 
and  in  every  one  of  these  cases  a  communication  had  been 
formed  by  ulceration  between  the  tube  and  the  pulmonic  abscess, 
the  latter  being  the  secondary  affection." 

(b)  According  to  Hertz,  "foreign  bodies  which  have  found 
their  way  into  the  lung  through  the  trachea,  especially  particles 
of  food  which  rapidly  decompose  under  the  influence  of  heat, 
air,  and  moisture,  may  establish  bronchopneumonia  accom- 
panied by  abscess  or  gangrene  of  the  lung.  This  frequently 
occurs  during  the  artificial  feeding  of  lunatics  or  paralytics,  and 
in  disease  of  the  larynx,  or  imperfect  closure  of  the  epiglottis."* 

(c)  According  to  Dr.  Wilson  Fox  this  secondary  inflammation 
in  the  surrounding  indurated  parts  is  not  uncommon,  and  is 
prone  in  some  instances  to  take  on  a  gangrenous  action.  Traube, 
indeed,  regards  this  process  as  one  of  the  most  common  causes 

*  Ziemssen's  Cyclopedia,  vol.  iv.,  Art.  Gangrene  of  the  Lung. 


GANGRENE  OF  THE  LUNG.  373 

of  gangrene  of  the  lung."  (See  also  Juergensen  ;  Ziemssen, 
vol.  v.  p.  48.) 

IV.  Hertz  considers  it  "a  doubtful  question  whether  lower- 
ing of  the  general  nutrition  can  by  itself  lead  to  gangrene."  "  It 
would  rather  appear  that  this  condition  produces  an  increased 
receptivity  and  want  of  power  of  resistance.  Thus  there  may 
easily  arise  asthenic  pneumonic  infiltrations,  which  are  often 
overlooked  owing  to  the  paucity  of  the  symptoms  or  the  insuffi- 
cient examination  of  the  patient.  Pneumonia  in  this  class  of 
persons  often  leads,  as  above  stated,  to  gangrene,  and  the  lung 
affection  is  not  recognized  until  it  betrays  itself  by  the  stinking 
sputa." 

Whether  we  consider  the  lowering  of  the  general  nutrition  in 
Bright's  disease,  diabetes,  chronic  alcoholism,  insanity,  or  para- 
lysis as  the  sole  cause,  or  as  a  predisponent,  there  can  be  no 
question  of  its  frequent  pre-existence  or  of  its  influence  in  mask- 
ing and  rendering  latent  the  symptoms  and  physical  signs  of 
the  pulmonary  affection. 

Of  this  latency  a  remarkable  example  was  communicated  to 
the  Pathological  Society  of  Dublin,  January  30th,  1858,  by  Dr. 
Gordon. 

The  patient  had  been  for  some  days  under  treatment  for  dia- 
betes, not  complaining  of  cough  or  dyspnoea,  and  presenting  no 
sign  of  thoracic  disease. 

On  the  21st  inst.  he  complained  of  having  caught  cold, 
and  of  feeling  weak,  and  wished  to  remain  in  bed.  On 
the  22nd  he  had  some  pain  in  the  right  side,  but  still  no 
cough  nor  dyspnoea.  Some  dulness  was  found  on  the  right 
side  posteriorly,  with  slight  bronchial  breathing.  On  the 
23rd  he  complained  of  sudden  violent  stitch,  with  intense 
dyspnoea  and  collapse,  the  physical  signs  of  pneumothorax 
being  found. 

On  the  24th  he  died. 

The  post  mortem  appearances  were  air  and  lymph,  without 
fluid,  in  the  pleura,  a  large  rent  in  the  upper  and  posterior  por- 
tion of  the  lung,  around  which  the  pleura  was  of  an  ashy  grey 
colour,  and  through  which  the  pulmonary  structure  protruded 
in  loose  shreds,  the  lung  in  the  vicinity  being  in  a  state  of 
gangrenous  suppuration. 

In  a  valuable  paper  by  Dr.  McDowel  on  the  connexion  between 


374  GANGRENE    OF    THE    LUNG. 

pneumonia  and  renal  disease,  lie  adduces  twelve  cases  in  proof 
of  the  following  conclusions  : — 

1.  That  in  fatal  cases  of  pneumonia,  renal  disease  is  very 
frequently  found  to  exist. 

2.  That  where  such  a  combination  of  disease  exists,  suppura- 
tion of  the  lung  will  be  very  constantly  met  with. 

3.  That  a  similar  morbid  condition  of  the  kidney  is  often 
found  in  gangrene  of  the  lung. 

4.  Stated  conversely — that  where  pneumonia  supervenes  in  a 
person  in  whom  renal  disease  has  previously  existed,  it  is  very 
apt  to  assume  the  suppurative  or  the  gangrenous  form.* 

In  the  course  of  his  observations  on  a  rare  example  of  universal 
gangrene  of  the  lungs,  which  he  communicated  to  the  Patho- 
logical Society  of  Dublin  in  December,  1866,  Dr.  Banks  said  : 
"  With  respect  to  the  great  comparative  frequency  of  gangrene 
of  the  lung  amongst  the  insane,  my  experience  does  not  support 
the  statement  made  by  foreign  physicians. 

"  I  have  seen  cases  of  fcetid  abscess  of  the  lung  in  the  insane, 
but  I  have  never  seen  a  case  of  true  gangrene.  My  friend  Dr. 
Lalor,  the  medical  superintendent  of  the  Eichmond  Asylum,  who 
has  been  engaged  for  twenty  years  in  the  treatment  of  the  insane, 
informs  me  that  he  has  never  seen  a  case  in  nearly  3,000  which 
have  passed  under  his  observation."  (Dublin  Quarterly  Journal, 
vol.  xliii.) 

V.  Embolism  and  hemorrhagic  infarction.  "  Interruption  to 
the  circulation  in  the  lungs,"  says  Hertz,  "  may  also  be  produced 
by  an  embolus  which  may  either  arise  from  a  clot  in  the  right 
heart,  or  owe  its  origin  to  some  thrombus  in  the  veins  of  the 
general  circulation.  The  hemorrhagic  infarction  which  results 
from  this  can  produce  putrefaction,  destruction,  and  gangrene  of 
the  lung  tissue  by  causing  complete  stasis  in  the  neighbouring 
vessels.  When  both  the  agents — pneumonia  and  embolus — exist, 
the  development  of  gangrene  becomes  still  more  probable,  as 
occurred  in  the  case  published  by  me."  t 

Besides  the  infectious  thrombi  arising  from  gangrenous  bed- 
sores, caries  of  the  temporal  bone,  &c,  Mr.  O'Ferrall  has  directed 
attention  to  the  occasional  connexion  between  purulent  cysts  in  the 
heart  and  gangrene  of  the  lung.     In  February,  1839,  he  com- 

*  Dublin  Quarterly  Journal,  May,  185G. 
f  Loc.  cit. 


GANGRENE    OF    THE    LUNG.  375 

muiiicated  to  the  Pathological  Society  a  case  of  several  softened 
purulent  cysts  (one  of  which  contained  nearly  two  drachms  of 
pus)  in  the  heart,  with  a  gangrenous  cavity  in  the  lung,  and  in  a 
subsequent  communication  he  argues  that  blood  extravasated  into 
the  tissue  of  the  lung  undergoes  a  similar  process  of  puriform 
softening,  leading  to  the  formation  of  gangrenous  abscess. 

VI.  This  cause  has  scarcely  met  with  the  attention  it  merits 
from  its  frequency  and  importance. 

(d)  As  regards  its  frequency.  On  my  once  remarking  to  Dr. 
Stokes  that  nearly  every  case  in  my  experience  had  been  thus 
caused,  his  reply  was,  "  At  least  six  out  of  seven  in  mine";  and  in  a 
valuable  communication  to  the  Dublin  Pathological  Society,  in 
March,  1864,  Dr.  Law  remarked  that  "  all  the  cases  of  gangrene 
of  the  lungs  that  had  come  under  his  observation  occurred  either  in 
persons  of  intemperate  habits,  or  in  those  who  at  the  time  of 
exposure  to  cold  were  more  or  less  under  the  influence  of  drink." 
One  of  the  preparations  which  he  exhibited  was  an  example 
of  circumscribed  gangrene  involving  almost  the  entire  lung. 
Almost  the  whole  pulmonary  structure  was  reduced  to  a  mere 
shreddy  pulp. 

The  dead  sloughy  portion  was  contained  in  a  distinct  cavity, 
whose  walls  were  formed  of  a  thin  stratum  of  the  pulmonary 
tissue.  In  this  cavity,  too,  there  was  a  quantity  of  blood  in  a 
state  of  decomposition.  The  patient  before  his  death  had  had 
profuse  haemoptysis.  The  subject  of  this  case  had  lain  out  on 
damp  hay  while  in  a  state  of  intoxication. 

Another  fatal  case  occurred  to  a  man  who,  when  not  sober,  in 
coming  on  shore  from  a  vessel  in  the  Liffey  along  the  quay  wall, 
fell  into  the  water.  He,  too,  had  profuse  haemoptysis,  and  the 
blood  emitted  a  most  foetid  smell. 

{b)  It  is  important  in  its  bearing  on  the  proper  prophylactic 
treatment.  Owing  to  the  propinquity  of  Jervis  Street  Hospital 
to  the  river  and  Custom  House  Docks,  persons  who  have  fallen 
into  the  water  while  intoxicated,  or  who,  being  unable  to  swim, 
have  been  long  immersed,  are  usually  carried  thither.  These 
persons  are  frequently  livid  and  collapsed  when  admitted,  and 
reaction,  unless  under  suitable  treatment,  has  been  followed  by 
congestive  pneumonia,  and  not  unfrequently  by  gangrene.  To 
obviate  this  result  no  measure  has  been  found  so  effectual  as 
general  blood-letting,  and  accordingly  this  practice,  adopted  at 


376  GANGRENE    OF    THE    LUNG. 

first  by  the  late  Mr.  Stapleton  and  Dr.  J.  Staunus  Hughes,  is 
usually  resorted  to.  In  a  communication  with  which  he  has 
favoured  me,  Dr.  Hughes  says,  "  The  treatment  we  have  adopted 
in  cases  of  submersion  for  years  past,  is  as  follows  :  as  soon  as  a 
sufficient  amount  of  reaction  has  been  established  to  justify  us  in 
doing  so,  we  have  recourse  to  general  blood-letting  from  the  arm, 
with  the  view  of  removing  pulmonic  congestion,  and  thus  pre- 
venting the  accession  of  inflammation,  and  probably  of  gangrene 
of  the  lungs.  At  times,  when  the  patient  was  young  and  healthy, 
and  the  symptoms  urgent,  we  have  bled  him  a  second  time  ;  in 
other  cases,  after  one  general  bleeding,  we  have  had  the  patient 
cupped  over  the  base  of  the  affected  lung. 

"  We   conceive  that  by  the  foregoing  treatment  many  lives 
have  been  saved." 

Dr.  Hughes  has  kindly  forwarded  the  notes  of  a  case  by  his 
former  colleague,  Dr.  Cooley,  which  well  illustrates  the  practice. 
"  Whilst  I  was  attached  to  Jervis  Street  Hospital,"  writes  Dr. 
Cooley,  "  I  had  the  advantage  of  seeing  three  cases  of  immersion 
treated  by  the  late  Dr.  Stapleton,  and  I  was  so  favourably  im- 
pressed by  the  result  that  I  should  adopt  his  method  in  any 
suitable  case. 

"  In  one  the  patient  had  been  taken  out  of  the  river  a  few  hours 
previously  quite  insensible,  but  had  revived,  and  was  apparently 
well  when  taken  into  the  hospital.     Almost  immediately  after 
admission,   difficulty  of  breathing  came  on,  and  in  three  or  four 
hours  he  was  insensible,  with  hurried  and  forced  respiration  and 
congested  face.     I  may  remark  that  the   pulse  was  quick  and  so 
weak  that  no  man,  unless  one  with  great  confidence  in  the  method 
of  treatment,  would  have  dared  to  bleed.'    However,  Mr.  Staple- 
ton  in  my  presence  opened  a  vein  at  the  bend  of  the  elbow.     At 
first  the  blood  would  hardly  flow — a  few  drops  thick  and  tarry  in 
appearance  trickled  from  the  wound,  and  soon  began  to  run  in 
a    stream,  gradually  becoming  more   fluid  and    red  in  colour. 
When  about  six  ounces  had  flowed  the  respiration  became  less 
oppressed,  the  pulse  fuller  and  stronger,  the  face  lost  its  dusky 
hue,  and  in  a  few  minutes  more  the  patient  opened  his  eyes 
and   was   restored   to    consciousness.      No    further    pulmonary 
symptoms  supervened,  and  he  left  perfectly  well  in  a  few  days. 

"  It  may  be  well  to  mention  that  Mr.  Stapleton  lays  down  the 
rule  very  definitely  as  to  the  time  at  which  the  bleeding  should 


GANGRENE    OF    THE    LUNG.  377 

be  done  to  be  most  effectual.  He  used  to  say  it  could  only  be 
depended  upon  at  the  beginning  of  the  secondary  insensibility, 
which  I  have  mentioned  before.  When  the  lungs  are  beginning 
to  fail  from  too  much  blood  being  in  them,  or  from  an  altered 
state  of  that  blood,  or  from  defective  innervation  due  to  poisoned 
cerebro-spinal  centres.  If  the  engorgement  of  the  lung  have 
passed  on  to  extravasation,  or  the  patient  survived  long  enough 
for  true  inflammation  to  supervene,  he  had  not  the  same  confi- 
dence in  the  remedy." 

Dr.  Hughes  considers  that  "  the  rationale  of  the  advantages 
derived  from  general  blood-letting  after  immersion  "  is  to  be  found 
in  the  fact  that  as  man  does  not  enjoy  "  those  provisions  which 
amphibious  animals  are  endowed  with  in  the  shape  of  vast  venous 
reservoirs  formed  by  the  inordinate  size  of  their  venae  cavae, 
venae  hepaticae,  veins  of  the  spinal  canal,  together  with  a  mass  of 
large  coiled  vessels  on  the  back  part  of  the  neck,  in  which  the 
living  liquid  blood  is  stored  temporarily  away  while  the  animal  is 
under  water — in  him  the  blood  is  necessarily  driven  by  the 
combined  effects  of  pressure  and  cold  from  the  surface  of  the 
body  to  some  internal  vital  organ,  and  notably  to  the  cerebrum, 
the  lungs,  and  the  liver ;  and  hence  general  blood-letting  acts 
by  relieving  the  congested  organs." 

Note. — There  is  one  fact  worthy  of  remark  which  I  do  not 
remember  to  have  seen  noticed.  It  is  the  destructive  influence 
on  the  vitality  of  the  blood,  of  long  continued  immersion,  espe- 
cially when  with  this  is  combined  unusual  exertion,  such  as,  e.g., 
ineffectual  attempts  to  reach  land.  I  have  seen  several  examples 
of  this  while  residing  in  the  country.  In  one  remarkable  case  a 
young  man  in  the  unsuccessful  endeavour  to  extricate  himself 
from  a  mass  of  weeds  in  the  river  Boyne,  became  exhausted  and 
insensible.  In  that  condition  he  was  rescued,  and  carried  into  a 
neighbouring  house.  The  recovery  of  consciousness  was  almost 
immediately  followed  by  profuse  haemoptysis  and  intense  heat  of 
the  surface,  and  these  by  death  within  twenty-four  hours. 

In  two  other  instances,  wading  for  many  hours  was  suc- 
ceeded by  necramia,  proved  by  the  rapid  appearance  of  petechias, 
boils  containing  grumous  blood  only,  and  by  fatal  haemorrhage 
from  the  gums,  lungs,  bowels,  and  kidneys.     (Ed.) 


378 


SECTION  VI. 


PERFORATING    ABSCESS    OF    THE    LUNG. 

We  may  thus  designate  those  cases  where  purulent  collections 
form  exterior  to  the  lung,  hut  afterwards  perforate  its  tissue,  and 
are  evacuated  hy  the  bronchial  tubes.  This  termination  may  be 
observed  in  the  following  cases  : — 

1st.  Abscess  of  the  thoracic  or  abdominal  integuments  passing 
across  the  pleura  by  adhesion,  and  forming  a  fistulous  com- 
munication with  the  lung. 

2ndly.  Purulent  collections  in  the  serous  membrane,  opening 
directly  into  the  lung. 

3rdly.  Hepatic  abscess  perforating  the  diaphragm,  and  being 
discharged  through  the  bronchial  tubes.* 

Of  these  the  last  is  the  most  frequent.  As  its  diagnosis  is  of 
importance  in  a  practical  point  of  view,  I  shall  dwell  upon  it  here. 

We  may  apply  to  the  diagnosis  of  the  opening  of  hepatic 
abscess  into  the  lung,  the  same  principles  which  guide  us  in  all 
cases  where  the  matter  is  evacuated  internally.  The  grounds 
of  the  diagnosis  are,  the  occurrence  of  new  and  extraordinary 
symptoms,  co-incident  with  the  subsidence  of  the  hepatic  disten- 
tion. Now  we  may  make  two  divisions  of  the  internal  openings, 
according  as  these  lead  into  shut  sacs,  as  the  serous  membranes, 
or  into  cavities  having  external  communications,  such  as  the 
digestive  canal  or  bronchial  tubes  ;  the  cases  of  the  first  class 
being  almost  always  fatal,  while  in  those  of  the  second,  recovery 
is  by  no  means  unfrequent. 

In  applying  these  views  to  practice,  we  find  that  the  sudden 
occurrence  of  inflammation  of  a  serous  membrane,  points  out  the 

*  With  reference  to  the  subject  of  perforation  of  the  hmg,  I  would  refer  to  the 
essay  of  M.  Berton  on  Bronchial  Phthisis.  See  the  translation  of  his  memoir  in  the 
Dublin  Journal  of  Medical  Science,  vol.  vii.  In  the  same  volume  there  is  a  valuable 
paper  by  Dr.  Froriep  of  Berlin,  on  abscesses  of  the  neck,  in  which  he  gives  a  case  of 
abscess  of  the  anterior  mediastinum,  communicating  with  the  ver.a  cava  and  lung.  See 
the  Medizinische  Zeitung,  July,  1834. 


PERFORATING    ABSCESS    OF    THE    LUNG.  379 

rupture  into  a  shut  sac  ;  while  purulent  discharges  from  the 
rectum  or  stomach  mark  the  opening  into  the  gastro-intestinal 
tube.  Lastly,  a  copious,  sudden,  and  purulent  expectoration 
shews  that  the  lung  has  been  made  subservient  to  the  evacuation 
of  the  matter.  Empyema  rarely  results  from  this  perforation, 
for,  in  consequence  of  adhesions,  the  matter  almost  always 
crosses  the  pleural  cavity,  and  enters  the  pulmonary  tissue.  No 
case  of  empyema  from  this  cause  has  ever  come  before  me, 
while  I  have  seen  several  in  which  the  matter  was  completely 
expectorated,  and  in  which  perfect  recovery  followed. 

When  I  speak  of  pleuritis,  I  shall  allude  to  the  second  case 
of  perforation,  in  which  an  original  collection  in  the  serous 
membrane  opens  into  the  lung.  Of  the  first  variety  the  following 
case  is  a  singular  instance. 

Case  I. — Abscess  of  the  Abdominal  Parietes  resting  on  the 
convex  surface  of  the  Liver,  opening  externally,  and  also 
perforating  the  Diaphragm,  and  forming  a  fistulous  com- 
munication with  the  Bronchial  Tubes. 

A  woman,  aged  23,  was  attacked  with  cough  and  haemoptysis, 
followed,  after  some  days,  by  fever.  Soon  after  this  she  com- 
plained of  pain  in  the  right  side  of  the  chest  and  hypochon- 
drium,  increased  by  coughing,  pressure,  or  motion.  She  had  a 
distressing  short  cough,  with  yellow,  tenacious  expectoration. 
The  inferior  portion  of  the  right  side  sounded  dull ;  and  the 
respiration  was  here  almost  inaudible,  except  on  a  forced  in- 
spiration. The  symptoms  having  continued  for  about  a  fortnight, 
an  uncircumscribed  tumour  appeared  between  the  second  and 
third  ribs  of  the  right  side  ;  the  haemoptysis  returned,  with  a 
hard  teasing  cough,  but  the  fever  disappeared.  Poultices  were 
diligently  applied  to  the  tumour,  which  rapidly  enlarged,  and 
became  fluctuating.  It  was  opened  on  the  thirteenth  day,  when 
a  great  quantity  of  matter  mixed  with  blood,  was  discharged ;  at 
this  time  the  haemoptysis  ceased.  In  about  three  weeks,  how- 
ever, the  abscess  again  appeared,  and  rapidly  increased  to  a  size 
much  greater  than  before ;  it  was  again  opened,  and  a  large 
quantity  of  purulent  matter  given  exit  to.  Next  day  it  presented 
the  appearance  of  an  enormous  anthrax,  with  edges  about  two 
inches  high,  from  which  a  quantity  of  whitish  slough  could  be 


380  PERFOKATING    ABSCESS    OF    THE    LUNG. 

detached  by  pressure.  The  patient  was  now  emaciated  ;  had 
diarrhoea  with  cough ;  and  sanguinolent  and  puriform  expec- 
toration. We  endeavoured  to  trace  the  extent  of  the  disease,  by 
introducing  a  probe ;  but  although  this  was  found  to  pass 
extensively  under  the  muscles  and  cellular  substance,  yet  it 
could  not  be  introduced  either  into  the  thoracic  or  abdominal 
cavity.  After  some  time  it  was  found,  that  when  the  patient 
coughed,  air  escaped  with  great  violence  from  the  base  of  the 
ulcer.  A  circular  fistula  was  now  discovered,  through  which  a 
probe  could  be  passed  upwards  for  about  three  inches,  when  it 
met  with  a  solid  resisting  body.  The  infra-mammary  region 
sounded  clear,  while  the  respiration  was  cavernous,  and  accom- 
panied during  inspiration  by  a  sound  like  the  tick  of  a  watch. 
When  the  patient  coughed  or  made  a  forced  inspiration,  a  loud 
gurgling  was  audible;  there  was  no  metallic  tinkling,  bour- 
donnement,  or  pectoriloquism  ;  but  the  voice  resounded  strongly 
from  the  sixth  rib  upwards,  while  anteriorly  and  posteriorly 
the  respiratory  murmur  appeared  natural.  She  soon  after 
sunk. 

Inspection.— Great  emaciation  ;  the  external  sore  extended 
from  the  sixth  to  the  tenth  rib,  and  was  about  four  inches  in 
breadth.  Between  the  eighth  and  ninth  ribs  the  fistula  was 
plainly  observable.  The  peritoneum  was  healthy,  with  the 
exception  of  that  portion  which  covered  the  liver  laterally  and 
superiorly.     Here  the  liver  adhered  to  the  diaphragm. 

On  the  centre  of  the  convex  surface  of  the  liver,  we  found  the 
base  of  the  abscess,  formed  by  a  circular  portion  of  thick,  false 
membrane  of  about  two  inches  in  diameter,  external  to  the 
hepatic  'peritoneum,  but  producing  a  depression  on  its  surface. 
The  costal  portion  of  the  diaphragm,  for  an  extent  corresponding 
to  the  base  of  the  abscess,  was  destroyed,  but  adhered  round  its 
edges.  This  abscess  communicated  with  the  right  lung  by  a 
perforation  through  the  diaphragm,  of  the  same  size  as  the  ex- 
ternal fistula,  which  led  into  a  cavity  in  the  lower  lobe,  narrow, 
elongated  upwards,  and  presenting  many  of  the  characters  of 
a  pneumonic  abscess.  It  had  no  lining  membrane,  and  com- 
municated with  numerous  bronchial  tubes.  Around  it  the 
pulmonary  tissue  was  of  a  greyish  white  colour,  softened,  but 
not  granular  ;  the  diseased  portion  did  not  terminate  by  any 
distinct  line,  and  occupied  about  two-thirds  of  the  lower  lobe, 


PERFORATING    ABSCESS    OF    THE    LUNG.  381 

which  adhered  to  the  diaphragm  and  costal  pleura;  the  remainder 
of  the  lung  was  health}7.* 

This  is  the  only  case  in  which  I  have  had  an  opportunity  of 
examining  the  mechanism  of  the  transit  of  pus  across  the  lung. 
An  ulcerous  cavity  communicating  with  the  bronchial  tubes,  and 
being  itself  the  continuation  of  the  diaphragmatic  fistula,  was 
found  to  exist,  and  its  presence  during  life  was  easily  detected 
by  auscultation.  It  may  be  inquired  whether  the  cavity  in  the 
lung  was  the  result  of  the  purulent  infiltration  merely,  or  caused 
by  a  distinct  attack  of  pneumonia.  It  seems  more  probable  that 
the  lower  lobe  of  the  lung  suffered  simultaneously  with  the  liver, 
and  that  thus  it  was  prepared  for  the  irruption  of  a  foreign 
substance  into  the  bronchial  tubes.  I  do  not  affirm  that  this 
occurs  in  all  cases,  for  I  have  seen  several  instances  in  which 
the  symptoms  left  no  doubt  as  to  what  had  happened,  yet  in 
which  the  stethoscope  failed  to  detect  the  cavity.  Viewed  with 
reference  to  physical  diagnosis,  the  case  furnishes  an  example 
of  large  abscess  in  the  lung  without  pectoriloquism.  I  once 
thought  that  this  was  explicable  by  the  fact  of  the  cavity  having 
an  external  opening  which  would  prevent  the  reverberations 
of  the  voice,  but  I  have  since  seen  several  cases  of  phthisical 
cavities,  in  which  this  phenomenon  was  wanting,  although  free 
bronchial  communication  existed.  Further  observations  are 
necessary  to  determine  the  conditions  which  regulate  the  occur- 
rence of  pectoriloquism. 

The  next  case  is  a  remarkable  instance  of  the  extent  of  organic 
lesion,  compatible  with  life. 

Case  II. — Fistulous  openings  from  the  Pleura  into  the  Lung  and 
Liver;  Gangrenous  Abscess  of  the  Lung;  Empyema  and 
Pneumothorax ;  fistulous  opening  of  the  Liver  into  the  trans- 
verse arch  of  the  Colon. 

A  middle-aged  man  had  for  some  time  laboured  under  the 
symptoms  of  empyema,  when  it  was  proposed  to  remove  the  fluid 
by  paracentesis  ;  he  was  then  seen  by  a  late  distinguished  friend 
of  mine,  who  ascertained  the  presence  not  only  of  empyema,  but 
pneumothorax,  with  pulmonary  fistula.  In  addition  to  these 
symptoms  it  was  found,   that  on   sitting  up,  the   patient    was 

*  Clinical  Report  of  the  Meath  Hospital,  Dub.  Hosp.  Reports,  vol.  v.     See  the 
Cyclopaedia  of  Practical  Medicine,  Art.  Inflammation  of  the  Liver. 


382  PERFORATING    ABSCESS    OP   THE    LUNG. 

immediately  attacked  with  a  tendency  to  diarrhoea,  and  discharged 
a  sero-purulent  fluid  in  considerable  quantity,  per  anum ;  on 
lying  down  the  discharge  always  ceased.  On  dissection  the 
following  lesions  were  found  :  a  gangrenous  cavity  existed  in  the 
upper  portion  of  the  right  lung,  communicating  with  the  bron- 
chial tubes  and  pleura ;  this  sac,  the  upper  part  of  which  con- 
tained air  in  quantity,  was  about  half  filled  with  a  yellowish  and 
foetid  liquid,  in  which  were  found  the  debris  of  numerous  hyda- 
tids. A  large  opening  passed  through  the  diaphragm  into  the 
substance  of  the  liver,  and  from  this  cavity  another  fistula  pro- 
ceeded to  the  ascending  colon  ;  so  that  a  false  passage  was 
formed  from  the  bronchial  tubes  to  the  colon  and  rectum,  and 
the  singular  symptom  of  diarrhoea  in  the  erect  position,  satisfac- 
torily explained.* 

The  next  case  illustrates  the  opening  of  an  hepatic  abscess  into 
the  left  lung. 

Case   III. — Fever  with  Jaundice,-    subsequent  hepatic  abscess 

opening  into  the  left  Lung. 

During  the  epidemic  fever  of  1826  and  18*27,  which  occurred 
in  Dublin,  a  man,  aged  28,  was  attacked  on  the  fourth  day  of  his 
fever  with  jaundice,  and  the  formidable  symptoms  of  yellow  fever, 

*  Professor  Carswell  has  recorded  a  case  very  similar  to  the  above.  He  says  : 
"When  the  diaphrngm  adheres  to  the  abscess,  and  is  perforated,  three  consequences 
may  follow :  the  contents  of  the  abscess  may  pass  into  the  cavity  of  the  chest ; 
into  the  bronchi  from  a  portion  of  the  lung  which  had  adhered  to  the  diaphragm, 
having  been  destroyed  by  ulceration  or  sloughing  ;  or  into  the  cavity  of  the  chest  and 
bronchi  at  the  same  time.  We  have  only  seen  one  case  of  the  last  variety  of  perfora- 
tion of  abscess  of  the  liver,  or,  more  correctly  speaking,  of  a  pnrulent  cyst  con- 
taining a  great  number  of  hydatids.  Although  these  vesicular  animals  have  some- 
times been  expectorated  in  cases  of  this  kind,  such  did  not  happen  in  the  case  to  which 
we  allude.  The  communication  between  the  bronchi  and  cyst  took  place  first,  followed 
by  a  yel low-coloured  expectoration,  which,  because  of  the  existence  of  the  cyst  in 
the  liver  having  previously  been  detected,  was  supposed  to  be  owing  to  the  passage 
of  the  bile  into  the  bronchi  from  perforation.  Soon  afterwards  symptoms  of  pleurisy 
manifested  themselves,  accompanied  with  those  of  effusion  and  pneumothorax,  the 
real  nature  of  which  was  not  understood  until  after  death.  Only  one  opening  was 
found  in  the  diaphragm,  where  it  covered  a  cyst  from  six  to  seven  inches  in  diameter, 
containing  a  yellow,  puriform  fluid,  and  hydatids  ;  this  opening,  sufficiently  large  to 
admit  the  fore-finger,  communicated  with  an  excavation  formed  in  the  inferior  lobe 
of  the  lung,  which  adhered  but  slightly  to  the  diaphragm.  In  the  bottom  of  this 
excavation  there  were  several  openings,  some  of  them,  which  were  small,  com- 
municating with  the  bronchi,  others  larger,  leading  into  the  cavity  of  the  pleura.  This 
cavity  contained  a  quantity  of  air,  yellow  sero-purulent  fluid,  and  a  great  number 
of  large  and  small  hydatids.  The  lung  was  considerably  compressed,  and  the  pleura 
covered  with  recent  coagulable  lymph." — Cyclopaedia  of  Practical  Medicine,  Art.  Per- 
foration of  Viscera. 


PERFORATING   ABSCESS    OF    THE    LUNG.  383 

to  which  so  many  at  that  time  fell  victims.*  The  symptoms 
were  subdued  by  the  most  active  treatment,  and  after  some  time 
he  was  discharged.  In  about  a  fortnight,  however,  he  was 
admitted,  labouring  under  hectic  fever,  with  a  continued  dry 
cough.  Fearing  that  he  was  becoming  phthisical,  I  repeatedly 
examined  both  lungs  with  the  greatest  care,  but  in  no  part  of 
the  thorax  could  I  find  anything  that  would  account  for  the 
symptoms.  His  distress  increased,  when  he  suddenly  began 
to  expectorate  large  quantities  of  purulent  matter  ;  and  during 
the  first  night  he  discharged  nearly  two  pounds  of  perfectly  formed 
pus.  On  the  following  morning,  the  left  lung,  which  the  day 
previously  had  presented  no  morbid  sign  u-Jiatever,  either  by  the 
stethoscope  or  percussion,  was  found  over  the  whole  region  of  the 
lower  lobe  completely  dull,  and  with  extinction  of  the  respiratory 
murmur.  There  was  no  bronchial  respiration,  resonance  of  the 
voice,  dilatation  of  the  side,  nor  displacement  of  the  heart ;  nor  any 
symptom  of  either  pleuritic  or  pneumonic  inflammation.  The 
patient  continued  to  expectorate  copiously  for  some  days  ;  after 
the  second  day  the  morbid  phenomena  began  to  subside.  We 
had,  first,  a  mucous  rattle  audible  at  the  root  of  the  lung,  which 
gradually  extended  over  the  dull  portion,  and  was  followed  by  a 
return  of  the  respiratory  murmur  and  resonance  of  the  voice. 

This  stethoscopic  observation,  for  the  accuracy  of  which  I 
pledge  myself,  is  explicable  only  by  the  sudden  filling  of  all  the 
bronchial  tubes  with  purulent  matter.  Let  us  observe,  first,  the 
sudden  supervention  of  dulness,  and  absence  of  respiration  in  a 
patient  whose  chest,  the  day  before,  presented  no  morbid  phe- 
nomenon ;  this  is  accompanied  by  a  copious  expectoration  of 
purulent  matter ;  and  there  are  no  constitutional  symptoms  of 
pleurisy  or  pneumonia.  The  absence  of  these  symptoms  is  of 
great  importance,  because  if  the  disease  had  proceeded  from  either 
of  these  lesions,  it  must  have  been  of  extraordinary  violence,  and 
would  have  certainly  been  accompanied  by  high  constitutional  and 
local  symptoms.  Dilatation  of  the  side,  and  displacement  of  the 
heart,  were  wanting,  so  that  the  diagnosis  lay  between  hepa- 
tization of  the  lung,  and  the  sudden  filling  of  the  tubes  with  pus  ; 
but  there  was  no  bronchial  respiration,  nor  resonance  of  the  voice, 
which  would  have  occurred  had  it  been  hepatization,  but  which 

*  Sej  Clyclopsedia  of  Practical  Medicine,  Art.  Enteritis,  for  a  brief  account  of  this 
extraordinary  and  fatal  form  of  disease. 


384  PERFORATING   ABSCESS    OF    THE    LUNG. 

were  absent  because  the  large  tubes  were  completely  filled. 
Further,  during  the  recovery  of  the  patient,  the  phenomena  of 
the  voice  were  exactly  the  reverse  of  those  in  pneumonic  resolution. 
In  the  latter,  the  resonance  decreases,  while  in  this  case  it 
increased ;  in  hepatization,  because  the  air  cells  recover  their 
permeability,  and  the  morbid  subsides  into  the  natural  bron- 
chophony ;  in  the  case  under  consideration,  on  the  other  hand,  s 
because  the  emptying  of  the  tubes  permitted  the  return  of  the 
natural  resonance  of  the  voice.  In  the  majority  of  cases  the 
matter  discharged  from  the  chest  consists  of  well  formed  pus.  In 
one,  however,  recorded  by  Annesley,  the  opening  of  an  hepatic 
abscess  was  followed  by  a  copious  purulent  and  bloody  expectora- 
tion. The  patient  experienced  a  great  sense  of  suffocation  when 
he  lay  on  his  back  ;  and  on  dissection,  a  vast  hepatic  abscess  was 
found  communicating  with  the  posterior  portion  of  the  lung.  We 
have  witnessed  a  case  of  the  same  lesion,  in  which,  whenever  the 
patient  turned  on  the  left  side,  a  large  quantity  of  purulent  matter 
was  discharged  from  the  mouth. 

It  is  hardly  possible  to  confound  this  accident  with  any  disease 
of  the  lung  properly  so  called,  particularly  if  by  stethoscopic 
observation  we  have  been  satisfied  of  the  previously  healthy  con- 
dition of  the  organ.  The  only  cases  which  might  be  confounded 
with  it,  are  the  rare  instances  of  the  opening  of  an  empyema  into 
the  lung,  or  the  sudden  secretion  of  purulent  matter  in  quantity, 
by  the  bronchial  membrane,  of  which  a  few  instances  are  recorded. 

We  have  now  seen,  with  reference  to  auscultation,  that  three 
cases  of  perforating  abscess  of  the  lung  may  be  distinguished,  viz. 
— those  with  signs  of  excavation  ;  next,  those  in  which  pneumo- 
thorax occurs  ;  and  lastly,  cases  presenting  the  phenomena  of  a 
complete  filling  of  the  bronchial  tubes  with  purulent  matter. 

But  there  is  a  fourth  class  in  which,  although  no  doubt  can 
exist  of  the  emptying  of  an  hepatic  abscess  through  the  air  tubes, 
the  stethoscopic  signs  are  unsatisfactory.  I  have  now  seen  two 
cases  in  which  the  trajet  of  the  purulent  matter  was  not  marked 
by  any  auscultatory  sign  ;  can  it  be,  that  in  such  cases,  the 
matter  passing  through  the  posterior  mediastinum  enters  the 
trachea  at  its  posterior  portion,  and  is  thus  evacuated  without 
involving  the  lung  ?  * 

*  It  will  be  seen  hereafter  that  Dr.  Ftokes  ascribes  the  evacuation  of  the  pus  in 
some  of  tbese  cases  to  vicarious  secretion  by  the  bronchial  mucous  membrane.  (See 
chapter  en  Diseases  of  the  Pleura.)     (Ed.) 


385 


SECTION    VII. 


CANCER   OP    THE    LUNG. 


[This  chapter  consists  of  two  portions,  namely,  the  text  of  the  first  edition,  with 
the  exception  of  a  few  passages  and  the  conclusions  ;  and  of  the  major  pare  of  a 
memoir  on  the  subject  by  the  author  in  the  twenty-first  volume  of  the  Dublin  Medical 
Journal,  First  Series,  omitting  passages  previously  published  in  his  treatise,  &c] 


Part  I. 

Cancerous  disease  of  the  lung  is  met  with  in  two  forms ;  in 
the  first,  a  degeneration  of  the  lung  occurs,  and  the  organ  is 
transformed  into  a  cancerous  mass  without  the  production  of 
any  tumour.  In  the  second,  the  scirrhous  or  encephaloid  matter 
forms  a  tumour,  at  first  external  to,  and  ultimately  displacing 
the  lung.  In  neither  case  can  we  apply  any  direct  diagnosis  ; 
and  I  do  not  know  how  the  first  could  be  determined  with 
certainty.  The  symptoms  are  always  obscure  ;  and  the  physical 
signs  being  merely  those  of  solidity,  more  or  less  extensive, 
the  greatest  difficulty  exists  in  making  an  accurate  diagnosis. 
Repeated  observations,  indeed,  might  lead  us  to  doubt  whether 
the  lesion  was  any  ordinary  disease — and  the  existence  of  external 
cancer  would  give  a  probability  that  the  internal  affection  was  of 
the  same  nature.  But  in  a  case  seen  for  the  first  time,  and  in 
which  no  such  external  disease  existed,  we  have  no  means  by 
which  its  nature  could  be  positively  determined. 

But,  in  the  second  case,  the  physical  condition  of  parts  is 
different,  and  we  have  a  mass  producing  compression,  displace- 
ment, and  obliteration  of  organs,  and  all  the  physical  signs  of 
an  intra-thoracic  tumour.  The  lung  may  be  displaced,  the 
oesophagus,  trachea,  or  bronchial  tubes  compressed,  the  subcla- 
vian or  carotid    arteries,  or   the  vena   innominata    obliterated, 

c  c 


386  CANCER   OF    THE    LUNG. 

leaving  no  doubt  of  the  existence  of  a  tumour,  the  nature  of 
which  must  be  determined  by  other  means. 

As  illustrative  of  these  principles,  the  following  cases  may  he 
studied.  The  first  shews  the  difficulty  of  diagnosis  in  the  simple 
degeneration  of  the  lung.* 

A  man,  aged  thirty-six,  about  a  year  previous  to  his  final 
admission  into  the  Meath  Hospital,  was  attacked  with  occasional 
stitches  of  the  right  side,  followed  by  cough,  hoarseness,  dysp- 
noea, and  scanty  mucous  expectoration —  after  some  time  a  little 
tinged  with  blood.  The  face  and  neck  became  cedematous,  and 
the  swelling  was  observed  to  be  greater  on  the  right  side.  He 
came  under  my  care  in  the  spring  of  1832,  and  remained  about 
six  weeks  in  hospital,  during  which  time,  after  most  careful  and 
repeated  examinations,  I  remained  undecided  as  to  the  nature  of 
the  disease.  He  left  the  hospital  somewhat  relieved,  but  without 
any  change  in  the  physical  signs,  which  were  that  the  whole  side 
sounded  dull,  yet  without  the  accompanying  physical  signs  of  a 
great  empyema  on  the  one  hand,  or  of  pneumonia  or  tubercular 
solidity  on  the  other.  I  successively  formed  and  abandoned 
many  opinions,  and  ultimately  gave  up  the  attempt  to  determine 
the  nature  of  the  disease. 

Soon  after  this  he  came  under  Dr.  Graves's  care,  labouring 
under  extreme  dyspnoea.  He  could  only  lie  on  the  right  side ; 
he  had  cough,  with  occasional  scanty  expectoration,  slightly 
tinged  with  blood,  pain  of  the  right  shoulder,  and  slight  stitches 
of  the  side.  He  experienced  some  difficulty  of  swallowing, 
and  referred  the  obstruction  to  the  lower  part  of  the  throat ; 
the  face  was  bloated,  pale,  and  slightly  cedematous,  which, 
with  an  appearance  of  the  eyes  as  if  the  balls  were  protruded 
from  the  sockets,  and  a  marked  dilatation  of  the  nostrils  durinc 
breathing,  gave  his  countenance  an  expression  of  distress  and 
suffering.  The  right  jugular  vein  ivas  much  distended,  as 
were  the  veins  in  the  right  axilla,-  but  this  symptom  ivas  chiefly 
remarkable  on  the  surface  of  the  belly,  where  two  veins  cor- 
responding to  the  situation  of  the  superior  epigastric  artery 
pursued  a  remarkably  tortuous  course  along  each  side  of  the 
linea  alba,  being  turgid  and  dilated  to  the  size  of  swan  quills. 

*  See  Dr.  Graves's  Paper,  Dublin  Medical  Journal,  vol.  iv.,  from  which  I  have 
abridged  the  above  case;  the  patient  was  first  under  my  own,  and  afterwards  his 
observation. 


CANCER    OF    THE    LUNG.  387 

His  bowels  were  constipated  and  subject  to  griping  pains  ;  urine 
scanty  and  high  coloured  ;  loss  of  appetite  ;  night  sweats  ;  slight 
thirst ;  tongue  clean  ;  pulse  100,  regular  and  compressible. 

The  intercostal  spaces  on  the  left  side  were  more  distinct, 
deeper,  and  more  dilated  in  respiration,  than  those  on  the 
right :  the  latter,  however,  although  not  so  well  marked,  wero  i 
by  no  means  obliterated  or  distended  by  pressure  from  within. 
The  right  side  of  the  chest  measured  about  half  an  inch  less 
than  the  left.  The  left  side  sounded  everywhere  clear,  to  within 
an  inch  of  the  sternal  median  line  where  it  became  dull.  Right 
side,  universally,  as  dull  as  possible.  Over  the  whole  left  side 
the  respiration  was  puerile,  except  on  approaching  the  sternal 
median  line,  where  it  assumed  a  tracheal  character.  This 
tracheal  respiration  was  observed  over  a  great  part  of  the  right 
side  anteriorly,  where  it  was  very  loud  and  distinct  above  the 
mamma,  feebler  immediately  below  it,  and  almost  entirely  lost 
still  lower.  Posteriorly,  the  respiration  was  not  so  decidedly 
tracheal. 

No  rales  were  audible  in  any  part  of  the  chest. 

At  the  upper  and  anterior  part  of  the  right  side,  the  voice 
was  resonant,  approaching  to,  if  not  identical  with  bronchophony ; 
elsewhere  nothing  remarkable  was  observed. 

•  The  heart  pulsated  in  its  natural  situation,  but  its  sounds 
were  audible  under  both  clavicles,  and  over  the  whole  of  the 
right  side.  The  right  side  of  the  chest,  during  respiration, 
obviously  moved  much  less  than  the  left ;  and  when  he  spoke, 
the  hand  placed  on  it  felt  the  vibrations  caused  by  the  voice  to 
be  feebler  than  on  the  left. 

"  The  physical  phenomena  here  detailed,"  says  Dr.  Graves, 
"  remained  unvaried  until  his  death,  except  that  all  traces  of 
bronchial  respiration  soon  disappeared  from  the  right  side  of 
his  chest,  except  at  one  spot  near  the  spine,  and  where  anything 
was  heard  in  other  parts,  it  was  now  evidently  a  tracheal  wheez- 
ing which  masked  all  other  sounds. 

"  When  this  patient  entered  the  hospital  on  the  1st  May, 
the  abdomen  felt  natural,  and  no  enlargement  of  the  liver  could 
be  felt,  but  after  some  time  the  liver  appeared  to  have  been 
rapidly  altered,  and  could  be  distinctly  felt  far  beyond  its  usual 
limits,  and  forming  a  hard  visible  tumour  in  the  hypochon- 
driac   and    epigastric    regions.      At  the  same  time  his  stools 

c  c  2 


388  CANCER    OF    THE    LUNG. 

became  clay-coloured,  and  be  was  jaundiced.     Tbe  yellow  colour, 
bowever,  was  not  of  a  deep,  but  of  a  ligbt  lemon  sbade. 

"Another  remarkable  phenomenon  developed  itself  before 
tbe  termination  of  the  disease ;  whenever  he  lay  down,  that 
instant  a  loud  wheezing  was  heard  in  his  chest,  accompanied  by 
a  sensation  of  imminent  suffocation ;  the  dysphagia  increased 
likewise,  but  was  never  very  urgent. 

"  Three  tumours  had  been  observed  on  his  body,  and  they 
had  latterly  increased  in  size  with  great  rapidity.  They  were 
immediately  under  the  skin  (which  was  of  the  natural  colour), 
were  smooth,  of  a  round  form,  of  the  size  of  walnuts  when 
first  observed,  but  now  are  very  nearly  as  large  as  oranges. 
They  were  slightly  moveable  at  first,  more  fixed  afterwards, 
and  never  accompanied  by  the  least  pain  or  soreness  ;  at  first 
they  felt  solid,  but  afterwards  more  elastic,  as  if  they  were  dis- 
tended with  fluid  contained  in  a  firm  capsule ;  they  occurred  on 
the  forehead,  the  ramus  of  the  lower  jaw,  and  near  the  lumbar 
spinous  processes. 

"Dissection. — Chest. — Left  lung  collapsed,  perfectly  healthy. 
Right  lung,  or  rather  the  contents  of  the  right  side  of  the 
thorax,  adhere  everywhere  to  the  parietes,  by  means  of  an 
intimate  adhesion  between  the  pleura  costalis  and  pulmonalis. 
The  pleura  is  exceedingly  thickened  and  dense.  In  place  of  the 
right  lung  was  found  a  solid  mass,  weighing  more  than  six 
pounds,  with  an  irregular,  somewhat  nodulated  surface  ;  this 
mass  filled  completely  the  right  cavity,  but  did  not  protrude 
between  the  ribs,  so  as  to  distend,  notably,  the  intercostal 
spaces  ;  it  encroached,  however,  upon  the  other  pide  of  the  chest, 
extending  a  little  beyond  the  median  line,  enveloping,  and  nearly 
concealing  from  view,  the  pericardium,  great  vessels,  and  trachea. 
This  solid  mass  was  removed  with  difficulty  on  account  of  the 
adhesions,  and  was  found  to  present,  over  a  small  portion  of  its 
posterior  surface,  a  thin  stratum  of  lung,  nearly  impervious  to 
tbe  air.  The  solid  mass  was  found  to  be  everywhere  homo- 
geneous, firm,  of  a  white  colour  slightly  stained  with  bile,  and 
tolerably  firm  and  consistent  in  its  structure,  which  resembled 
a  brain  partly  hardened  by  artificial  means.  When  cut,  each 
section  exhibited  an  oozing  of  the  softer  brain-like  fluid  from 
the  exposed  surfaces,  which  oozing  was  much  increased  by 
pressure ;  so  much,   indeed,  that  it  was  obvious  that  the  soft 


CANCER   OF   THE    LUNG.  389 

cerebriform  matter,  bore  a  large  proportion  to  the  cellular  and 
other  structure  in  which  it  was  lodged,  and  upon  which  the  firm- 
ness and  apparent  solidity  of  the  whole  depended.  The  mass  was 
somewhat  lobulated  posteriorly,  and  contained  a  few  small  cysts 
tilled  with  a  jaundiced  serum.  The  right  bronchial  tube  could 
be  traced  for  a  short  distance  into  the  substance  of  the  mass,  but 
was  considerably  diminished  in  calibre ;  the  heart  was  pale, 
and  rather  atrophied :  its  great  vessels  seemed  to  run  through 
the  substance  of  the  mass  which  surrounded  the  base  of  the 
heart,  so  that  only  its  lower  part  was  visible. 

"  Contrary  to  expectation,  the  liver  was  found  perfectly  natural 
in  size,  but  the  gall  bladder  was  enormously  distended  with  bile, 
and  was  at  least  three  times  its  natural  size.  The  apparent 
tumefaction  of  the  liver  was  owing  to  its  being  depressed  by  the 
thoracic  tumour.  A  tumour,  consisting  of  several  smaller  ones, 
occupied  the  situation  of  some  of  the  mesenteric  glands,  and 
equalled  two  fists  in  size.  It  consisted  of  the  same  cerebriform 
substance  as  that  observed  in  the  chest,  and  appeared  to  have 
arisen  from  degeneration  of  the  mesenteric  glands.  This  tumour 
pushing  the  transverse  arch  of  the  colon  upwards,  and  the  small 
intestines  downwards,  pressed  upon  the  ductus  communis  chole- 
dochus,  so  as  to  prevent  altogether  the  passage  of  bile  into  the 
duodenum,  while  its  lateral  portions  extending  to  the  kidneys 
pressed  upon  these  organs.  The  substance  of  the  liver  was 
healthy  but  green,  being  injected  with  bile.'' 

In  this  important  case,  the  want  of  agreement  between  the 
physical  signs,  aad  those  of  the  ordinary  affections  of  the  lung, 
the  absence  of  the  signs  of  the  earlier  stages  of  pneumonia, 
while  the  lung  advanced  to  solidity,  and  the  contraction  of  the 
side,  while  the  dulness  extended  beyond  the  mesian  line,  made 
strongly  against  the  opinion  that  the  disease  was  hepatization. 

In  the  next  place,  the  phenomena  did  not  accord  with  those 
of  tubercular  solidity.  The  disease  spread  from  below  upwards  ; 
the  solidity  was  complete,  and  no  sign  whatever  of  tubercular 
softening  was  observed ;  if  we  add  to  these  the  healthy  state  of 
the  opposite  lung,  and  the  absence  of  symptoms  of  phthisis,  we 
have  a  group  of  circumstances  opposed  to  the  phenomena  of 
tubercle. 

Lastly,  it  was  at  one  time  supposed  that  the  case  was  em- 
pyema, but  with  this  the  signs  were  also  irreconcileable  ;   the 


,r>90  CANCER    OF    THE    LUNG. 

side  was  contracted,  the  intercostal  spaces  unaffected,  the  vibra- 
tion of  the  voice  was  not  extinguished,  position  made  no 
difference  in  the  signs,  the  heart  was  in  its  natural  situation, 
and  the  liver  not  displaced  until  a  short  time  Before  death. 
The  dulness  and  absence  of  respiration,  if  proceeding  from 
empyema,  would  point  out  the  greatest  possible  effusion,  yet 
the  remaining  phenomena  were  inconsistent  with  this  condition. 

But  other  unusual  circumstances  existed  :  namely,  the  varicose 
state  of  the  subcutaneous  veins,  the  dysphagia,  the  predominance 
of  oedema  on  the  right  side,  the  apparent  enlargement  of  the 
liver,  and  the  growth  of  those  external  tumours  which  were, 
doubtless,  of  the  same  nature  as  the  internal  lesion.  We  must 
then  admit  that  there  was  here  a  group  of  phenomena  irrecon- 
cileable  with  those  of  pneumonia,  phthisis,  or  empyema,  but 
which  were  explained  by  the  condition  of  the  lung. 

The  next  case  is  illustrative  of  the  second  form,  or  that  in 
which  the  cancerous  disease  forms  a  compressing  tumour.  A 
woman,  aged  thirty,  had  laboured  some  months  under  cough, 
mucous  expectoration,  and  great  debility.  On  admission  into 
hospital  the  countenance  was  livid  and  anxious ;  dyspnoea  con- 
siderable ;  pulse  quick  and  small.  She  had  frequent  cough 
with  mucous  expectoration,  but  presented  no  symptom  of  ab- 
dominal disease.  Next  to  the  cough,  she  complained  most  of 
difficulty  of  swallowing,  which  she  referred  to  a  lump  in  her 
throat,  existing  under  the  top  of  the  sternum.  This  had  ex- 
isted for  some  months,  but  had  lately  much  increased.  The 
pharynx  appeared  healthy,  and  no  tumour  could  be  felt  by 
external  examination. 

The  clavicle,  antero-superior,  and  infra- spinous  regions  of  the 
left  side  sounded  completely  dull ;  the  respiration  was  here  dis- 
tinctly bronchial,  and  the  resonance  of  the  voice  approached  to 
perfect  pectoriloquism.  Over  the  rest  of  the  lung  the  sound  on 
percussion  was  clear,  but  respiration  was  masked  by  bronchitic 
rales.     In  the  right  lung  the  respiration  was  puerile. 

From  these  observations  we  concluded  that  the  superior  portion 
of  the  left  lung  was  solid,  in  all  probability  from  tubercle.  We 
could  not,  however,  explain  the  dysphagia.  She  expired  on  the 
night  following  her  admission. 

The  left  lung  was  found  compressed  from  above  downwards, 
•by  an  extensive  encephaloid  tumour,  which  filled  the  posterior 


CANCER    OF    THE   LUNG.  391 

mediastinum,  and  extended  into  the  upper  portion  of  the  left 
thoracic  cavity.  The  trachea  and  oesophagus,  from  the  lower 
portion  of  the  neck  downwards,  were  enveloped  by  this  mass. 
At  the  left  side,  exactly  at  the  situation  to  which  the  patient 
referred  the  obstruction  in  swallowing,  the  tumour  formed  three 
lobes  or  masses,  each  about  the  size  of  a  pigeon's  egg.  One  of 
these  so  pressed  on  the  oesophagus  as  to  form  an  elevation  on  its 
internal  surface,  and  considerably  diminish  its  calibre.  The 
sub-clavicular  and  acromial  regions  were  filled  by  the  tumour, 
which  answered  exactly  to  Laennec's  description  of  the  non- 
cneystcd  cerebHform  masses  :  no  softening  had  commenced  in 
any  portion  of  it.  The  lung  proportionably  diminished  in  size, 
contained  numerous  masses  of  the  same  nature,  varying  from 
the  size  of  a  pea  to  that  of  a  kidney  bean.  The  right  lung  was 
healthy.* 

When  describing  the  pulsation  of  the  lung  in  pneumonia,  I 
alluded  to  a  case  of  encephaloid  tumour,  with  a  diastolic  throb- 
bing which  simulated  an  aneurism  of  the  aorta.  I  shall  now 
detail  this  novel  and  important  case. 

The  patient,  a  man  aged  forty-five,  of  full  habit,  had  for  the 
four  years  previous  to  his  death,  complained  of  occasional  severe 
pains  in  the  left  side.  These  attacks  were  generally  attended 
with  haemoptysis,  and  yielded  to  general  bleeding,  nauseating 
doses  of  tartar  emetic,  and  other  antiphlogistic  measures.  He 
was  recovering  from  one  of  these  attacks,  when  he  was  seized 
with  convulsions,  followed  by  paralysis  of  the  left  side.  The 
attack  frequently  recurred  with  many  of  the  characters  of  epi- 
lepsy, during  which  the  dyspnoea  increased.  The  pains  of  the 
side  became  more  constant,  and  extended  to  the  shoulder  and 
inter-scapular  region ;  he  complained  of  oppression,  wheezing, 
and  some  palpitation,  and  had  a  continued  mucous  and  bloody 
expectoration. 

I  saw  this  patient  with  Mr.  Carmichael  two  months  previous 
to  his  death ;  he  was  not  emaciated,  nor  hectic.  He  complained 
of  some  dyspnoea,  with  severe  pain  in  the  left  shoulder.  The 
respiration  was  tracheal  and  of  the  character  which  I  have 
described  when  speaking  of  the  pressure  of  tumours  on  the 
windpipe ;   voice  unaffected.     There  was  some    dysphagia,  and 

*  Clinical  Report  of  Cases  in  the  Medical  Wards  of  the  Heath  Hospital,  &c,  Dub. 
Hos.  Reports,  vol.  v. 


392  CANCER    OF    THE    LUNG. 

the  pulse  of  the  left  radial  artery  was  exceedingly  small,  while 
that  of  the  right  was  full  and  developed.  The  whole  antero- 
superior  portion  of  the  left  side,  and  the  corresponding  scapular 
ridge,  sounded  completely  dull.  In  these  situations  there  ex- 
isted a  distinct  tracheal  respiration ;  the  respiratory  murmur 
was  audible  over  the  lower  lobe,  but  was  extremely  feeble  when 
compared  with  that  of  the  right  lung.* 

But  the  most  remarkable  circumstance  in  this  case  was,  that 
a  distinct  double  pulsation,  a  little  subsequent  to  that  of  the 
heart,  and  accompanied  by  the  bellows-murmur,  existed  in  the 
upper  sternal  and  sub-clavicular  regions.  The  sounds  were 
almost  identical  with  those  of  a  deep-seated  aneurism,  and 
although  there  existed  no  external  tumour,  a  distinct  diastolic 
pulsation  could  be  perceived  by  the  hand  when  pressed  on  the 
chest.  This  pulsation  manifestly  succeeded  that  of  the  heart, 
the  action  of  which  was  natural,  so  that  the  existence  of  two 
distinct  centres  of  pulsation  within  the  chest  did  not  admit  of 
the  slightest  doubt. 

No  signs  of  tubercular  softening  could  be  found  in  any  part  of 
the  chest. 

The  diagnosis  in  this  case  was  full  of  difficulty.  Some  ex- 
tensive organic  disease  obviously  existed  ;  the  pains,  the  dulness 
of  sound,  the  haemoptysis,  and  the  absence  of  vesicular  murmur, 
seemed  at  first  to  favour  the  opinion  that  tubercular  solidity 
existed,  while  the  absence  of  emaciation,  of  hectic,  and  of  the 
signs  of  cavities,  did  not  accord  with  such  an  idea. 

On  the  other  hand,  there  were  signs  altogether  inconsistent 
with  the  existence  of  mere  pulmonary  disease.  The  tracheal 
breathing,  the  dysphagia,  the  smallness  of  the  left  pulse,  and 
the  pulsation  of  the  upper  part  of  the  thorax,  all  indicated  that 
a  tumour  existed  within  the  cavity. 

Some  time  previous  to  his  death  he  suddenly  expectorated 
foetid  purulent  matter  ;  this  continued  to  be  copiously  discharged 
for  several  days,  giving  the  impression  that  a  gangrenous  abscess 
had  formed. 

Dissection. — Upon  laying  open  the  cavity  of  the  thorax,  a  large 
tumour  was  observed  occupying  the  left  lung  from  its  apex  to 

*  For  observations  on  the  importance  of  feebleness  of  respiration  in  one  lung  in 
ca=es  of  intra-thoracic  tumour,  I  would  refer  to  the  section  on  Diseases  of  the  Larynx  ; 
also  to  my  paper  on  the  Diagnosis  of  Aneurism,  Dublin  Journal  of  Medical  Science, 
vol.  v. 


CANCER    OF    THE    LUNG.  393 

its  root ;  it  closely  adhered  to  the  parietes  of  the  chest ;  it  was 
of  a  glohular  form,  larger  than  an  orange,  perfectly  white  in 
colour,  remarkably  elastic  to  the  feel,  and  of  different  degrees  of 
firmness,  but  nowhere  possessing  the  hardness  of  a  scirrhous 
structure ;  it  completely  surrounded  the  left  branch  of  the  pulmo- 
nary artery,  and  projected  into  the  pericardium.  When  a  section 
was  made  through  the  tumour,  the  trunk  of  the  pulmonary  artery 
was  seen  compressed  and  flattened,  its  section  presented  an 
elliptical  form,  and  its  calibre  was  so  much  diminished  as  to 
admit  only  a  full-sized  catheter  ;  the  lung  beneath  the  tumour 
was  in  an  inflamed  condition,  and  at  one  part  there  existed  a 
cavity,  which  in  appearance  and  in  the  nature  of  its  contents 
resembled  a  gangrenous  abscess  ;  there  were  no  tubercles  in  the 
lungs  ;  both  hemispheres  of  the  brain  were  extensively  softened 
in  their  interior,  as  were  also  both  lobes  of  the  cerebellum.* 

The  great  interest  of  this  case  consists  in  the  cancerous  mass 
forming  a  second  centre  of  pulsation,  and  in  its  other  signs 
agreeing  so  closely  with  aneurism  : — that  a  tumour  of  some 
kind  existed,  appeared  evident  to  Mr.  Carmichael  and  me,  long 
previous  to  the  disease,  and  with  the  knowledge  I  then  possessed, 
I  could  only  explain  the  phenomena  on  the  supposition  of  aneurism. 
It  is  true  that  no  external  tumour  existed,  and  that  the  pulsation 
was  feebler  than  what  occurs  in  most  cases  of  this  disease. 

There  were  two  circumstances,  however,  which  did  not  agree 
with  the  symptoms  of  aneurism,  the  one,  the  continued  hcemop- 
tysis,  and  the  other  the  leant  of  proportion  between  the  apparent 
size  of  the  tumour  and  the  strength  of  its  pulsations.  We  know 
that  the  violence  of  pulsation  is  in  general  proportional  to  the 
size  of  the  tumour,  so  that  the  combination  of  extensive  dulness 
with  but  feeble  pulsation,  may  indicate  cancerous  rather  than 
aneurismal  disease. 

The  preceding  facts  shew  that  there  would  be  grounds  for 
suspecting  the  existence  of  cancerous  disease  in  two  cases. 

First. — Where  there  were  evidences  of  simple  solidification 
without  the  signs  of  pneumonia  or  tubercle. 

*  It  would  be  interesting  to  examine  whether  in  this  instance  the  pulsation  was 
from  the  vessels  of  the  cerebriform  mass,  or  communicated  by  the  pulmonary  artery. 
I  incline  strongly  to  the  latter  opinion.  The  nature  of  the  pulsation  of  cancerous 
tumours  is  still  to  be  determined,  but  if  it  appears  that  the  thoracic  cancers  only  pulsate 
when  embracing  a  large  vessel,  the  value  of  the  sigi  as  indicative  of  tumour,  will  be 
to  far  diminished. 


394  CANCER    OF    THE    LUNG. 

Secondly. — Where  there  were  evidences  of  an  intra-thoracic 
tumour  ;  in  which  case  the  diagnosis  would  lie  between  a  pul- 
sating cancer  and  an  aneurism  of  the  aorta. 

It  need  scarcely  be  observed,  that  the  existence  of  external 
cancerous  disease  would  aid  in  settling  the  question,  but  such 
a  combination  is  by  no  means  constant,  and  even  when  present, 
the  visceral  may  precede  the  external  cancer,  as  in  the  case  which 
I  have  given. 

But  there  is  a  point  connected  with  the  physical  signs,  which 
must  not  be  passed  over.  In  none  of  our  cases  were  there  any 
evidences  of  cavities  forming  in  the  cancerous  mass  ;  and  there 
is  no  instance  (hitherto)  recorded  in  which  the  stethoscopic  signs 
of  ulceration  have  been  observed.  In  my  third  case,  indeed,  a 
gangrenous  cavity  formed  a  little  before  death,  but  this  engaged 
the  lung,  it  did  not  occur  in  the  cancerous  structure,  and  was 
evidently  accidental.  Bayle  details  a  case  of  ulcerated  cancer  of 
the  lung,  but  does  not  state  whether  the  cavities  communicated 
with  the  bronchial  tubes.  I  subjoin  an  abstract  of  this  case.  In 
the  same  author  we  find  an  instance  recorded  of  the  combination 
of  tubercle  and  cancer  :  here  the  diagnosis,  from  physical  pheno- 
mena at  least,  would  be  impossible. 

Under  the  name  of  cancerous  phthisis,  we  find  three  cases  of 
the  disease  related  by  Bayle. 

Case  I. — A  man,  aged  55  years,  of  a  bilious  temperament,  was 
attacked  with  dyspnoea,  a  dry  cough  occurring  in  paroxysms,  and 
pains  of  the  chest.  The  skin  became  gradually  yellow,  although 
the  conjunctiva  preserved  its  natural  colour.  Towards  the  tenth 
month  of  his  disease  the  skin  became  dry  and  rough,  and  the 
cough,  which  was  frequent,  was  followed  by  scanty  mucous 
expectoration,  after  some  time  succeeded  by  slight  haemoptysis, 
which  continued  for  seventeen  days. 

Fifteen  months  elapsed,  yet  the  patient's  strength  was  scarcely 
diminished,  the  expectoration  became  purulent,  and  he  some- 
times felt  severe  pains  in  the  chest.  Soon  after  this,  he  was 
attacked  with  adynamic  fever,  from  which  he  recovered  in  about 
a  month ;  the  cough  increased,  the  expectoration  became  more 
abundant,  and  the  patient  rapidly  emaciated.  At  this  time,  a  soft 
and  fluctuating  tumour,  unaccompanied  by  pain  or  change  of  colour 
of  the  skin,  appeared  above  the  humeral  extremity  of  the  right 
clavicle.    The  patient  sunk  in  the  eighteenth  month  of  his  disease. 


CANCER    OF    THE    LUNG.  395 

Dissection. — Both  lungs  were  found  to  contain  numerous 
tumours  of  a  rounded  form,  and  of  a  structure  similar  to  that  of 
fresh  lard,  they  had  a  shining  white  colour,  and  were  of  various 
degrees  of  hardness  :  some  red  capillaries,  similar  to  those  of  the 
brain,  could  be  seen  ramifying  in  their  substance  ;  from  some 
of  these  tumours  a  whitish  pus  of  a  creamy  consistence  could 
be  expressed,  while  others  were  converted  into  true  ulcerations, 
around  which  the  pulmonary  tissue  was  slightly  hardened : 
abdominal  viscera  healthy. 

Case  II. — A  man,  aged  35  years,  was  afflicted  with  a  tumour 
on  the  forearm,  which,  after  continuing  for  ten  j*ears,  increased 
so  rapidly  as  to  render  amputation  necessary  ;  but  the  opera- 
tion was  postponed  on  account  of  dyspnoea  which  had  existed 
for  some  time ;  on  this  subsiding,  the  operation  was  performed, 
but  the  pectoral  symptoms  returned,  and  the  patient  died  with 
suffocation  on  the  twentieth  day  after  operation. 

The  lungs  contained  numerous  tumours  of  the  cerebriform 
matter,  of  different  degrees  of  consistence,  and  supplied  by 
capillaries.  In  some,  excavations  could  be  perceived,  filled  with 
a  serous  or  bloody  fluid  ;  some  of  which  were  lined  with  a  delicate 
and  vascular  membrane,  while  others  seemed  to  result  from  the 
destruction  of  the  cerebriform  matter  itself. 

The  pulmonary  tissue  between  the  tumours  was  perfectly 
healthy. 

Case  III. — A  man,  aged  72  years,  had  enjoyed  good  health 
until  within  six  weeks  of  his  admission  into  hospital ;  his  disease 
set  in  with  pains  affecting  the  whole  body,  but  principally 
engaging  the  chest  and  epigastrium.  A  slight  cough,  with  a 
white  and  opaque  expectoration,  set  in,  the  appetite  failed,  and 
the  bowels  became  obstinately  costive  ;  the  liver  was  enlarged 
and  irregular,  filling  the  epigastrium,  and  extending  almost  to 
the  umbilicus.  Three  hard,  indolent,  moveable  bodies,  of  about 
the  size  of  nuts,  were  found  to  exist  in  the  epigastric  and  right 
lrypochondriac  regions. 

On  dissection  the  lungs  presented  few  adhesions,  and  appeared 
externally  healthy.  On  cutting  through  them  the  root  of  the 
left  lung  was  found  occupied  by  a  mass  of  shining  white 
appearance,  in  the  interior  of  which  red  capillary  vessels  could  be 
seen.  In  the  centre  of  this  substance,  which  resembled  brain, 
and  also  hV  the  lung  itself,  tuberculous  masses  could  be  detected, 


896  CANCER    OF    THE    LUNG. 

easily  distinguished  from  the  cancerous  matter  by  their  yellow 
opaque  appearance  ;  several  small  tuberculous  cavities  were  found 
in  the  remainder  of  the  lung.  The  liver  contained  numerous 
cerebriform  masses,  and  the  moveable  subcutaneous  bodies  were 
evidently  of  the  same  nature  as  the  internal  tumours.* 


Part  II. 


When  I  published  my  observations  on  the  Diagnosis  of  Cancer 
of  the  Lung  in  my  treatise  on  Diseases   of  the  Lung,  I  endea- 
voured to  express  the  state   of  our  knowledge  of  the  subject  at 
the  time.     Since  that  period,  however,  I  have  been  enabled  to 
arrive  at  a  direct  diagnosis   of  the  first  form  of  cancer.     I  have 
also  been   fortunate  enough  to  meet  with  a  remarkable  case  of 
ulcerated  cancer  of  the  lung,  and  have  extended  my  observations 
upon  cancerous  tumours  within  the  thorax.     So  that  we  can  now 
affirm  without  presumption,  that  in  many  cases  of  this   disease, 
whether  it  affects  the   lung  simply,    or  occurs  as  a  mediastinal 
tumour,  a  direct  diagnosis  can  be  arrived  at.     By  direct  diagnosis 
I  mean  the  discovery  of  the  internal  disease,  in  cases  where  there 
is  no  recognized  cancer  in  other  situations,  such  as  the  mamma, 
uterus,  extremities,  &c. 

We  may  now  enumerate  the  different  forms  of  thoracic  cancer 
which  have  fallen  under  our  observation.  It  is  scarcely  necessary 
to  say  that  some   of  these  have  already  been  noticed  by  others. 

1st.  Isolated  and  generally  well-defined  encephaloid  tubercles 
of  a  rounded  form,  the  intervening  tissue  healthy,  and  the 
tumours  equably  distributed  through  both  lungs. 

2nd.  Isolated  masses  of  irregular  forms  ;  sometimes  coincid- 
ing with  a  mass  of  complete  cancerous  degeneration. 

3rd.  Tubercles  of  various  species  of  cancer  co-existing,  such 
as  scirrhus,  the  encephaloid,  and  the  black  spongiform  cancer. 

4th.  Simple  degeneration  of  the  whole  or  part  of  a  lung  into 
the  homogeneous  encephaloid  matter. 

5th.  Encephaloid  tumours  of  the  posterior  mediastinum  com- 
pressing the  lung. 

Gth.  The  same  condition  combined  with  cancerous  degenera- 
tion, and  cancerous  tubercles  of  the  lung  itself. 

*  Recherches  sur  la  Phthhie  Pulmonaire,  par  G.  L.  Bayle.      Paris,  1810. 


CANCER    OF    THE    LUNG.  397 

7th.  Cancerous  tumour  of  the  anterior  mediastinum. 

8th.  Tumours  of  fluid  white  cancerous  matter  perfectly  en- 
cysted, and  surrounding  the  trachea  and  oesophagus,  combined 
with  a  white  cancerous  infiltration  of  a  portion  of  the  lung,  and 
cancerous  coagula  of  the  bronchial  tubes. 

9th.  Cancerous  degeneration  of  the  whole  lung,  with  deep- 
seated  and  superficial  ulcerous  action,  extensively  separating  the 
lung  from  the  pulmonary  pleura. 

Before  proceeding  further,  I  will  enumerate  the  combinations 
with  other  diseases,  which  have  fallen  under  my  observation. 
They  are — 

1st.  The  combination  of  homogeneous  cancer  of  the  lung  with 
empyema. 

2nd.  Cancerous  tumour  of  the  posterior  mediastinum  with 
gangrene  of  the  lung. 

3rd.  Cancer  of  the  mediastinum    and   lung,  in    combination 

with  dilated  tubes. 

4th.  Cancerous  tubercles  of  the  lung  with  bronchitis. 

With  respect  to  those  cases  of  pulmonary  cancer,  in  which  the 
malignant  matter  is  deposited  in  the  form  of  isolated  tubercles 
throughout  the  lungs,  our  information  is  still  extremely  scanty. 
The  tumours  in  some  cases  are  purely  encephaloid  ;  in  others 
they  are  found  of  scirrhous  hardness;  and  in  a  third  class,  these 
varieties  are  combined  in  various  degrees.*  Of  this  last  variety, 
an  interesting  specimen  was  exhibited  by  Dr.  Law,  at  the  Patho- 
logical Society,  during  the  Session  1838-9 ;  and  at  the  first 
meeting  of  the  Society,  Sir  Philip  Crampton  exhibited  the 
recently  removed  parts  in  a  case  of  this  disease.  The  lungs  con- 
tained a  large  number  of  encysted  tumours,  the  contents  of  which 
consisted  of  two  substances ;  the  one  a  soft  and  spongy  structure 
of  a  dark  brown  colour,  the  other  a  dark  coloured  fluid,  which 
spurted  out  when  an  incision  was  made  into  the  tumour.  The 
structure  of  the  tumour  exactly  resembled  that  of  the  left  testis, 
which  had  been  removed  by  Sir  Philip  Crampton  three  months 

*  "  The  relative  frequency,"  says  Dr.  Walshe,  "  with  which  the  different  species  of 
cancer  grow  in  the  lungs  is  shewn  in  the  following  arrangement  of  106  cases,  58 
formerly  collected  by  myself,  48  by  Aviolat : — 

Enccpbaloid 60  Htematoid 1 

Sc  rrhus 16  Fibroplastic 1 

Mixed 20  Doubtful 5 

Colloid 3  (On  Diseases  of  the  Lunge,  p.  516.)     (Ed.) 


398  CANCER    OF    THE    LUNG. 

previous  to  death;  bronchial  glands  healthy.  A  remarkable 
instance  of  the  latency  of  this  form  of  cancer  is  given  by  Dr. 
Hughes  in  his  third  case.  Here  the  disease  of  the  knee-joint, 
however,  may  have  prevented  the  occurrence  of  pulmonary 
symptoms. 

A  girl,  aged  14,  was  admitted  into  Guy's  Hospital,  for  an  affec- 
tion of  the  knee,  January  6th,  1841.  She  died  six  months  after. 
During  her  stay  in  the  hospital,  she  never  had  cough,  dyspnoea, 
haemoptysis,  or  any  other  symptom  referrible  to  the  chest. 

Dissection. — The  knee-joint  was  converted  into  a  large  cance- 
rous mass  ;  the  lungs  contained  numerous  tubercles,  about  the 
size  of  peas  and  chestnuts ;  firm,  roundish,  nodular,  semi-carti- 
laginous, somewhat  translucent,  and  some  very  earthy  ;  the  heart 
was  small.*  At  the  first  meeting  of  the  Pathological  Society  for 
1839-40,  Professor  Harrison  exhibited  the  recent  parts  in  a  case 
of  medullary  tumour  of  the  pelvis.  In  this  case,  the  lungs  con- 
tained a  great  number  of  small  tubercles  and  masses,  which  pre- 
sented the  characters  and  structure  of  medullary  sarcoma  ;  the 
intervening  pulmonary  tissue  was  healthy ;  a  large  medullary 
tumour  existed  in  the  pelvis.  The  subject  of  the  case  was  a 
young  woman,  aged  20,  of  a  robust  and  healthy  appearance. 
About  a  week  before  her  death  she  complained  of  some  dyspnoea ; 
but  the  stethoscope  did  not  indicate  the  existence  of  any  organic 
lesion.     She  died  rather  suddenly. 

There  are  two  circumstances  common  to  all  the  cases  of  this 
disease  which  we  have  seen  ;  one,  the  nearly  equable  distribution 
of  the  cancerous  deposits  over  both  lungs  ;  the  other,  the  healthy 
condition  of  the  intervening  tissue.  We  shall  return  to  this 
subject  when  speaking  of  the  general  diagnosis,  and  here  merely 
remark  that  the  physical  conditions  above  stated  throw  great 
difficulty  in  the  way  of  direct  diagnosis. 

CANCEROUS    DEGENERATION    OF    THE     LUNG. 

Of  the  different  forms  of  thoracic  cancer  this  seems  to  be,  per- 
haps, the  most  frequent.  The  first  case  in  which  any  accurate 
physical  examination  was  instituted  is  that  published  by  Dr. 
Graves,  of  which  I  have  already  given  an  abstract.  In  this  case 
the  most  remarkable  phenomena  were  :  1st.  The  absence  of  rale. 
2nd.  The  want  of  coincidence   between  the  physical  signs  and 

*  Guy's  Hospital  Reports,  1841. 


CANCER    OF    THE    LUNG.  399 

those  of  pleurisy,  pneumonia,  or  tubercle.  3rd.  The  contraction 
of  the  side  with  extension  of  dulness  beyond  the  mesial  line. 
4th.  The  varicose  condition  of  the  veins.  5th.  The  appearance 
of  external  cancerous  disease  towards  the  close  of  the  case. 

Cancerous  Degeneration  of  the  whole  Left  Lung  ,•  displacement 
of  the  Heart;  appearance  of  External  Tumours  two  months 
before  death.* 

A  peasant,  aged  24,  of  strong  and  healthy  constitution,  and 
who  had  always  enjoyed  good  health,  was  attacked  in  the  autumn 
of  1834  with  pleurisy,  which  yielded  to  antiphlogistic  treatment. 
In  the  following  December  he  had  a  second  attack ;  he  com- 
plained particularly  of  dyspnoea,  and  of  acute  pain  in  the  left 
side  every  time  he  took  in  a  deep  breath.  These  symptoms 
were  aggravated  by  coughing,  or  by  change  of  position  to  the  left 
side.  General  and  local  bleeding  relieved  the  pain,  but  the  cough 
resisted  all  treatment.  He  got  a  fresh  attack  of  cold,  followed 
by  increase  of  suffering.  He  had  the  most  severe  pains  shooting 
through  the  affected  side,  extending  from  the  shoulder  down  to 
the  short  rib,  and  from  the  sternum  to  the  vertebral  column. 
Antiphlogistic  treatment  was  again  resorted  to  without  any 
benefit.  I  saw  him  now  for  the  first  time.  He  was  lying  on  his 
back,  having  the  right  side  of  the  chest  a  little  elevated ;  he  had 
a  frequent  dry  and  short  cough,  accompanied  with  great  d\  spneea. 
The  left  side  of  the  chest  was  fixed  during  inspiration  and  expi- 
ration ;  the  sternum  was  pushed  forward  and  towards  the  right 
side ;  there  was  a  remarkable  dilatation  of  the  left  side,  just 
below  the  mamma  ;  percussion  gave  a  dull  sound  over  the  left 
side,  and  a  clear  one  over  the  right ;  over  the  left  side  the  respi- 
ratory murmur  was  lost ;  over  the  right  it  was  loud,  though  un- 
equally so.  The  patient  could  get  up  and  walk  about  his  room 
with  less  distress  than  lying  on  the  left  side  produced  ;  pulse 
quick,  small,  variable,  but  not  intermitting ;  sleep  disturbed 
and  interrupted  by  the  cough ;  loss  of  appetite  ;  slight  thirst ; 
tongue  clean  ;  countenance  expressive  of  suffering  ;  surface  lead 
coloured  and  livid;  breath  free  from  foetor ;  slight  emaciation ; 
skin  dry,  A  month  after,  a  tumour  appeared  on  the  front  of  the 
left  side  of  the  chest,  about  the  size  of  two  fists,  resembling  the 
female  breast ;  no  change  in  the  physical  signs,  the  pulsations  of 

*  Heyfelder's  Archives  Generates. 


400  CANCER   OF    THE    LUNG. 

the  heart  were  felt  to  the  right  of  the  sternum,  and  a  visible 
pulsation  was  observed  both  in  the  carotid  and  temporal  arteries  ; 
the  left  side  more  dilated  ;  the  voice  was  weak  and  without  reso- 
nance ;  the  patient  could  not  lie  on  the  right  side  ;  left  side  fixed 
during  inspiration  ;  cough  dry  and  persistent ;  colour  of  surface 
leaden ;  expression  of  countenance  more  indicative  of  distress  ; 
pulse  unsteady  and  intermitting  ;  dyspnoea  increased.  "  I  con- 
fess," says  Heyfelder,  "  I  could  not  form  any  satisfactory  opinion 
as  to  the  nature  of  the  complaint.  The  want  of  cegophony,  the 
size  of  the  chest,  the  shape  and  situation  of  the  tumour,  pre- 
vented me  considering  it  an  empyema."  From  this  time  out  I 
saw  the  patient  daily.  Two  months  before  his  death  the  axillary 
glands  became  enlarged  and  hardened,  and  two  tumours  formed 
under  the  left  clavicle.  The  patient  died  dropsical,  having,  up  to 
the  moment  of  death,  the  harassing  cough,  attended  with  expec- 
toration of  a  glairy  mucus. 

Dissection. — The  right  pleura  was  full  of  serum,  and  the  lung 
was  engorged  and  adherent  to  the  diaphragm  ;  it  was  free  from 
tubercle.  The  heart  was  compressed,  and  smaller  than  natural, 
and  in  every  situation  adherent  to  the  pericardium,  which  latter 
adhered  to  both  lungs.  The  left  lung  was  fixed  to  the  ribs  ;  it 
was  converted  into  one  mass,  completely  filling  the  left  pleural 
cavity,  and  extending  over  into  the  right  one.  It  was  trans- 
formed into  a  solid  white  lardaceous  mass,  totally  devoid  of 
nerves,  blood  vessels,  and  small  bronchial  tubes.  Towards  the 
centre  the  mass  was  soft  and  brain-like,  and  of  a  greyish-white 
colour,  presenting  an  opening,  the  remains  of  the  large  bronchial 
tube.  The  pulmonary  arteries  and  veins  were  obliterated  or 
changed  into  ligamentous  bands,  up  to  their  attachment  to  the 
heart.  Our  external  examination  of  the  left  side  in  front  dis- 
closed a  large  mass  of  the  same  lardaceous  character,  softened 
towards  the  centre,  and  communicating  with  the  disease  inside 
the  chest,  the  intervening  ribs  being  displaced  and  separated. 
There  was  no  trace  either  of  pectoral  or  intercostal  muscles,  and 
the  ribs  themselves  were  atrophied  to  an  extreme  degree.  All 
the  abdominal  viscera  were  healthy.  The  left  testicle  and  epi- 
didymis were  occupied  by  scirrhus.  The  tumours  under  the 
clavicle  and  the  axilla  are  not  particularly  described.  One  of 
the  most  interesting  circumstances  in  this  case  was  the  growth 
of  the  external  tumour  during  the  last  period  of  the  patient's 


CANCEK    OF    THE    LUNG.  401 

illness ;  a  similar  phenomenon  was  observed  in  the  case  pub- 
lished by  Dr.  Graves,  in  which,  towards  the  close  of  the  disease, 
three  tumours  appeared,  and  increased  with  great  rapidity ;  they 
were  on  the  forehead,  the  ramus  of  the  lower  jaw,  and  on  the 
lumbar  spinous  processes ;  and,  as  in  Bayle's  case,  they  were 
unaccompanied  by  pain,  soreness,  or  any  inflammatory  phe- 
nomenon. The  first  case  in  which  the  precedence  of  the  visceral 
to  the  external  cancer  was  recognized  is  that  by  Dr.  Graves, 
and  the  fact  of  its  having  now  been  observed  in  three  instances 
is  quite  sufficient  to  make  it  an  important  element  in  the 
diagnosis.  It  is  very  probable  the  occurrence  has  been  often 
overlooked,  from  the  singular  latency  and  freedom  from  inflam- 
matory action  under  which  these  external  tumours  occur.  In 
the  first  case  the  discovery  of  these  tumours  was  purely  acci- 
dental. The  two  following  cases  are  given  by  Dr.  Hughes  in 
the  communication  already  quoted  : — 

Conversion  of  the  Right  Lung  into  a  nearly  Homogeneous 

Mass  of  Cancer. 

A  man,  aged  43,  was  admitted  into  Guy's  Hospital,  labour- 
ing under  cough,  pain  in  the  right  side  of  the  chest,  with 
expectoration  of  a  frothy  nature,  tinged  with  blood ;  his  legs 
were  cedematous,  as  were  also  the  right  arm  and  right  side  of 
the  chest,  and  his  eyelids  were  puffy.  He  constantly  lay  on  the 
right  side,  from  the  occurrence  of  severe  dyspnoea  when  he 
turned  to  the  left.  The  tongue  was  pale  and  moist,  the  skin 
dry,  and  the  pulse  frequent  and  feeble. 

Physical  Signs. — Complete  dulness  of  the  right,  except  just 
under  the  clavicle.  It  was  also  full  and  prominent,  but  in  con- 
sequence of  the  oedema  of  the  parietes,  it  could  not  be  ascer- 
tained whether  the  intercostal  spaces  were  protruded ;  complete 
absence  of  respiration  at  the  lower  part.  In  the  mammary 
regions  it  was  tubular  and  distant,  and  under  the  clavicles  harsh 
and  hoarse ;  behind  there  was  complete  dulness,  with  absence 
of  respiration  in  the  subscapular  region.  In  the  scapular  the 
respiration  was  tubular,  with  bronchophony ;  no  vibration  on 
coughing  or  speaking,  either  before  or  behind  ;  the  left  side  of  the 
chest  appeared  healthy,  and  the  sounds  natural,  except  that  the 
respiration  was  puerile.  The  oedema  of  right  arm  and  side  in- 
creased, and  his  dyspnoea  prevented  the  least  change  of  position. 

D    D 


402  CANCER    OF    THE    LUNG. 

Dissection. — The  right  pleura  was  universally  and  strongly 
adherent ;  the  entire  of  right  lung,  except  a  small  portion  at 
its  apex,  was  converted  into  a  fungoid  mass,  which  was  generally 
white  and  pultacious,  except  near  the  centre,  where  it  was  of  a 
pink  colour,  and  reduced  to  a  diffluent  pulp  :  and  opposite  the 
scapula,  near  the  surface,  where  there  was  an  irregulurly-shaped 
cavity,  containing  little  or  no  fluid.  In  the  bronchial  tubes  was 
much  viscid  secretion,  and  the  mucous  membrane  was  slightly 
congested.  The  left  pleura  was  partially  adherent  from  old 
disease ;  but  the  lung  and  the  bronchial  tubes  on  this  side  were 
healthy.  Several  bronchial  glands  were  much  enlarged,  but  did 
not  appear  to  have  assumed  any  of  the  characters  of  the  malig- 
nant disease.  The  right  auricle  of  the  heart  appeared  con- 
siderably flattened,  and  the  entire  organ  was  pushed  considerably 
to  the  left  side  by  the  pulmonary  tumour.  There  was  nothing 
remarkable  in  the  abdomen,  except  that  at  the  head  of  the 
pancreas  was  an  enlarged  gland,  about  the  size  of  an  orange, 
which  contained  a  straw-coloured  fluid. 

Cancerous  Degeneration  of  the  upper  portion  of  the  Right  Lung. 

A  woman,  aged  50,  caught  cold  two  years  before  her  death, 
during  which  time  she  suffered  frequently  from  haemoptysis. 
She  was  admitted  into  Guy's  Hospital  August  19th,  1841,  when 
she  presented  the  following  appearances  : — her  countenance  was 
pale  and  sallow,  with  a  few  enlarged  cuticular  veins  in  the  cheeks ; 
her  legs  were  swollen  ;  she  had  no  pain,  nor  was  she  particu- 
larly emaciated.  She  lay  on  her  back,  with  the  shoulders  rather 
raised,  and  somewhat  inclined  to  the  right,  but  could  turn  to 
cither  side,  or  get  up  without  inconvenience  ;  she  complained  of 
cough,  accompanied  with  shortness  of  breath,  and  sanguineous 
expectoration ;  her  tongue  slightly  coated  and  moist ;  her  skin 
unctuous  and  soft ;  her  pulse  frequent  and  feeble ;  her  bowels 
regular.  The  expectoration  consisted  of  white  frothy  mucus, 
with  light  crimson  blood  mixed  through  it.  She  had  one  ab- 
sorbent gland,  nearly  as  large  as  a  pigeon's  egg,  in  the  right 
axilla,  and  a  smaller  one  under  the  right  clavicle  ;  but  had  not 
been  aware  of  their  existence  until  they  were  pointed  out  to  her. 
The  superficial  cutaneous  veins  of  the  right  side  of  the  abdomen 
were  considerably  increased  in  size,  and  rather  tortuous. 

Physical  Signs. — Evident  flattening  below  the  right  clavicle, 


CANCER   OF    THE    LUNG.  403 

extending  down  to  the  mamma ;  the  ribs  moved  very  little,  and 
were  elevated  en  masse  during  inspiration ;  there  was  complete 
dulness  and  absence  of  respiratory  murmur  over  the  upper 
portion  of  this  lung,  both  before  and  behind  ;  occasionally  there 
was  heard  bronchial  respiration,  and  now  and  then  slight  rale ; 
there  was  an  imperfect  pectoriloquy  with  an  increased  tactile 
vibration.  The  morbid  phenomena  appeared  to  terminate  at  a 
denned  line,  just  above  the  mamma,  and  to  pass  round  the  whole 
of  the  right  side  of  the  chest ;  the  lower  portion  of  the  right 
and  entire  left  lung  appeared  healthy.  Her  symptoms  gradually 
increased  in  severity  ;  her  legs  began  to  swell,  and  orthopncea 
set  in,  and  two  months  after  admission  she  died. 

Dissection. — The  left  pleura  was  slightly  adherent;  the  left 
lung  was  crepitant  throughout,  and  partially  emphysematous ; 
the  right  pleura  was  universally  firmly  adherent,  and  superiorly 
altered  in  texture  by  a  white,  flaky,  malignant  deposit ;  the 
entire  upper  part  of  the  right  lung  was  converted  into  a  mass  of 
medullary  fungus,  the  cut  surface  of  which  exhibited  a  dead 
white,  cheesy  substance,  intersected  with  bands  of  cellular  tissue. 
By  slight  pressure  a  creamy  fluid  exuded,  together  with  portions 
of  soft,  brain-like  matter  from  cells,  varying  in  size  from  a  pin's 
head  to  a  marble.  The  middle  lobe  contained  some  portions  of 
the  malignant  growth,  appearing  like  elongations  or  processes 
of  the  diseased  mass  above  them,  from  being  clearly  connected 
with  and  traceable  into  it,  and  separated  from  each  other  by  the 
intervention  of  healthy,  or  simply  compressed  lung.  The  inferior 
lobe  contained  a  few  small  detached  masses  of  fungoid  matter, 
and  was  posteriorly  firm,  dark-coloured,  and  lacerable,  probably 
from  gravitation.  In  the  branch  of  the  right  pulmonary  artery, 
going  to  the  upper  lobe,  there  was  a  small  pedunculated  medul- 
lary tubercle,  and  another  on  its  external  surface.  The  heart 
and  pericardium  were  healthy. 

Abdomen. — The  liver  had  the  nutmeg  character,  and  presented 
one  patch  of  malignant  disease.  Both  kidneys  and  renal  cap- 
sules presented  small  masses  of  medullary  matter,  and  near  the 
os  uteri  were  found  three  pea-like  scirrhous  tubercles.  The 
gland  in  the  axilla  was  clearly  affected  with  the  same  disease. 

In  a  case  given  by  Dr.  Carswell,  almost  the  whole  of  the  left 
lung  was  converted  into  a  dense  substance,  resembling  a  section 
of  fresh  pork.     The  lobular  structure,  however,  of  the  organ  was 

d  d  2 


404  CANCER    OF    THE    LUNG. 

very  conspicuous  ;  but  the  blood  vessels  and  bronchi  were  either 
greatly  compressed  or  obliterated.  Towards  the  upper  extremity 
of  the  lung,  the  carcinomatous  deposit  was  seen  extending  from 
lobule  to  lobule,  and  had  made  its  way  through  the  bronchi. 
The  pleura  costalis  and  pulmonalis  were  studded  with  tumours 
of  the  same  kind,  varying  from  the  size  of  a  pin's  head  to  that  of 
a  walnut.  Several  of  these  tumours  were  seen  on  the  pleura 
pulmonalis,  the  largest  arose  by  a  broad  base,  the  others  were 
round  or  pyriform,  and  attached  by  a  peduncle. 

In  the  next  variety  of  the  disease,  we  find  cancerous  tumours 
of  the  posterior  mediastinum  not  unfrequently  co-existing  with 
the  degeneration  of  the  lung  and  isolated  tubercles  in  its  sub- 
stance. These  tumours  are  of  various  sizes,  and  are  commonly 
of  the  encephaloid  structure,  and  I  have  seen  no  example  of  their 
ulceration.  As  might  be  expected,  they  may  produce  all  those 
effects  of  excentric  pressure  which  are  commonly  observed  in 
deep-seated  aneurisms  ;  thus,  they  may  displace  the  lung,  press 
on  and  diminish  the  calibre  of  the  trachea  or  bronchial  tubes, 
compress  the  oesophagus,  so  as  to  cause  a  fatal  dysphagia,  and 
obliterate  the  subclavian  artery.  I  have  seen  no  instance,  how- 
ever, of  their  inducing  absorption  of  the  bones,  or  forming 
external  tumours,  as  is  so  commonly  the  case  in  aneurism.  The 
occurrence  of  these  signs  of  excentric  pressure,  renders  the 
diagnosis  of  this  form  of  the  disease  comparatively  easy. 

I  have  noticed  but  two  varieties  of  this  affection.  In  the  first, 
which  is  not  uncommon,  the  tumour  is  of  a  pure  encephaloid 
structure,  presenting  rounded,  but  irregular  masses,  involving 
the  trachea,  oesophagus,  and  great  vessels  ;  while  in  the  second, 
of  which  I  have  seen  but  a  single  instance,  a  ring  of  tumours, 
varying  from  the  size  of  a  hazel  nut  to  that  of  a  hen's  egg, 
existed  immediately  above  the  bifurcation  of  the  trachea.  These 
tumours  were  all  encysted;  some  containing  a  perfectly  fluid 
creamy  matter,  while  others  contained  a  dark  grumous  liquid. 
The  lungs  contained  many  tumours  of  the  same  kind ;  there  was 
no  tubercle,  but  in  various  parts  of  the  lung  we  observed  portions 
infiltrated  with  a  white  liquid,  perfectly  similar  to  the  contents 
of  many  of  the  tumours.  Some  of  these  portions  were  more 
than  an  inch  and  a  half  in  length,  and  half  an  inch  in  depth. 
In  many  of  the  bronchial  tubes,  deposits  of  a  pearly  white 
cancerous  matter,  in  a  semi-fluid  state,  were  discovered,  having 


CANCER   OF    THE    LUNG.  405 

more  consistence  than  that  of  the  tumours,  but  not  adhering 
with  any  force  to  the  mucous  membrane.  This  is  the  only 
instance  of  cancer  of  the  bronchial  tubes  which  I  have  seen  ;  but 
I  find  that  Professor  Carswell,  in  a  case  of  the  isolated  form  of 
cancer,  gives  a  representation  of  a  cancerous  tumour  attached  to 
the  mucous  membrane  of  a  large  bronchial  tube.*  It  might  be 
supposed  that  the  case  above  stated  was  one  of  ulcerated  cancer, 
but  I  entertain  an  opposite  opinion,  from  the  fact  that  in  none  of 
the  masses  could  the  transition  from  a  hardened  to  a  liquid  state 
be  observed ;  and  this  view  is  borne  out  by  the  infiltration  of 
portions  of  the  lung  with  a  liquid  precisely  similar  to  that 
contained  in  the  cysts,  and  by  the  analogous  deposits  in  the 
bronchial  tubes  themselves. 

In  my  work  on  Diseases  of  the  Chest,  I  have  given  two  cases, 
in  which  the  encephaloid  matter  formed  a  compressing  tumour ; 
in  one  the  lung  was  engaged.  In  both  these  cases  the  sign  of 
inequality  of  respiration,  induced  by  the  pressure  of  the  tumour, 
was  observed,  and  the  situation  of  the  disease  was  established  by 
manifest  dulness  on  percussion ;  but  as  in  aneurism  this  last 
physical  sign  is  not  always  present.  We  read,  in  Andral's 
Clinique  Medicale,  the  particulars  of  a  case  in  which  a  mass  of 
melanosis  compressed  the  right  bronchus  so  as  to  diminish  its 
calibre  to  nearly  one-half;  the  respiratory  murmur  on  the  left 
side  was  extremely  feeble,  but  on  the  right  puerile ;  the  sound 
on  percussion  on  both  sides  was  equal.  The  two  following 
cases  are  taken  from  Dr.  Syms'  paper,  in  the  18th  vol.  of  the 
Medico- Chirurgical  Transactions. 

Encephaloid  Tumour  of  the  Posterior  Mediastinum,  Cancerous 
Degeneration  of  the  Right  Lung,  dc.,  d-c. 

A  tall,  well-formed  young  woman,  aged  23,  and  who  had  enjoyed 
good  health  till  near  the  period  when  her  present  disease  was  first 
noticed.  A  short  time  before  her  death  she  complained  of  great 
difficulty  of  breathing,  frequent  cough,  and  considerable  pain  in  the 
chest,  with  other  symptoms  supposed  to  indicate  a  severe  inflam- 
matory affection  of  the  lungs.  The  usual  remedies  were  had  re- 
course to  for  her  relief,  but  the  symptoms  did  not  give  way  to  the 
treatment  adopted,  and  in  a  short  time  others  appeared  of  a  more 
formidable  character.     She  had  also  swelling  in  the  lower  part 

*  Elementary  Forms  of  Disease,  Fase  3,  Fig.  8,  Plate  II. 


406  CANCER    OF    THE    LUNG. 

of  the  abdomen,  and  on  examination,  several  distinct  and  large 
tumours  could  be  felt  rising  out  of  the  pelvis.  Above  the 
clavicles,  and  along  the  blood  vessels  of  the  right  side  of  the 
neck,  there  were  a  number  of  enlarged  lymphatic  glands  of 
various  sizes.  Her  disease  advanced  rapidly ;  she  got  ascites ; 
the  tumours  rose  higher,  and  increased  in  magnitude  ;  the  lower 
extremities  became  cedematous ;  the  dyspnoea  increased,  and 
also  the  cough,  but  she  had  no  expectoration.  A  remarkable 
symptom  now  occurred ;  the  sounds  of  the  ventricles  were  per- 
ceived in  their  usual  situation,  but  the  impulse  of  one  or  both 
ventricles  was  equally  distinct  over  a  considerable  part  of  the 
right  side  of  the  thorax  anteriorly.  Her  right  arm  became 
painful  and  enormously  swollen,  presenting  all  the  signs  of 
phlegmasia  dolens  from  inflamed  veins  ;  she  constantly  lay  on 
her  back,  and  was  unable  to  vary  her  position.  She  soon  after 
died. 

Dissection. — On  opening  the  thorax,  a  tumour  of  very  con- 
siderable size  was  found  imbedded  in  the  right  lung  ;  it  was 
closely  attached  to  the  great  vessels  at  the  base  of  the  heart.  It 
was  moveable  within  the  thorax.  On  making  sections  through 
it,  some  portions  appeared  firm  and  fibrous,  and  others  softer 
and  brain-like.  Its  colour  was  of  a  dirty  white,  intermixed  with 
streaks  of  a  lead  colour,  apparently  in  the  direction  of  its  few 
blood  vessels.  It  closely  involved  the  bronchi  and  blood  vessels 
at  the  root  of  the  right  lung,  and  was  firmly  attached  to  the 
pericardium  and  vessels  immediately  issuing  from  the  heart. 
Nothing  remarkable  was  observed  in  the  left  lung,  or  the  texture 
of  the  heart.  On  dissecting  out  the  right  subclavian  vein,  it 
was  found  to  be  filled  with  successive  layers  of  fibrine,  the 
product  of  inflammation,  and  the  valves  at  its  junction  with  the 
jugular  were  seen  distended  with  this  deposit.  Several  tumours 
of  a  similar  nature  were  attached  to  the  uterus  and  its  appendages. 

Encephaloid  Tumour  of  the  Posterior  Mediastinum,  producing 
depression  of  Diaphragm  and  displacement  of  the  Heart ; 
cancerous  degeneration  of  the  Right  Lung. 

A  strong  athletic  man,  aged  43,  was  attacked  about  a  year 
before  his  death  with  haemoptysis,  cough,  dyspnoea.  The  hae- 
morrhage frequently  recurred,  but  he  was  able  to  follow  his  usual 


CANCER    OF    THE    LUNG.  407 

occupations  for  several  months  after,  when  his  symptoms  became 
much  aggravated,  and  he  was  then  admitted  into  St.  Marylebone 
Infirmary.  He  now  laboured  under  severe  dyspnoea  and  cough, 
attended  with  mucous  expectoration,  and  he  had  frequent  attacks 
of  haemoptysis  ;  a  considerable  part  of  the  right  side  of  the  thorax, 
anteriorly,  sounded  dull  on  percussion,  and  respiration  was 
inaudible ;  the  jugular  veins  were  dilated  to  three  times  their 
usual  size,  and,  with  part  of  the  subclavian,  presented  large 
tumours  above  the  clavicles,  alternately  increasing  and  diminish- 
ing in  size  ;  his  face  was  swollen,  he  complained  of  severe  head- 
ache, sharp  pulse,  very  little  emaciation,  bowels  costive.  Two 
months  from  the  date  of  admission  he  died,  previous  to  which 
his  sufferings  had  been  excessive. 

Dissection. — On  raising  the  parietes  of  the  thorax  a  large 
tumour,  several  inches  in  circumference,  came  into  view  on  the 
right  side.  The  tumours  of  the  right  lung  occupied  about  two- 
thirds  the  capacity  of  the  entire  chest,  the  diaphragm  was  pushed 
down,  and  the  space  for  the  left  lung  was  occupied  by  the  tumours 
from  the  opposite  side  ;  the  heart  was  situated  several  inches  lower 
than  usual,  and  pushed  much  beyond  the  mesial  line ;  the  left  lung 
contained  much  black  matter,  and  in  some  situations  was  indu- 
rated, and  presented  a  red  hepatization.  There  was  no  trace  of 
any  other  disease  in  this  lung.  The  right  lung  occupied  a  con- 
siderable space,  for  the  morbid  growth  from  it  encroached  upon 
the  abdomen  ;  a  great  portion  of  it  was  consolidated,  apparently 
from  old  hepatization,  and  some  parts  presented  an  infiltration 
of  pus.  The  tumour  was  extensively  attached  to  this  lung,  it 
also  pressed  upon  the  trachea  and  completely  surrounded  the  right 
bronchus,  with  several  of  its  bifurcations.  It  also  pressed  upon 
the  posterior  part  of  the  right  auricle,  so  as  to  burst  it  inwards, 
and,  in  one  part,  a  small  tubercle,  about  the  size  of  a  pea,  had 
penetrated ;  it  had  also  made  its  way  into  the  cavity  of  the  left 
auricle,  and  two  tubercles,  suspended  by  narrow  peduncles,  hung 
down  from  the  tumour  into  this  cavity.  All  the  great  vessels 
were  connected  to  the  tumour  except  the  inferior  cava.  The 
tumour  presented  various  degrees  of  consistence  ;  in  some  situa- 
tions it  was  hard  and  cartilaginous,  in  others  it  was  soft, 
though  solid,  and  in  a  third  it  was  pulpy  and  fluctuating,  but 
retained  its  cellular  or  fibrous  appearance.  On  making  a  section 
of  any  part  of  it  a  milk-white   fluid  escaped,  resembling  cream. 


408  CANCER    OF    THE    LUNG. 

The  firmest  portions  of  the  tumour  were  connected  with  the 
disease  of  the  lung,  the  softest  portion  was  that  situated  between 
the  trachea  and  bronchi,  the  great  vessels,  and  attached  to 
the  heart ;  it  was  almost  entirely  of  a  milk-white  colour,  in  some 
places  slightly  tinged  by  the  ramification  of  minute  blood  vessels, 
whose  number  was  extremely  small ;  in  some  parts  the  tumour 
could  be  removed  from  the  lung,  and  a  membrane  resembling 
the  pleura  was  observed  to  intervene.  The  abdominal  viscera 
were  all  healthy. 

The  foregoing  cases  by  Dr.  Syms  present  some  interesting 
points  for  consideration,  to  which  we  shall  briefly  allude.  In 
the  first  case  we  see  a  patient  attacked  with  severe  symptoms 
of  pulmonary  disease  which  resist  ordinary  treatment.  This 
circumstance  is  not  without  its  value  in  the  diagnosis  of  the 
heterologous  diseases  of  the  lung.  I  have  elsewhere  shown  its 
importance  in  the  diagnosis  of  the  acute  development  of  tubercle  : 
and  in  cancer  of  the  lung  the  accompanying  signs  of  irritation  are 
observed  to  be  either  uninfluenced  by  treatment,  or,  if  they  are 
removed,  they  return  again  and  again  without  apparent  cause. 
Whether  the  cancerous  masses  themselves  form  foci  of  irritation, 
or  that  the  irritation  itself  is  of  a  specific  character,  and,  like 
other  affections  of  this  kind,  but  little  influenced  by  ordinary 
treatment,  remains  to  be  determined.  I  incline  strongly  to  the 
latter  opinion,  from  the  fact  of  finding,  in  many  cases  of  isolated 
cancer  of  the  lung,  the  intervening  tissue  in  a  perfectly  normal 
state.  There  are  three  circumstances  in  this  case  of  great  im- 
portance in  the  differential  diagnosis — viz. :  1.  The  rapid 
formation  of  internal  and  external  tumours.  2.  The  occurrence 
of  ascites  and  oedema.  8.  The  transmission  of  the  impulses  of 
the  heart  over  the  diseased  side.  It  is  hardly  -necessary  to 
remark  that  the  combination  of  all  these  circumstances  forms  a 
group  of  phenomena  for  which  there  is  no  parallel  in  any  recorded 
cases  of  pneumonia,  tubercle,  or  pleuritic  effusion.  The  pulsa- 
tion of  the  lung  has  been,  for  the  first  time,  described  by  Dr. 
Graves  in  a  case  of  acute  pneumonia.  In  this  instance  the 
pulsation  of  the  heart  was  felt  all  over  the  right  lung,  at  a 
time  when  the  organ  was  in  an  engorged,  and,  as  it  were,  semi- 
fluid state ;  but  it  is  unlikely  that,  in  the  diagnosis  of  cancer, 
any  difficulty  will  arise  from  the  knowledge  of  this  fact,  in- 
asmuch as    the    pulsation  in  Dr.  Graves'  case  occurred  at  an 


CANCER    OF    THE    LUNG.  409 

early  period,  and  in  an  acute  disease,  so  that  the  expression  of 
our  knowledge  on  this  subject  will  be  that  an  extensive  pulsation 
of  the  lung  in  an  acute  case  points  out  an  engorged  condition, 
but,  in  a  chronic  case,  has  only  been  observed  in  cancer.  In  the 
second  case  the  frequently  recurring  haemorrhage  and  the  absence 
of  emaciation  in  so  chronic  a  case,  are  circumstances  not  in 
accordance  with  the  usual  diseases  of  the  lung.  I  have  noted 
similar  facts  in  another  case  already  spoken  of,  and  if  to  these  be 
added  the  very  extensive  dulness  and  absence  of  respiration,  com- 
bined with  the  extreme  dilatation  of  the  jugular  veins,  the  existence 
of  a  group  of  phenomena,  belonging  only  to  cancer  of  the  lung, 
must  be  admitted. 

CANCEROUS  TUMOURS  OF  THE  ANTERIOR  MEDIASTINUM. 

On  this  subject  I  cannot  at  present  give  any  original  observa- 
tions. Cruveilhier  and  others  have  recorded  examples  of  cancerous 
deposits  beneath  the  sternum  in  cases  of  malignant  diseases  of 
the  breast,  but  we  want  observations  of  primary  cancerous  disease 
in  this  situation.  It  is  probable,  however,  that  the  diagnosis 
would  not  be  found  to  be  difficult,  at  least  in  cases  where  the 
tumour  was  sufficiently  large  to  compress  the  trachea  or  great 
vessels,  for  in  this  situation  the  aneurismal  or  non-aneurismal 
character  of  the  disease  would  be  easily  determined. 

ULCERATED  CANCER    OF   THE  LUNG. 

That  ulceration  of  cancers  of  the  lung  is  a  rare  occurrence, 
must  be  admitted  on  examining  the  recorded  cases  of  the  affec- 
tion ;  I  have  only  seen  one  example  of  it,  which  I  will  presently 
describe.  I  have  never  met  with  it  in  any  case  of  mediastinal 
tumours,  even  where  the  lung  itself  was  engaged  ;  and  it  seems 
probable  that  some  of  the  cases  of  supposed  ulcerated  tubercles 
of  the  lung  were  but  examples  of  original  deposits  of  cancerous 
matter  in  different  varieties  and  degrees  of  consistence.  Bayle 
has  described  two  cases  in  which  the  lung  contained  tumours  of 
cerebriform  matter,  in  which  excavations  existed,  seemingly  the 
result  of  ulceration  of  the  cancer.  I  have  stated  in  my  work,  that 
no  instance  was  recorded  in  which  the  stethoscopic  signs  of  ulcera- 
tion had  been  observed,  and  this,  which  sufficiently  shows  the  rarity 
of  the  occurrence,  will  be  found  to  have  been  hitherto  the  case. 


410  CANCER    OF    THE    LUNG. 

Ulcerated  Cancer  of  the  Lung,  with  extensive  Separation  of  the 
Pleura  ;  singular  variations  of  the  Physical  Signs. 

A  woman,  aged  35,  was  admitted  into  my  wards  on  the 
21st  of  Ma}-,  1838.  Four  months  previously  she  had  been  in 
the  enjoyment  of  good  health,  when  she  was  exposed  to  cold, 
and,  for  the  first  time,  was  attacked  with  cough  and  severe  pain 
in  the  right  side,  which  continued  up  to  the  period  of  her  ad- 
mission. Her  complexion  was  sallow,  and  she  had  a  remarkably 
cachectic  appearance  ;  she  complained  of  a  constant,  troublesome 
cough,  with  copious  viscid  mucous  expectoration,  frequently 
mixed  with  blood,  and  she  stated  that  spitting  of  blood  had 
frequently  occurred  during  the  course  of  her  illness  ;  the  pain 
was  referred  to  the  right  mammary  region,  to  the  postero-inferior 
part  of  the  right  side,  and  to  the  shoulder.  In  the  two  first  of 
these  situations  the  integuments  were  so  tender,  that  she  could 
scarcely  bear  the  ap])lication  of  the  stethoscope.  Decubitus  on 
the  left  side;   pulse  108;   night  sweats. 

Physical  Signs. — Over  the  anterior  portion  of  the  right  side 
the  sound  on  percussion  was  distinctly  tympanitic  ;  this  extended 
from  the  clavicle  to  below  the  mamma;  there  was  no  bruit  <h' 
pot  felc,  nor  was  the  sound  similar  to  that  given  by  a  large 
cavity ;  it  was  a  true  tympanitic  clearness,  but  such  as  is 
observed  in  cases  of  empyema  and  pneumothorax,  when  the 
liquid  effusion  has  so  far  increased  as  to  leave  but  a  thin 
stratum  of  air  within  the  pleura  ;  bronchial  rales  were  heard 
over  the  surface  of  the  lung,  and  an  obscure  bronchio-cavernous 
respiration  could  be  perceived  along  the  sternum  ;  the  voice  was 
very  resonant  over  the  whole  surface,  and  a  strong  vibration 
communicated  to  the  hand,  but  there  was  no  pectoriloquism  ; 
posteriorly,  the  lung  was  everywhere  dull,  with  a  very  feeble 
murmur,  mixed  with  muco-crepitating  rale ;  the  left  side  gave  a 
natural  sound  on  percussion,  and  the  murmur  was  puerile,  un- 
mixed with  any  rale.  The  next  report  was  made  on  the  28th  of 
May.  The  general  symptoms  and  signs  remained  the  same, 
except  that  the  tympanitic  sound  was  less  distinct.  In  the 
recumbent  position,  the  respiration  anteriorly  was  exceedingly 
feeble ;  but  when  she  sat  up,  a  loud  musical  rale  was  heard  over 
the  right  side.  On  coughing,  a  large  mucous  rale,  approaching 
to  gargouillement,  could  be  heard  under  the  third  rib. 


CANCER    OF    THE    LUNG.  411 

31st — The  cavernous  character  of  the  respiration  appeared  t  > 
increase,  and  the  degree  of  tympanitic  sound  has  varied  more  or 
less  from  day  to  day. 

June  6th. — The  tympanitic  sound  has  disappeared,  the  antero- 
superior  portion  being  completely  dull,  while  below  and  to  the 
side  of  the  mamma  the  respiration  is  decidedly  cavernous. 
The  pain  in  the  side  was  last  night  extremely  severe,  extending 
to  the  stomach. 

9^//.- — The  tympanitic  sound  has  in  some  degree  returned. 

10  th. — On  this  day  complete  dulness  was  found  extending 
from  the  clavicle  to  the  inferior  line  of  the  mamma ;  but  from 
this  point  to  the  last  false  rib  there  was  manifest  tympanitic 
clearness.     The  patient  expectorated  a  large  quantity  of  blood. 

12th. — Another  change  in  the  phenomena  was  observed  :  under 
the  clavicle  the  sound  was  what  we  have  elsewhere  described  as 
tympanitic  dulness  ;  lower  down  there  was  complete  dulness. 
and  at  the  most  inferior  portion  the  tympanitic  clearness  re- 
mained ;  here  the  respiration  was  feeble  and  accompanied  by  a 
large  mucous  rattle ;  about  the  centre  of  the  lung  it  had  a 
tracheal  character,  while  under  the  clavicle  it  was  feeble,  but 
apparently  vesicular. 

IStli. — The  sound  of  the  sub-clavicular  region  has  become 
completely  dull,  while  the  tympanitic  clearness  observed  inferiorly 
has  extended  up  to  the  third  rib. 

17th. — All  tympanitic  sound  has  now  disappeared,  and  from 
the  clavicle  downwards  there  is  complete  dulness.  From  this 
period  but  little  change  took  place  in  the  physical  phenomena, 
except  that  on  the  3rd  of  July  the  posterior  part  of  the  chest 
gave  at  different  points  some  of  the  tympanitic  sound  on  per- 
cussion. During  this  period  the  principal  symptoms  were,  the 
sweats,  diarrhoea,  severe  pain,  and  tenderness  of  the  lower  part  of 
the  right  side,  dyspnoea,  and  oedema  of  the  face,  eyelids,  lower 
extremities,  and  the  left  hand.  She  died  on  the  12th  of  July, 
the  duration  of  her  illness  being  between  five  and  six  months. 

Dissection. — The  pleural  cavity  was  found  completely  obli- 
terated ;  but,  through  the  serous  membrane,  the  lung  could 
be  seen  not  collapsed,  apparently  solid,  and  of  a  yellowish-white 
colour.  The  whole  organ  was  converted  into  a  mass,  having 
less  consistence  than  is  observed  in  ordinary  encephaloid  disease  ; 
nor  was  its  structure  homogeneous,   but  rather  granular,  and 


412  CANCER    OF    THE    LUNG. 

exhibiting  traces  of  the  pulmonary  lobules  and  cells,  infiltrated 
everywhere  with  a  pearly-white  gelatinous  fluid,  giving  it  a  semi- 
transparent  appearance.  A  large  portion  of  the  lung  was  bur- 
rowed by  anfractuous  excavations,  communicating  on  the  one 
hand  with  the  bronchial  tubes,  and  on  the  other  terminating 
in  fistulas,  running  in  various  directions  to  the  surface  of  the 
lung,  where  they  terminated  in  superficial  cavities,  containing 
air  and  a  whitish  purulent  fluid,  bounded  on  the  one  hand  by 
the  posterior  surface  of  the  pulmonary  pleura,  and  on  the  other 
by  the  degenerated  pulmonary  substance.  This  dissection  of 
the  pleura  from  the  lung  extended  over  almost  the  lower  two- 
thirds  of  the  organ.  Towards  the  rest  of  the  lung  there  was  a 
mass,  exhibiting  the  cancerous  disease  in  its  more  ordinary 
appearance  ;  part  of  this  was  white,  another  portion  more  red 
and  vascular,  and  a  part  of  it  was  quite  broken  down.  The 
pericardium  contained  a  large  quantity  of  fluid  ;  the  left  lung 
and  pleura  were  healthy,  with  the  exception  of  a  few  small 
hydatids,  which  existed  in  different  portions  of  the  lung.  I 
have  given  this  case  at  considerable  length,  as  an  example  of 
an  hitherto  undescribed  condition  of  the  lung,  as  the  physical 
phenomena  presented  combinations  and  modes  of  succession 
which  have  never  before  been  observed.  And  as  in  this 
case  I  never  ventured  on  giving  a  diagnosis,  the  account  of 
the  physical  signs  may  be  received  with  greater  confidence. 
Many  opinions  were  formed  as  to  the  nature  of  the  disease  by 
the  members  of  the  class,  and  by  several  practitioners  who 
visited  the  patient ;  thus,  some  conceived  it  to  be  an  example  of 
tuberculous  phthisis  ;  others,  chronic  pneumonia,  with  ulcera- 
tion ;  some,  empyema  and  pneumothorax.  It  was  conjectured, 
at  one  time,  that  there  was  a  hernia  of  the  abdominal  viscera 
through  the  diaphragm ;  at  another  period,  it  was  supposed  that 
the  liver  was  in  a  state  of  emphysema,  of  which  a  remarkable 
example  had  occurred  some  time  previously  in  the  hospital ;  and 
it  was  also  suggested  that  the  case  might  be  an  example  of  the 
tympanitic  sound  occurring  in  typhoid  solidifications,  which  has 
been  described  by  Dr.  A.  Hudson.  When  I  first  examined  the 
patient,  soon  after  admission,  I  conjectured  that  the  physical 
phenomena  might  be  explained  by  the  existence  of  a  superficial 
layer  of  dilated  cells  anteriorly,  while  tubercle  in  great  quantity 
existed  in  the  rest  of  the  lung  ;  but,  on  my  second  examina- 


CANCER    OF    THE    LUNG.  413 

tion,  on  the  28th  of  May,  the  phenomena  were  such  as  to 
render  this  notion  quite  untenable.  We  see  in  this  case  the 
singular  phenomena  of  an  empyema  and  pneumothorax  com- 
municating with  the  bronchial  tuhes,  yet  not  in  the  cavity  of  the 
pleura,  but  between  the  lung  and  the  pulmonary  layer  of  that 
membrane ;  and  it  is  obvious,  that  the  singular  variations  of 
the  phenomena  were  attributable  to  the  varying  proportions  of 
liquid  and  aeriform  effusions  in  the  cavities  which  separated  the 
pleura  from  the  subjacent  lung  ;  and  the  extended  resonance  of 
the  voice,  and  strong  vibration  communicated  to  the  hand, 
together  with  the  tracheo-cavernous  respiration,  are  all  explained 
by  the  condition  of  the  parts. 

Finally,  we  may  observe,  that  although  with  physical  pheno- 
mena totally  different  from  anything  hitherto  observed,  the 
same  general  principle  is  applicable  to  this  as  well  as  many 
other  recorded  cases  of  cancer,  viz.,  that  in  cases  where  the 
phenomena  in  their  nature  or  combinations  are  different  from 
those  of  pneumonia,  tubercle,  pleurisy,  and  pulmonary  apoplexy, 
we  have  good  reason  to  suspect  the  existence  of  cancer. 


GENERAL   PRINCIPLES    OF    DIAGNOSIS. 

In  examining  the  principles  of  diagnosis,  we  may  take  three 
physical  conditions  of  the  cancer  for  consideration  :  1st,  cancer- 
ous tubercles;  2nd,  degeneration  of  a  part  or  the  whole  of  a 
lung  into  the  homogeneous  cancer ;  3rd,  mediastinal  tumours. 
In  many  of  the  first  form  of  cases  we  are  deprived  of  some 
valuable  sources  of  physical  diagnosis.  Thus,  it  often  happens 
that  we  cannot  avail  ourselves  of  the  signs  of  irritation,  so 
important  in  ordinary  tubercle,  for,  although  great  quantities 
of  cancerous  masses  exist,  the  intervening  tissue  may  preserve 
a  singularly  healthy  condition.  There  is  a  much  more  intimate 
association  between  ordinary  tubercle  and  inflammation  of  the 
organ  in  which  it  is  deposited,  than  in  this  affection. 

In  the  next  place,  we  are  commonly  deprived  of  all  the  signs 
of  ulceration  so  valuable  in  phthisis.  I  have  never  met  with  a 
case  of  isolated  cancerous  tubercles  in  a  state  of  ulceration,  and 
if  anything  was  wanting  to  increase  the  difficulties,  the  test  of 
comparison  is  often  inapplicable  in  these  cases,  from  the  nearly 
equable  distribution  of  the  cancerous  tubercles  over  the  whole  of 


414  CANCER    OF    THE    LUNG. 

both  lungs,  so  that  it  is  possible  that  a  large  quantity  of  can- 
eerous  masses  might  exist,  and  the  sound  on.  percussion  be 
everywhere  equal,  and  not  dull. 

I  have  no  experience  of  this  form  of  the  disease  in  relation  to 
diagnosis ;  but,  even  in  this  difficult  case,  assistance  is  afforded 
us  by  auscultation,  in  the  discovery  of  bronchitis,  coming  on 
without  any  apparent  cause ;  at  first,  amenable  to  treatment, 
but  returning  almost  immediately,  though  the  patient  has  not 
been  exposed  to  any  of  those  influences  that  usually  give  rise  to 
bronchitic  inflammations.     These  attacks  will  recur  with  great 
frequency  ;  at  first,  slightly,  but  gradually  getting  worse,  till  at 
last,  a  severe  bronchitis  is   established,   resisting  all  means  of 
treatment,  and  terminating  in  the  patient's   death.     This  has 
been  the  case  in  two  very  remarkable  examples  of  this  form  of 
cancer  of  the  lung  which  occurred  in  this  country.     If  with  these 
frequent  attacks  of  bronchitis  we  have  evidence  of  cancer  in  any 
other  situation,  we  may,  in  such  a  case,  pronounce  with  con- 
siderable confidence,  that  the  patient  labours  under  cancer  of  the 
lung  (presenting  itself  in  isolated  tubercles  equally  distributed 
throughout  the  lung).     We  may  safely  anticipate  that  the  same 
principles  of  diagnosis  which  are  applicable  to   acute  tubercle, 
will  be  found  to  apply  to  this  affection ;  and  state  that  if,  with 
the  symptoms  and  signs  of  bronchitis  we  find  the  chest  to  be- 
come   dull ;    if  this  dulness  be  extensive,  yet  incomplete,   the 
stethoscope  showing  that  the  lung  is  still  permeable,  the  solidity 
only  occurring  in   points,  we  may  make  the  diagnosis  either  of 
acute  tubercle  or  of  this  form  of  cancer ;  and  as  the  symptoms 
of  acute  phthisis  are  generally  strikingly  marked,  there  would 
be  probably  no  difficulty  in  determining  on  the  nature  of  the 
affection. 

I  have  already  given  the  state  of  our  knowledge  of  the  second 
form,  at  the  date  of  the  publication  of  my  work,  1837,  in  which 
I  stated,  that  neither  in  the  cancerous  transformation  of  the 
lung  nor  the  mediastinal  tumour,  could  we  apply  any  direct 
diagnosis,  and  that  in  a  case  seen  for  the  first  time,  and  in  which 
no  external  cancer  existed,  there  were  no  means  by  which  we 
could  determine  the  point.  The  following  case,  however,  will 
show  that  our  knowledge  of  this  subject  has  advanced  since  this 
period.  The  following  is  an  abstract  of  the  notes  and  details  of 
this  case,  for  which  I  am  indebted  to  Dr.  Carroll,  of  Waterford, 


CANCER    OF    THE    LUNG.  41H 

with  whom  I  saw  the  patient  in  consultation  with  Drs.  Mackesy 
and  Conolly  : — 

Encephaloid  Degeneration    of  the  Right  Lung,   in  combination 

with  Empyema. 

Mr.  J.,  the  subject  of  the  following  report,  was  about  forty- 
four  years  of  age  ;  of  middle  height  and  robust  frame  ;  with  a 
well-formed  chest ;  temperament  neuro-bilious  ;  eyes  and  hair 
dark.  He  had  always  enjoyed  good  health,  with  the  exception 
of  a  tic  doloureux  in  the  gums  which  followed  the  extraction  of  a 
molar  tooth. 

June  11th,  1839. — He  returned  from  Dublin,  complaining  of 
uneasiness  in  the  right  hypochondrium  ;  stools  clay-coloured  : 
breathing  hurried,  particularly  in  the  evening;  took  hydrarg.  c. 
creta  for  a  few  days.     The  functions  of  the  liver  were  restored. 

July  9th. — Difficulty  of  breathing  having  much  increased, 
attended  with  cough,  he  applied  a  blister  to  the  chest,  and  was 
bled  to  3  xiv ;  blood  very  slightly  buffed  ;  breathing  relieved. 
He  at  this  time  was  going  about  his  ordinary  business  ;  appetite 
and  digestion  good. 

August  1th. — I  visited  him  for  the  first  time  ;  he  expectorated 
some  bloody  mucus  for  the  first  time,  and  was  attacked  with  a 
severe  lancinating  pain  in  the  right  side  of  the  chest,  between 
the  fourth  and  sixth  ribs,  shooting  backwards  to  the  scapula. 
Pulse  70  and  regular ;  respiration  twenty-six  in  a  minute ; 
tongue  clean  and  moist ;  skin  cool ;  bowels  free ;  ajmetite  good  ; 
unable  to  make  a  full  respiration  in  consequence  of  the  severe 
pain  which  it  produced.  On  inspecting  the  chest  both  sides 
were  found  perfectly  symmetrical.  On  percussion  the  left  side 
sounded  well  near  the  median  line ;  the  entire  of  the  anterior 
and  inferior  portion  of  the  right  side  sounded  dull,  as  did  the 
posterior  and  inferior  on  percussion,  dulness  rather  greater 
behind.  From  a  point  corresponding  to  the  fifth  rib  upwards, 
the  sound  on  percussion  was  clear  and  good,  respiration  puerile 
in  the  left  lung  ;  in  the  upper  part  of  the  right  side,  both  before 
and  behind,  respiration  was  natural,  from  the  nipple  downwards, 
throughout  the  entire  right  side  it  was  very  feeble,  but  distinct, 
accompanied  with  a  loud  sonorous  rale,  more  properly  termed  a 
wheeze  giving  the  impression  of  a  compressed  condition  of  the 


41G  CANCER    OF    THE    LUNG. 

bronchial  tubes,  no  mucous  or  crepitating  sounds.  The  sputa 
was  very  peculiar,  such  as  I  never  saw  before  ;  they  presented 
the  appearance  of  black  currant  jelly,  being  not  unlike  it  in  con- 
sistence. They  had  none  of  the  viscidity  of  pneumonic  sputa, 
but  gave  the  notion  of  pure  mucus  and  pure  blood  mechanically 
blended.  He  lies  chiefly  on  the  back,  being  unable  to  lie  with 
comfort  on  either  side  for  some  time. 

August  27th. — Since  last  report  the  pain  has  continued  with- 
out any  relief.  Observed  two  large  veins  corresponding  to  the 
epigastric  arteries  ramifying  on  the  abdomen ;  the  superficial 
veins  of  the  thorax  manifestly  enlarged.  Pulse  112  ;  respira- 
tion 30 ;  dulness  of  the  right  side,  increasing  in  extent 
(upwards)  and  in  degree  ;  respiration  in  the  some  region  nearly 
extinct ;  in  the  superior  portion  of  the  lung,  it  is  becoming  of  a 
bronchial  character. 

August  28t1i. — Dyspnoea  greatly  increased,  coming  on  in 
violent  paroxysms,  threatening  suffocation,  obliged  to  be  propped 
up  in  bed  with  pillows  ;  at  his  own  request,  an  accurate  physical 
examination  was  made,  when  amid  a  great  deal  of  uncertainty, 
from  the  anomalous  nature  of  his  symptoms,  we  arrived  at  the 
conclusion  that  his  disease  was  either  a  tumour  of  or  in  the 
lung,  compressing  it  and  so  interfering  with  its  functions,  or  an 
empyema  the  result  of  the  pleuritis.  The  latter  we  adopted  as 
most  probable,  and  its  peculiar  symptoms  subsequently  in- 
creasing, we  thought  no  more  of  a  tumour. 

September  lOtli. — Orthopnoea ;  confusion  and  giddiness  of 
the  head  during  the  exacerbation  of  dyspnoea. 

October  2nd. — On  examining  the  chest,  found  right  side  on 
measurement  two  inches-  larger  than  the  left ;  slight  oedema  of 
the  chest  and  face  ;  legs  considerably  swollen  ;  intercostal  spaces 
not  obliterated,  though  in  less  action  than  the  other  side ;  veins 
greatly  enlarged,  and  two,  corresponding  to  the  internal  mam- 
mary vessels,  meet  those  on  the  abdomen ;  entire  right  side 
sounds  dull ;  respiration  absent  over  the  entire  side  from  the 
fourth  rib  down  ;  it  is  bronchial  above.  Both  before  and  behind 
great  resonance  of  voice ;  pressure  on  the  epigastrium  causes  an 
insufferable  sense  of  suffocation. 

November  Qth. — Has  been  rather  improving  since  last  report ; 
feels  altogether  more  comfortable,  and  can  lie  much  better  in  the 
horizontal  posture.     On  measurement  both  sides  are  found  of 


CANCER   OF   THE   LUNG.  417 

equal  girth  ;  there  is  no  displacement  of  the  liver ;  intercostal 
spaces  more  distinct ;  cedema  of  side  and  face  gone. 

November  1th. — Visited  by  Dr.  Stokes,  who  pronounced  his 
opinion,  that  he  laboured  under  malignant  disease  of  the  lung 
together  with  an  empyema,  and  that  he  could  not  recover. 

November  20th. — The  affected  side  is  now  found  to  be  about 
half  an  inch  less  in  circumference  than  the  other. 

During  the  months  of  January  and  February  there  was  a  pro- 
gressive decline  of  strength  and  flesh,  notwithstanding  that  his 
appetite  was  good  during  that  time.  Towards  the  last  week  or 
fortnight  he  complained  very  much  of  oppression  at  the  epi- 
gastrium, as  if  a  heavy  weight  were  there.  The  liver  could  be 
plainly  distinguished ;  his  legs  swelled  again,  and  face  became 
^edematous.  For  three  days  before  his  death,  he  sat  in  a  chair 
in  the  most  distressing  state  of  orthopnoea,  with  a  pillow  on  his 
knees  and  his  elbows  leaning  on  the  pillow.  He  had  no  pain  at 
the  struggle.  There  was  no  tumour  or  other  mark  of  disease  on 
his  body." 

I  did  not  see  this  patient  again,  but  in  the  following  March 
the  account  of  the  dissection  was  given  in  a  letter  I  received  from 
Dr.  Carroll.  "  I  opened  his  body  thirty-three  hours  after  death, 
in  presence  of  several  practitioners  of  this  city,  and  I  was  greatly 
gratified  to  find  your  diagnosis  verified  to  the  letter.  The  fol- 
lowing were  the  appearances  observed:  the  body  was  much 
emaciated ;  the  legs  infiltrated  with  serum  ;  the  superficial  veins 
which  ramified  on  the  surface  of  the  thorax  and  abdomen,  and 
which  were  enormously  enlarged  during  life,  had  almost  disap- 
peared. 

"  On  opening  the  thorax,  a  quantity  of  pure  pus,  amounting 
to  about  three  pints,  was  found  occupying  a  space  in  the  right 
side  of  the  chest,  extending  from  the  sixth  rib  to  the  diaphragm. 
The  cavity  in  which  it  was  contained  was  lined  throughout  by  a 
very  thick  and  smooth  membrane.  The  lung  compressed  into 
the  upper  part  of  the  chest  was  found  intimately  adherent  to 
the  parietes  and  all  the  surrounding  parts;  so  much  so  as  to 
resist  every  attempt  at  separation  with  the  fingers,  and  was  only 
removed  by  the  knife.  On  cutting  into  its  substance  it  presented 
a  very  remarkable  appearance,  being  converted  throughout  into  a 
solid,  heavy  fibro-cartilaginous  mass  of  brilliant  white  brain-like 
colour,  interspersed  with  black  spots,  of  the  diameter  of  a  six- 

E  E 


418  CANCER  OF   THE   LUNG. 

pence,  each  contrasting  singularly  with  the  white  portion.  On 
close  examination,  this  white  substance  was  found  to  be  fibrous 
in  its  texture,  and  radiated  like  (but  not  so  distinctly)  as  scirrhus ; 
and  notwithstanding  its  extreme  closeness  and  density,  a  white, 
creamy  fluid  exuded  from  the  surface  on  incision.  The  black 
patches  were  of  a  soft,  semi-fluid  consistence,  and  it  appeared 
doubtful  whether  they  were  melanotic  deposits,  which  sometimes 
occur  in  conjunction  with  encephaloid  tumours,  or  merely  the 
remains  of  bronchial  glands.  I  rather  incline  to  the  former 
opinion.  There  were  some  few  traces  of  vascularity  in  some 
parts  of  the  lung,  and  these  confined  to  the  apex,  the  lesser 
bronchial  tubes  were  obliterated,  while  the  larger  ones  in  the 
upper  and  posterior  part  were  dilated.  There  was  no  ulcerous 
cavity.  In  the  left  pleura  about  a  pint  of  clear  serum  was 
found.  The  lung  at  that  side  was  free  from  adhesions,  and 
presented  a  healthy  appearance  on  the  surface,  and  crepitated 
on  pressure ;  it  was,  however,  much  compressed,  and  pushed  up 
by  the  diseased  mass  at  the  other  side  ;  a  section  of  it  exhibited 
a  slightly  whitish  appearance,  which,  in  all  probability,  was 
the  commencement  of  a  similar  disorganisation  as  that  which 
existed  in  the  right.  There  was  some  bronchitis.  The  peri- 
cardium contained  about  eight  ounces  of  serum ;  the  heart  was 
perfectly  healthy ;  the  liver  was  sound,  but  somewhat  enlarged, 
and  projected  about  three  inches  below  the  cartilages  of  the 
ribs,  and  at  the  point  of  contact  with  them  presented  a  very 
deep  sulcus,  such  as  you  have  described  in  your  '  Observations 
on  the  Diagnosis  of  Empyema' ;  the  remaining  abdominal  viscera 
were  healthy.     The  brain  not  examined." 

When  I  saw  this  patient  he  was  sitting  in  an  arm-chair,  with 
his  body  bent  forward ;  he  had  orthopncea  and  oedema  of  the 
legs.  The  question  had  been  agitated,  as  to  whether  para- 
centesis of  the  chest  might  be  advisable.  We  found,  however, 
that  both  sides  of  the  chest  were  of  equal  size,  the  right 
being  covered  with'  a  network  of  large  varicose  veins,  which 
could  not  be  attributed  to  the  pressure  of  the  empyema,  as  they 
had  been  increasing  since  the  return  of  the  side  to  its  ordinary 
dimensions.  It  was  obvious,  that  even  admitting  the  existence 
of  a  pleuritic  effusion,  some  other  disease  must  be  present  to 
account  for  the  venous  obstruction.  The  side  sounded  com- 
pletely dull  in  every  portion,  and  in  the  upper  part  there  was 


CANCER    OF    THE    LUNG.  419 

a  total  absence  of  respiration.  The  upper  portion  then  of  the 
lung  was  completely  solid,  and  it  was  not  unlikely  that  some 
remains  of  the  empyema  still  existed  inferiorly ;  but  at  this 
period  the  point  could  not  be  absolutely  determined.  I  may 
now  enumerate  the  different  points  leading  to  the  diagnosis  of 
cancer  in  this  instance. 

1.  The  violent  attack  of  pain  in  the  side,  the  pulse  remaining 
natural.  2.  The  peculiar  currant-jelly-like  sputa.  3.  The 
resistance  of  the  symptoms  and  signs  to  treatment.  4.  The 
continuance  of  symptoms  of  pulmonary  distress,  after  the  sides 
had  become  symmetrical,  pointing  out  that  some  new  disease  of 
the  substance  of  the  lung  had  formed  and  was  progressing. 
5.  The  existence  of  the  varicose  veins,  and  their  increasing 
after  the  return  of  the  side  to  its  natural  size.  6.  The  total 
impermeability  of  the  upper  portion  of  the  lung,  and  the  com- 
plete absence  of  all  signs  of  ulceration. 

Of  these,  the  three  most  important  were  the  obstinacy  of  the 
symptoms,  the  complete  consolidation,  and  the  varicose  state  of 
the  veins.* 

On  the  subject  of  the  pulsation  of  cancerous  tumours  I  have 
nothing  new  to  communicate,  and  beg  to  refer  to  my  work  on 
the  Diseases  of  the  Chest.  It  may  be  stated,  however,  that  the 
pulsation  is  not  a  constant  attendant  on  these  tumours,  and 
that,  in  my  case  and  in  that  by  Dr.  Syms,  the  pulsation  was 
obviously  communicated  to  the  tumour,  as  we  so  commonly 
see  it  in  the  abdomen.  No  mention  of  bruit  de  souffiet  is  made 
by  Dr.  Syms.  The  disease  of  cancer  of  the  lung  may  be  a 
primary  affection,  or  succeed  to  cancer  of  some  of  the  external 
parts.  We  yet  want  facts  to  determine  the  comparative  frequency 
of  the  two  cases.  Its  most  common  form  seems  to  be  the  dege- 
neration of  a  portion  of  the  lung  into  homogeneous  encephaloid 
matter,  and  in  that  of  isolated  tubercles,  which  I  think,  if  the 
patient  lives  long  enough,  may  increase  so  as  to  form  a  vast 

*  A  case  which  strikingly  resembled  the  above  in  many  particulars  is  admirably 
reported  by  Dr.  Mayne  in  the  third  volume  of  the  Dublin  Pathological  Society's 
Transactions.  The  characteristic  symptoms  and  physical  signs  are  thus  summarized 
by  Dr.  Mayne  :— "  Severe  thoracic  pains  gradually  progressive,  and  never  attended  by 
fever  ;  progressive  emaciation  without  sweating,  without  diarrhoea,  and  almost  with- 
out expectoration  ;  scanty  slate-coloured  sputa  ;  enlarged  thoracic  and  cervical  veins  ; 
constant  cough,  extreme  dyspnoea,  and  an  amount  of  dulness  and  inelasticity  of  the 
side  to  which  I  had  never  be/ore  seen  a  parallel,  were  the  prominent  signs  and 
symptoms." 

E    E  2 


420  CANCER   OF   THE   LUNG. 

mass  of  cancer.  Yet  not  quite  homogeneous,  but  presenting  a 
congeries  of  very  large  tumours,  touching  one  another,  and  com- 
pressing the  intervening  lung.  I  will  now  give  the  general 
conclusions  to  which  we  have  arrived,  marking  with  an  asterisk 
those  which  I  already  stated  in  my  work  on  the  Diseases 
of  the  Chest,  and  with  two  asterisks  those  which  have  been 
modified.  *  That  the  facility  of  diagnosis  mainly  depends 
on  the  anatomical  disposition  of  the  disease.  **  That  we 
may  divide  the  cases  with  a  view  to  diagnosis  into  those 
in  which  isolated  tubercles  exist,  with  the  intervening 
tissues  healthy;  those  in  which  simple  degeneration  occurs 
without  ulceration  and  with  ulceration ;  and  those  in  which  a 
tumour  of  the  mediastinum  exists,  causing  compression.  That 
the  diagnosis  in  the  first  case  is  difficult,  from  our  being  seldom 
able  to  avail  ourselves  of  the  signs  of  irritation  and  ulceration, 
so  important  in  ordinary  tubercles,  and  the  fact  of  the  equable 
distribution  of  the  disease  preventing  comparison.  That  in 
some  cases  of  isolated  cancerous  masses,  the  diagnosis  may  be 
founded  on  the  same  general  principles  as  that  of  acute  phthisis. 
##  That  in  simple  cancerous  degeneration  of  the  lung,  the  prin- 
cipal physical  signs  are  the  gradual  diminution  of  the  vesicular 
murmur,  without  rale  ;  its  ultimate  extinction,  and  the  signs  of 
perfect  solidification.  That  the  evidences  of  perfect  solidifica- 
tion are  better  found  in  this  disease  than  in  any  other  pulmo- 
nary affection.  That  this  form  of  the  disease  may  exist, 
simply,  or  in  combination  with  empyema,  and  may  be  secondary 
to  cancerous  tumours  of  the  mediastinum.  That  the  sides  may 
be  symmetrical  in  this  affection,  and  that  either  dilatation  or 
contraction  of  the  side  may  occur.  That  the  mediastinum  may 
be  displaced,  even  though  the  side  be  contracted.  *  That 
under  these  circumstances  we  may  have  the  signs  of  perfect 
solidification,  accompanied  by  imperfect  pectoriloquism,  and 
increased  vibration  to  the  hand.  **  That  the  mediastinum 
may  be  displaced  and  the  liver  depressed  without  protrusion  of 
the  intercostal  spaces.  That  the  heart  may  be  compressed  and 
dislocated  in  this  form  of  disease. — Hughes,  Syms,  Houston.f 
That  the  flattening  of  the  upper  part  of  the  chest  may  occur 
from  degeneration  of  the  upper  lobe. — Hughes.  **  That  the 
absence   of  signs  of  ulceration   is   very  characteristic  of   this 

f  Dublin  Medical  Journal,  vol.  iii.,  First  Series. 


CANCER   OF  THE   LUNG.  421 

disease.  That  we  have  observed  these  signs  in  but  a  single 
case,  and  that  the  phenomena,  though  they  might  be  produced 
by  other  diseases  causing  the  same  physical  conditions  of  the 
lung,  have  never  before  been  met  with.  That  cancerous  tumours 
of  the  mediastinum  generally  co-exist  with  either  degeneration 
of  the  lung,  or  isolated  tubercles  in  its  substance.  That  they 
may  be  solid  or  fluid.  That  they  may  co-exist  with  can- 
cerous infiltration  of  the  lung,  or  the  deposit  of  cancer  in  the 
bronchial  tubes.  That  they  are  to  be  recognized  more  by  the 
signs  of  the  tumour  than  by  those  of  disease  of  the  lung. 
**  That  dysphagia,  tracheal  stridor,  feebleness  of  one  pulse, 
difference  of  respiratory  murmur  from  pressure  on  the  bronchial 
tube,  displacement  of  the  diaphragm,  and  dilatation  of  the  heart, 
may  occur  in  this  form  of  the  disease.  **  That  a  cancerous 
tumour  may  exhibit  pulsation  with  or  without  bellows  murmur, 
but  that  pulsation  is  not  always  attendant  on  it.  *  That  though 
the  previous  existence  of  external  cancer  may  assist  in  diagnosis, 
yet  that  the  disease  may  be  all  through  internal,  or  the  visceral 
precede  the  external  cancer.  #That  the  feebleness  of  pulsation 
connected  with  the  extent  of  dulness  may  assist  in  distinguishing 
the  disease  from  aneurism.  That  in  the  advanced  periods,  as 
in  aneurism,  gangrene  of  a  portion  of  the  lung  may  supervene. f 
That  the  following  symptoms  are  important  as  indicative  of  this 
disease  :  pain  of  a  continued  kind ;  a  varicose  state  of  the 
veins  in  the  neck,  thorax,  and  abdomen ;  oedema  of  one 
extremity ;  rapid  formation  of  external  tumours  of  a  cancerous 
character ;  expectoration  similar  in  appearance  to  currant  jelly  ; 
resistance  of  symptoms  to  ordinary  treatment. 

That  though  none  of  the  physical  signs  of  this  disease  are, 
separately  considered,  peculiar  to  it,  yet  that  their  combinations 
and  modes  of  succession  are  not  seen  in  any  other  affection  of  the 
lung. 

f  My  friend,  Mr.  MacDonnell,  has  shewn  that  from  the  anatomical  disposition  of 
the  nutritive  arteries  of  the  lung,  pressure  upon  any  part  of  the  main  bronchus 
might  cause  the  death  of  the  lung.  Of  course,  the  liability  to  this  is  greater  in 
the  case  of  mediastinal  tumours  than  in  the  simple  degeneration.  Dr.  Greene  has 
met  with  this  gangrene,  from  the  same  physical  causes,  in  aneurism.  See  the 
Transactions  of  the  Pathological  Society, 


422 


SECTION  VIII. 


TUBERCLE    OF    THE    LUNG. 


In  conformity  with  the  plan  of  this  work,  I  shall  confine  my- 
self solely  to  the  diagnosis  and  treatment  of  phthisis,  and  only 
discuss  the  pathology  of  tuhercle  incidentally,  and  so  far  as  may 
be  necessary  for  the  elucidation  of  the  subject. 

The  diagnosis  in  this  affection  is  drawn  from  the  study  of  the 
former  and  actually  existing  symptoms  considered  in  relation  to 
the  pliysical  signs  and  their  mutations.  It  is  to  be  recollected 
that  there  are  no  physical  signs  peculiar  to  tubercle  ;  it  is  in 
their  combinations,  situation,  successive  changes,  and  connexion 
with  pure  symptoms  that  they  have  their  value. 

It  is  not  to  be  denied,  that  a  correct  diagnosis  of  phthisis  may 
be  frequently  made  without  the  aid  of  physical  signs,  for  there 
are  abundant  cases  presenting  such  a  combination  of  circum- 
stances, as  to  render  the  existence  of  tubercle  all  but  certain ; 
these  are  the  more  obvious,  ordinary,  and  advanced  cases.  But 
in  the  earlier  periods,  when  the  diagnosis  is  practically  useful, 
and  in  that  vast  category  of  cases  in  no  respect  corresponding  to 
the  description  of  books,  the  symptomatologist  is  continually  at 
fault.  We  shall  not  enter,  therefore,  into  a  detailed  account  of 
symptoms,  for  it  would  be  a  hopeless  task  to  frame  any  descrip- 
tion which  would  apply  even  to  the  majority  of  cases,  but  after 
having  examined  the  sources  of  the  physical  signs,  we  shall  com- 
bine and  study  the  symptoms  and  signs  of  the  more  prominent 
varieties  of  the  disease. 

As  in  phthisis  all  the  structures  of  the  lung  may  be  engaged, 
so  in  a  single  case  we  may  meet  every  known  auscultatory  sign  of 
disease  of  the  mucous  membrane,  parenchyma,  and  serous  invest- 
ment. These  occur  in  infinitely  various  combinations,  according 
to  the  degree  of  irritation,  the  number  of  tissues  engaged,  the 
extent  of  ulceration,  and  the  chronicity  of  the  disease. 

In  the  first  section  of  this  work  I  have  shewn  how  comparison 


TUBERCLE   OF   THE   LUNG.  423 

aids  us  in  physical' diagnosis,  and  there  is  no  disease  in  which 
it  is  so  applicable  as  phthisis.  In  this  respect  an  important 
division  may  be  made,  of  those  cases,  on  the  one  hand,  in  which 
comparison  subserves  to  diagnosis;  and  those  in  which  the 
phenomena  being  similar  and  universal,  the  principle  is  inap- 
plicable. In  the  first  class,  or  that  in  which  the  disease  is 
originally  local,  may  be  placed  by  far  the  greater  number  of 
cases,  for  those  in  which  the  disease  engages  the  whole  lung  in  a 
nearly  equable  manner  are  exceedingly  rare. 

For  example,  the  existence  of  tubercle  of  the  upper  portion 
of  one  lung  is  recognized  by  the  difference  between  its  physical 
signs  and  that  of  the  lower  lobe ;  in  other  words,  by  applying 
comparison.  And  in  like  manner,  if  the  whole  of  one  lung  be 
diseased  we  recognize  the  lesion  by  comparing  it  with  the  other. 
But  when  tubercle  is  scattered  equably  throughout  both  lungs, 
and  accompanied  everywhere  by  the  same  amount  of  irritation, 
then  the  diagnosis  becomes  difficult  indeed,  and  can  only  be 
arrived  at  by  successive  observations. 

Let  us  now  enumerate  the  physical  signs  of  pulmonary  phthisis. 

1st.  Signs  of  irritation. 

(a.)  Of  the  mucous  membrane,     (b.)  Of  the  air  cells,  or 
parenchyma,     (c.)  Of  the  serous  membrane. 

2nd.  Signs  of  solidification. 

3rd.  Signs  of  ulceration. 

4th.  Signs  of  atrophy. 

5th.  Signs  referrible  to  the  circulating  system. 

(a.)  Action  of  the  heart,     (b.)  Of  the  arteries,     (c.)  Dis- 
placement of  the  heart. 

I  shall  examine  these  sources  of  diagnosis  separately. 

Signs  of  Bronchial  Irritation. — In  the  great  majority  of 
cases  these  precede  and  accompany  the  development  of  tubercle, 
and  the  rales  occur  in  every  degree  of  intensity  and  variety  of 
combination.  In  some  a  single  occasional  mucous  bubble  is  the 
only  sign,  while  in  others  the  respiration  is  altogether  masked 
by  a  combination  of  the  sonorous,  sibilous,  and  muco-crepitating 
rales.  These  signs  are  audible  under  the  clavicle,  in  the  axilla, 
or  in  the  acromial  or  supra-spinous  regions ;  in  some  cases 
accompanying  the  ordinary  breathing,  in  others  only  audible  on 
a  forced  inspiration,  and  thus  it  commonly  happens  that  the 
signs  escape  the  superficial  observer,  for  the  murmur  may  be 


424  TUBEKCLE    OF   THE    LUNG. 

pure  during  ordinary  breathing,  and  yet  intense  bronchial  rales 
be  revealed  by  a  forced  expansion.* 

Of  these  rales  the  most  common  are,  the  mucous  and  muco- 
crepitating,  next  in  frequency  are  the  sibilous,  while  the  rarest 
are  the  deep-toned  sonorous  rales.  These  results  we  might 
expect  from  the  tuberculous  irritation  first  engaging  the  minute 
air  tubes.  Connected  with  this  we  find  that  although  these 
phenomena  may  exist  simultaneously  in  the  subclavicular, 
axillary  and  postero-superior  portions,  yet  that  their  existence  in 
one  of  these  situations  does  not  imply  that  we  can  detect  them 
in  the  others.  The  utility  of  this  rule  in  examination  is  obvious, 
but  in  most  cases  we  may  content  ourselves  with  exploring  the 
anterior  and  posterior  faces  of  the  lung. 

Combined  with  the  direct  signs  of  bronchial  irritation  we  find 
in  most  cases  a  feebleness  of  the  vesicular  murmur,  and  a  shade 
of  dulness  of  the  clavicle  or  spinous  ridge.  The  less  musical 
the  rale  the  greater  the  probability  that  these  signs  shall  accom- 
pany it,  but  we  may  have  a  loud  musical  rale,  or  scattered 
mucous  bubbles,  with  clearness  of  sound,  and  even  a  puerile 
respiration. 

Now  if  it  be  asked,  what  gives  these  signs  of  bronchitis  their 
value  as  diagnostics  of  incipient  tubercle,  the  answer  is,  that  it 
is  not  by  their  mere  characters  (for  these  do  not  differ  from 
ordinary  bronchitis),  but  it  is  from  their  situation,  localization, 
and  combination  with  comparative  dulness  of  sound  that  they 
derive  this  value.  The  same  phenomena  scattered  over,  or  even 
existing  intensely  throughout  the  lung,  but  being  equable  and 
unaccompanied  by  dulness,  would  not  only  have  no  value  in  the 
diagnosis  of  phthisis,  but  would  render  the  existence  of  tubercle 
improbable. 

Simple  bronchitis  is  seldom  circumscribed,  while  that  of  the 
consumptive  is  commonly  so ;  the  latter  begins  in  the  upper 
portion  of  the  lung,  remains  obstinately  fixed  in  the  air  tubes, 
gradually  spreads  downwards,  and  while  in  its  first  stages  in  the 
lower  lobe,  is  combined  with  tuberculous  ulceration  in  the 
upper ;  it  may  be  intense  in  the  upper  lobe  while  the  lower  is 
altogether  free,  or  engage  the  whole  of  one  lung  while  the  other 

*  To  Dr.  Forbes  is  due  the  great  merit  of  first  pointing  out  the  importance  of  in- 
vestigating the  respiration  in  the  earliest  stages  of  phthisis,  a  subject  which  Laennec 
comparatively  neglected. 


TUBERCLE    OF    THE    LUNG.  425 

is  scarcely  affected.  These  are  not  the  characters  of  ordinary 
bronchitis. 

These  observations  apply  to  the  ordinary  cases  in  which  the 
tubercle  and  bronchial  irritation  are  at  first  local  and  advance 
together,  but  the  whole  lung  may  be  simultaneously  and  equably 
tuberculated,  when  of  course  these  principles  do  not  apply.  The 
cases  may  be  divided  into  two  classes,  the  acute  and  chronic. 
As  these  cases  shall  be  hereafter  considered,  I  shall  now  allude 
to  them  only  in  connexion  with  bronchitis. 

In  the  first  or  acute  form  a  patient  previously  in  good  health 
is  suddenly  attacked  with  the  most  violent  symptoms ;  there  is 
high  fever,  extreme  dyspnoea,  lividity,  and  tenacious  expectora- 
tion. In  the  early  periods  the  chest  sounds  clear,  but  the 
signs  of  the  most  intense  bronchitis  affecting  the  tubes  of  all 
diameters  are  universally  audible.  The  symptoms  and  signs 
continue  with  unabated  violence,  and  after  a  few  days  the  whole 
chest  presents  a  certain  degree  of  dulncss.  The  patient  dies 
from  the  violence  of  the  pulmonary  inflammation,  and  on 
dissection  every  bronchial  tube  is  found  inflamed,  and  the  lung 
equably  and  closely  studded  with  the  miliary  and  granular 
tubercles.  In  the  second  or  chronic  case,  the  lung  becomes,  as 
in  the  former,  equally  tuberculated,  but  with  a  much  lower 
degree  of  bronchial  irritation ;  the  disease  goes  on  for  a  long 
period ;  the  bronchial  signs  scarcely  predominate  in  any  one 
part  of  the  lung,  but  are  accompanied  by  general,  and  sometimes 
decided  dulness. 

When  the  upper  lobe  contains  a  sufficient  quantity  of  tubercle 
to  give  dulness  of  sound,  a  large  mucous  or  muco-crepitating  rale 
is  often  observable  over  the  lower  portions,  and  hence  we 
commonly  find  that  while  cavities  or  anfractuosities  exist 
superiorly,  the  signs  of  bronchitis  alone  are  to  be  observed  below  ; 
and  I  have  often  been  led  to  the  discovery  of  tubercle  in  the  upper 
lobe,  by  this  lurking  bronchitis  confined  to  the  lower  portion  of  a 
single  lung. 

Signs  of  Irritation  of  the  Parenchybia. — It  is  sometimes 
difficult  to  distinguish  between  these  and  the  preceding  signs. 
The  crepitating  rales,  feebleness  of  respiration,  and  dulness  of 
sound,  may  be  enumerated  as  the  phenomena  of  this  class  ;  yet 
of  these  the  first  alone  can  be  properly  said  to  indicate  parenchy- 
matous inflammation ;    the  second  may  be  explained  on  other 


426  TUBERCLE    OF    THE    LUNG. 

principles ;  and  the  third  has  characters  very  different  from  that 
in  simple  pneumonia. 

But  the  crepitating  rale  of  pneumonia  is  rarely  observed  in 
phthisis,  and  I  have  never  heard  it  unless  on  a  forced  inspiration; 
it  is  then  accompanied  with  a  degree  of  dulness  ;  unlike  the  rale 
of  pneumonia  it  hardly  ever  disappears,  to  be  replaced  by 
bronchial  respiration,  but  passes  imperceptibly  from  the  finest 
crepitus  to  the  gurgling  of  anfractuosities. 

Even  when  acute  pneumonia  of  the  lower  lobe  succeeds  to 
chronic  phthisis,  the  crepitation  continues  much  longer  than  in 
the  ordinary  disease. 

There  is  in  phthisis  a  remarkable  character  of  the  crepitating 
and  finer  muco-crepitating  rales  which  must  be  noticed ;  these 
signs  may  occur  in  a  very  circumscribed  portion  of  the  lung,  and 
after  existing  twenty-four  or  forty-eight  hours,  disappear,  but 
again  to  return  in  about  the  same  time  ;  and  they  may  thus  recur 
and  subside  many  times  in  the  course  of  a  few  weeks.  I  look 
upon  this  recurrent  crepitus  as  an  excellent  diagnostic  in  many 
obscure  cases,  and  in  one,  although  the  place  of  its  first  appear- 
ance was  not  in  the  superior  portion,  yet  it  satisfied  me  that 
tubercle  existed,  and  dissection  verified  the  opinion. 

Lastly,  we  find  that  local  depletion  frequently  removes  these 
finer  rales  for  a  time,  and  this  is  almost  always  accompanied  by 
diminution  or  removal  of  the  hectic,  and  a  general  relief.  When 
on  the  treatment  of  phthisis,  I  shall  return  to  this  subject. 

Let  us  now  examine  the  important  sign  of  feebleness  of  respira- 
tion. 

Of  the  different  signs  of  incipient  phthisis  there  is  none  more 
important  than  this  ;  it  is  to  be  ascertained  by  comparison  of  the 
corresponding  portions  of  the  lungs,  and  of  the  upper  with  the 
lower  lobes,  the  observation  being  made  on  the  forced,  as  well  as 
the  ordinary  respiration. 

I  have  found  that  in  many  individuals  there  is  a  natural 
difference  between  the  intensity  of  the  murmur  in  either  lung, 
and  in  such  cases,  with  scarcely  an  exception,  the  murmur  of 
the  left  is  distinctly  louder  than  that  of  the  right  lung.  This 
character  is  particularly  evident  in  females,  and  nervous  indivi- 
duals, and  has  not  been  noticed  by  Laennec.  It  is  of  the  greatest 
importance  to  bear  it  in  mind,  as  we  may  thus  be  often  relieved 
from  the  anxiety  which  such  a  discovery  might  produce.     The 


TUBERCLE    OF    THE    LUNG.  427 

following  circumstances  serve  to  distinguish  this  natural  feeble- 
ness of  respiration. 

1st.  Its  occurrence  in  the  right  lung. 

2nd.  Its  being  unaccompanied  by  rale  or  dulness  of  sound  on 
percussion. 

3rd.  Its  being  the  same  over  the  whole  lung,  and  not  confined  to 
the  upper  portion  merely,  as  in  incipient  phthisis. 

It  need  scarcely  be  added,  that  the  value  of  feebleness  of  respi- 
ration is  greater  when  it  occurs  in  the  left  than  the  right  lung. 

So  many  cases  concur  to  produce  morbid  feebleness  of  respira- 
tion that  it  is  difficult  to  explain  it  by  a  reference  to  any  one  of 
them.  All  the  pathologic  states  of  the  lung  in  incipient  phthisis 
tend  to  this  result.  The'  bronchial  irritation,  the  adhesive 
obliteration  of  the  minute  tubes,  and  the  deposition  of  tubercle, 
would  all  produce  a  feeble  respiratory  murmur.  Of  these,  however, 
the  second  cause  is  probably  the  most  important,  and  the  fact  of 
feebleness  of  respiration  occurring  at  so  early  a  period,  is  what 
we  might  expect  from  the  obliteration  of  a  certain  number  of 
minute  tubes  before  the  air  cells  had  been  filled  up  or  the  inter- 
vening tissue  consolidated.*  To  this  subject  I  have  already 
alluded  in  the  section  on  Bronchitis. 

But  there  is  a  feebleness  of  respiration  which  is  difficult  of 
explanation,  and  which  seems  to  result  from  a  spastic  state  of  the 
lung.     The  following  is  a  remarkable  instance  of  this  : — 

A  boy,  aged  12  years,  after  recovering  from  a  succession  of 
eruptive  fevers,  by  which  he  was  greatly  reduced,  became  sud- 
denly affected  with  glandular  swellings  on  the  right  side  of  the 
neck.  These  increased  rapidly  ;  the  whole  chain  of  lymphatic 
glands  from  the  clavicle  to  the  mastoid  process  became  enlarged 
and  indurated,  causing  considerable  deformity.  In  little  more 
than  a  fortnight,  however,  the  tumours  had  nearly  disappeared, 
when  he  was  attacked  with  a  violent  cough,  difficulty  of  breathing, 
and  acceleration  of  pulse.  I  saw  him  on  the  third  day  of  this 
new  illness  ;  all  traces  of  the  glandular  swellings  had  subsided, 
the  breathing  was  hurried,  and  the  cough  dry.  Both  sides  of  the 
chest  sounded  perfectly  well ;  but  while  the  respiration  teas  loud 
over  the  left  lung  and  lower  half  of  the  right,  it  was  totally  absent 

*  See  M.  Reynaud's  Memoir  on  Obliteration  of  the  Minute  Bronchial  Tubes 
Me'moires  de  l'Acade'mie  Royale  de  Me'decine,  torn,  iv.,  1835.  The  paper  is  translated 
in  the  Dublin  Journal  of  Medical  Science,  vol.  vii. 


428  TUBERCLE    OF    THE    LUNG. 

over  the  ivhole  right  upper  lobe.  Bleeding  from  the  arm  was  per- 
formed, and  the  axilla  was  freely  leeched  ;  and  on  the  next  day 
the  respiratory  murmur  had  returned  with  nearly  its  natural 
intensity.  The  lymphatic  swellings  now  began  to  re-appear,  and 
in  less  than  a  week  had  attained  their  former  magnitude,  the 
chest  being  completely  relieved.  Iodine  was  now  used  both 
externally  and  internally.  For  upwards  of  two  weeks  the 
tumours  resisted  the  remedy,  when  they  suddenly  began  to  dis- 
appear, and  in  three  days  nothing  was  left  but  a  slight  induration 
above  the  clavicle.  Cough,  pain,  acceleration  of  breathing,  and 
quickness  of  pulse  set  in,  and  the  respiration  of  the  upper  lobe 
became  as  before  extinct,  while  it  was  intensely  puerile  in  the 
other  portions. 

Leeching  and  blistering  were  employed  on  the  affected  portion ; 
the  symptoms  were  again  removed,  and  again,  in  the  course  of  a 
week,  did  the  cervical  swellings  return.  These  of  course  were  no 
longer  interfered  with,  and  by  a  steady  perseverance  in  constitu- 
tional treatment  the  boy  gradually  recovered  ;  but  a  year  elapsed 
before  the  lymphatic  tumours  had  disappeared. 

In  this  important  case  we  see  the  alternation  of  scrofulous 
action  between  the  neck  and  upper  portion  of  the  right  lung,  for 
that  the  patient  was  twice  on  the  point  of  passing  into  acute 
phthisis  no  one  can  reasonably  doubt. 

But  the  nature  of  the  feebleness  of  respiration  remains  to  be 
ascertained.  It  occurred  as  the  sole  phenomenon  ;  neither  rale 
nor  dulness  accompanied  it,  and  its  subsidence  under  treatment 
was  followed  by  the  re-appearance  of  lymphatic  irritation  of  the 
neck.  Was  the  obliteration  of  the  tubes  the  result  of  inflamma- 
tory spasm,  or  a  combination  of  this  with  the  adhesive  process?* 

In  the  ordinary  cases  the  feebleness  of  respiration  is  almost 
always  modified,  and  often  removed,  by  a  timely  antiphlogistic 
and  revulsive  treatment,  and  there  can  be  no  doubt,  that  in  this 
way  many  a  patient  can  be  saved  from  impending  consumption. 

Connected  with  this  subject  we  may  notice  the  interrupted 
respiration,  "respiration  entrecoupee  "  of  Laennec,  in  which  the 
inspiratory  murmur  is  broken  into  a  succession  of  efforts.  It 
indicates  the  first  stage  of  tubercular  irritation,  and  may  be 
removed  by  local  treatment.     As  a  diagnostic,  however,  it  has 

*  But  may  not  the  extinction  of  the  respirafon  sounds  have  been  caused  by  com- 
pression of  the  bronchus  by  alternating  enlargement  of  the  bronchial  glands  ?    (Ed.) 


TUBERCLE    OF   THE    LUNG.  429 

no  value,  unless  when  it  is  local,  and  occurring  in  a  case  in 
which  tubercle  has  been  already  recognized,  when  it  becomes 
the  avant  courier  of  more  unequivocal  signs.* 

Signs  of  irritation  of  the  Serous  Membrane. — Although 
pleural  adhesions  so  commonly  attend  pulmonary  tubercle,  yet 
the  physical  signs  of  pleuritis  are  comparatively  rare.  I  have 
never  found  them  in  the  earlier  periods,  even  when  the  signs  of 
bronchial  and  parenchymatous  irritation  were  manifest. 

It  is  in  the  advanced  stages  when  the  upper  lobe  contains 
ulcerated  tubercle,  that  the  "frottement "  of  Laennec  is  some- 
times discovered  in  the  mammary,  lateral,  or  postero- inferior 
portions.  It  is  most  commonly  ushered  in  by  pain  of  the  side, 
but  continues  long  after  this  has  disappeared ;  indeed,  some  of 
the  most  remarkable  instances  of  the  persistence  of  frottement 
may  be  seen  in  pulmonary  phthisis,  and  the  phenomenon  may 
continue  for  several  weeks  without  decided  change. 

*  The  interesting  phenomenon  of  the  contraction  of  the  muscular  fibres  of  the  chest 
on  percussion,  must  be  here  noticed.  "  Some  time  ago,  on  percussing  a  patient  who 
had  laboured  under  a  pectoral  affection,  with  several  symptoms  indicative  of  tubercular 
development,  we  were  surprised  to  observe  that  after  each  stroke  of  the  ends  of  the 
fingers  a  number  of  little  tumours  appeared,  answering  exactly  to  the  number  and 
situation  of  the  points  of  the  fingers  where  they  had  struck  the  integuments  of  the 
chest.  These  having  continued  visible  for  a  few  moments,  subsided  ;  but  could  be 
again  made  to  appear  on  repeating  the  percussion.  In  this  case  percussion  excited 
a  good  deal  of  pain  ;  the  situation  in  which  these  little  tumours  were  most  apparent 
was  in  the  subclavicular  region,  and  over  the  great  pectoral  muscle.  Since  this 
observation  we  have  seen  the  same  phenomenon  in  a  number  of  cases. 

"  How  far  this  phenomenon  may  be  connected  with,  or  depending  on,  internal 
disease,  is  yet  to  be  ascertained.  It  is  seldom  met  with  unless  in  cases  where  the 
patients  are  emaciated  to  a  certain  degree.  In  these  individuals  we  often  find,  on 
using  percussion  quickly  and  with  some  force,  that  after  each  blow  a  degree  of  pallor 
is  observed  in  the  parts  struck,  exactly  answering  to  the  points  of  the  fingers  ;  this  is 
instantly  succeeded  by  the  return  of  rednsss,  and  the  erection  of  a  little  tumour,  which 
has  often  a  slight  quivering  motion,  and  which  subsides  in  the  course  of  one  or  two 
seconds. 

"  We  have  observed  this  to  occur  most  frequently  in  the  superior  and  anterior 
portions  of  the  chest,  but  have  also  met  with  it  in  other  situations  ;  such  as  the  arms, 
back,  &c.  In  some  cases  the  patients  complained  much  of  pain  on  percussion  ;  while 
in  others  they  did  not  appear  to  suffer  more  than  usual." — Clinical  Report  of  Cases  in 
the  Medical  Wards  of  the  Meath  Hospital,  during  the  Session  of  1828  and  1829; 
Dublin  Hospital  Reports,  vol.  v. 

There  is  nothing  in  this  muscular  irritability  peculiar  to  phthisis,  but  that  it  is 
commonly  connected  with  irritation  of  the  lung,  or  pleura,  there  can  be  no  doubt ; 
and  in  this  way,  like  the  other  signs  of  irritation,  it  becomes  available  in  the  diagnosis 
of  phthisis.  It  is  always  more  evident  in  the  earlier  periods;  thus  in  incipient 
phthisis  it  occurs  over  the  primary  seat  of  irritation,  while  in  the  confirmed  and 
chronic  cases  we  may  often  find  it  absent  over  the  lung  first  diseased,  and  strikingly 
marked  on  the  side  last  and  least  engaged. 


430  TUBERCLE    OF    THE    LUNG. 

It  almost  always  exists  with  clearness  of  sound,  and  a  per- 
ceptible murmur.  The  patient  is  frequently  conscious  of  the 
rubbing,  on  drawing  a  deep  inspiration — a  sensation  quite  inde- 
pendent of  pain.  In  the  earlier  periods,  the  sensation  is  com- 
municated to  the  hand,  but  the  sound  may  continue  for  weeks 
after  the  signs  from  touch  have  disappeared. 

The  same  causes  which  produce  the  rarity  of  frottement.  in 
pneumonia  operate  also  in  phthisis.  There  is  a  great  similarity 
between  the  mode  of  adhesion  in  both  cases,  and  the  surfaces  of 
the  membrane  may  unite  without  the  conditions  which  best 
induce  the  friction  sound.* 

If  the  phenomena  of  dry  pleuritis  be  rare  in  phthisis,  those 
of  liquid  effusion  are  still  more  so.f  The  signs  are  the  following  : 
rapid  didncss  of  the  lower  portion  and  absence  of  respiration 
ivithout  the  signs  of  progressive  pneumonic  solidity.  I  have  no 
observations  to  determine  how  far  the  previously  tuberculated 
state  of  the  upper  lobe  may  modify  the  signs  of  displacement. 

Signs  of  Solidification. — In  phthisis  condensation  of  the 
lung  occurs  in  two  forms.  In  the  first  it  is  complete  ;  in  the 
second  incomplete,  or,  as  it  were,  interrupted.  Of  these  the 
first  is  rare,  the  second  extremely  common ;  consequently  the 
physical  signs  of  complete  solidity  are  rarely  observed,  and  this 
constitutes  an  important  difference  between  the  signs  of  phthisis 
and  pneumonia,  or  cancer  of  the  lung. 

Even  in  cases  of  the  tubercular  infiltration,  inducing  a  homo- 
geneous structure,  complete  solidity  is  seldom  observed,  in  con- 
sequence of  ulceration  causing  an  anormal  permeability. 

A  slight  dulness  of  one  clavicle  or  scapular  ridge  is  one  of 
the  earliest  signs,  and  can  often  be  detected  only  by  the  most 
delicate  comparative  percussion.  It  may  exist  with  or  without 
stethoscopic  signs,  and  in  the  earlier  periods  may  vary  to  a 
certain  degree.  We  may  diminish,  or  for  a  time  remove,  the 
dulness  of  sound  by  treatment,  which  proves  that  in  the  earlier 
stages  it  is  owing  more  to  the  congestion  or  inflammation  of 
the  lung  than  to  the  existence  of  tubercle. 

*  The  existence  of  the  ordinary  pains  of  the  side  in  consumptive  patients  does  not 
by  any  means  imply  that  we  can  detect  the  friction  signs.  The  nature  of  these  pains 
is  still  obscure,  but  that  injury  is  commonly  done  by  treating  them  as  if  they  arose 
from  pleuritis  in  every  case,  there  can  be  no  doubt.  May  they  not  often  be  neuralgic, 
or  analogous  to  cancerous  pains  ? 

f  The  case  of  empyema  with  pneumothorax  and  fistula  is  of  course  excluded. 


TUBERCLE    OF    THE    LUNG.  431 

As  in  the  case  of  the  bronchitic  signs,  we  cannot  infer  the 
amount,  or  existence  of  clulness  of  the  posterior  portion,  from 
the  examination  of  the  anterior;  or  vice  versa,  both  clavicles 
may  sound  equally  well,  yet  a  distinct  difference  be  observed  in 
the  ridges  of  the  scapula ;  and  it  is  obvious  that  the  reverse 
may  happen.  In  a  few  cases  the  dulness  begins  at  about  the 
third  rib  anteriorly,  or  the  sub-spinous  region  posteriorly,  and 
spreads  upwards  ;  and  in  a  still  rarer  class  we  have  first  dulness 
of  the  lower,  and  afterwards  of  the  upper  lobe ;  but  in  these 
cases  the  disease  begins  with  pneumonia,  a  chronic  hepatization 
is  produced,  and  the  lung  becomes  slowly  tuberculated  from 
below  upwards.     - 

The  clavicular  dulness  is  almost  always  accompanied  by  a 
corresponding  feebleness  of  respiration.  But  the  reverse  of  this 
may  occur,  and  a  tubercular  dulness  of  the  clavicle  coincide  with 
a  puerile  respiration.  This  happens  when  the  posterior  half  of 
the  lung  is  greatly  condensed,  while  the  anterior  remains  per- 
meable. As  the  disease  advances,  however,  the  apparent  anomaly 
disappears. 

In  a  few  cases  the  dulness  coincides  with  a  bronchial  or 
tracheal  respiration.  I  have  already  shewn  why  this  sign  is 
comparatively  rare  in  phthisis ;  when  it  exists,  however,  it  is 
always  most  distinct  in  the  erect  position,  and  may  then  be 
pure,  or  what  is  more  frequent,  combined  with  the  muco- 
crepitating  or  mucous  rales.  I  have  often  found  that  the 
respiration  was  merely  feeble,  and  without  the  slightest  bron- 
chial character,  when  the  patient  was  lying  down,  but  on  his 
getting  up  the  bronchial  respiration  became  evident. 

As  in  pneumonia,  this  appearance  of  the  bronchial  respiration 
proceeds  from  the  greater  expansion  of  the  lung. 

But  the  equal  sonoriety  of  both  clavicles  may  co-exist  with 
tubercle.  It  may  arise  from  a  small  but  equal  quantity  of 
tubercle  in  both  lungs,  or  its  predominance  in  one  lung  pos- 
teriorly. In  the  first  case  comparison  must  be  instituted  between 
the  lower  and  upper  lobes.  Delicate  and  successive  percussion 
of  each  rib  from  the  sixth  upwards  must  be  performed,  when  the 
disease  will  be  often  discovered. 

In  doubtful  cases  condensation  can  often  be  detected  by  the 
following  manoeuvre.  Having  noted  the  ordinary  sound  of  the 
clavicle,  we  are  to  direct  the  patient  to  inspire  deeply,  and  hold 


432  TUBEBCLE    OF    THE    LUNG. 

in  his  breath ;  from  obvious  reasons,  percussion  will  now  detect 
a  difference  of  sound  before  imperceptible. 

As  disease  advances,  the  dulness  extending  downwards,  may 
occupy  the  entire  lung,  but  it  rarely  happens  that  the  whole  side 
is  equally  dull,  the  lower  generally  sounding  clearer  than  the 
upper  portions.  General  dulness  of  one  side  may,  however,  be 
met  with  ;  I  have  observed  it  from  the  following  causes. 

First.  General  tuberculization  of  the  lung,  the  tubercles  being 
in  the  crude  or  ulcerated  condition. 

Second.  Pneumonic  solidity  of  the  lower  lobe.  In  most  cases 
the  pneumonia  is  the  primary  affection. 

Third.  Effusions  into  the  pleura. 

Fourth.  Complication  with  enlarged  liver.  This  only  applies 
to  the  right  side. 

Fifth.  General  solidity,  with  great  atrophy  of  the  whole  lung, 
causing  contraction  of  the  side. 

Of  these  cases  the  first  is  by  far  the  most  common  ;  that  of 
unresolved  pneumonia  passing  into  tubercle,  is  next  in  frequency. 
The  others  are  exceedingly  rare.  The  dulness  being  established 
is  modified  in  two  modes.  In  the  first,  ulcerous  cavities  forming 
in  the  lung  diminish  the  dulness,  although  without  restoring  the 
natural  sound.  When  the  cavity  is  empty,  the  sound  is  somewhat 
tympanitic,  and  often  accompanied  by  the  bruit  de  pot  fele. 
When  it  is  large,  the  sound  might  be  confounded  with  the 
natural  resonance,  but  the  stethoscope  will  at  once  detect  the 
error.  The  second  cause  has  been  already  mentioned  under 
the  head  of  Pneumonia.  The  distention  of  the  stomach  with 
air  gives  a  peculiar  resonance  to  the  left  lung,  and  this  false 
clearness,  which  can  be  dissipated  by  a  carminative  draught,  is 
often  made  the  ground  of  unfounded  hope,  and  the  source  of 
bitter  disappointment.  It  need  hardly  be  observed,  however,  that 
to  the  experienced  stethoscopist  the  mere  character  of  the  sound 
suffices  to  prevent  error. 

General  acute  Development  of  Tubercle. — Hitherto  we  have 
studied  the  signs  of  solidification  in  their  ordinary  progress,  the 
tubercle  being  at  first  localized,  and  gradually  extending.  But 
when  the  whole  lung  is  equably  and  simultaneously  tuberculated, 
the  diagnosis  by  comparison  becomes  impossible.  Here  the 
diagnosis  is  drawn  from  the  succession  of  physical  signs  ;  the 
chest,  as  before  stated,  becomes  dull  without  the  usual  signs  of 


TUBERCLE    OF    THE    LUNG.  433 

pneumonia  and  pleurisy,  and  in  most  cases  with  the  phenomena 
of  bronchitis  merely.  This  principle  will  be  elucidated  when 
we  discuss  the  symptoms  of  phthisis  in  connexion  with  physical 
sisrns. 

In  the  general  chronic  tubercular  development  the  facility  of 
diagnosis  depends  mainly  on  the  suppuration  of  the  tubercle :  if 
it  be  nearly  equally  developed  in  both  lungs  and  still  in  the  crude 
granular  condition,  the  diagnosis  is  difficult ;  this  may  be  seen 
in  the  general  cachexia  and  in  old  persons.  Bronchial  rales, 
equally  diffused,  exist,  and  from  the  emaciation  of  the  patient, 
the  dulness  of  sound  may  escape  observation.  These  cases,  too, 
being  almost  always  of  long  duration,  dilatation  of  the  air  cells 
often  occurs,  the  clearness  of  which  compensates  for  the  dulness 
of  the  tubercle.  But  when  suppuration  exists  the  difficulties  are 
removed,  and  we  have  either  the  signs  of  cavities  in  the  upper 
portions,  or  a  general  mucous  or  muco-crepitating  rale,  at  once 
distinguishable  from  that  of  mere  bronchitis  by  the  general  and 
extreme  dulness  which  accompanies  it,  for  in  this  suppurative 
phthisis  the  dulness  is  always  more  decided  than  in  the  granular 
variety. 

Let  us  now  enumerate  the  different  modes  and  circumstances 
of  tubercular  dulness  : — 

1st.  Slight  variable  dulness  of  the  clavicle  or  scapular  ridge, 
occurring  in  the  first  stage,  and  influenced  by  treatment. 

2nd.  Comparative  permanent  dulness  of  these  situations. 

3rd.  Both  clavicles  dull — one  more  so  than  the  other. 

4th.  Both  clavicles  equally  dull. 

5th.  The  same  with  respect  to  the  scapular  ridges. 

6th.  Eight  clavicle  and  left  scapular  ridge  dull. 

7th.  Left  clavicle  and  right  scapular  ridge  dull. 

8th.  Dulness  of  the  clavicle,  the  corresponding  scapular  ridge 
clear. 

9th.  Dulness  of  the  scapular  ridge,  the  corresponding  clavicle 
sounding  clear. 

10th.  Dulness  most  evident  at  the  third  rib  anteriorly,  and  the 
sub-spinous  or  inter-scapular  region  posteriorly. 

11th.  Dulness  of  the  whole  upper  lobe. 

12th.  Dulness  of  the  whole  lung,  most  evident  superiorly. 

13th.  Dulness  at  the  root  of  the  lung,  extending  upwards. 

14th.  Dulness  of  the  lower  lobe  proceeding  upwards. 

F    F 


434  TUBERCLE    OF    THE    LUNG. 

15th.  Equal  dulness  of  the  whole  lung,  the  opposite  sounding 
clear. 

16th.  Equal  dulness  of  one  lung  and  of  the  opposite  upper 
lohe. 

17th.  Comparative  dulness  with  feeble  or  interrupted  respira- 
tion. 

18th.  The  same  with  mucous,  or  muco-crepitating  rale. 

19th.  The  same  with  semi-tracheal  respiration. 

20th.  The  same  with  puerile  respiration  under  one  clavicle. 

21st.  Complete  dulness  of  one  lung  with  the  rale  of  anfrac- 
tuosities. 

22nd.  The  same  with  the  usual  signs  of  a  well  defined 
cavity. 

23rd.  Incomplete  dulness  with  the  resonance  on  percussion  of 
a  cavity. 

24th.  Incomplete  dulness  in  the  upper  lobe  from  a  large 
excavation ;  perfect  dulness  of  the  lower,  from  tubercular  solidity. 

25th.  Incomplete  dulness,  varying  with  the  quantity  of  fluid 
contained  in  an  excavation. 

26th.  General  but  incomplete  dulness  of  both  lungs  super- 
vening on  bronchitis,  or  with  crepitating  rale  persisting  to  the 
fatal  termination. 

Other  combinations  may  of  course  occur,  but  I  have  verified 
the  connexion  between  the  above  and  tubercle  in  a  great  number 
of  cases.  Of  these  the  most  interesting  are  the  sixth  and  seventh, 
the  twentieth  and  twenty- sixth  cases.  The  dulness  of  a  clavicle 
and  the  opposite  scapula  is  one  of  the  most  interesting  of  the 
passive  signs,  it  is  by  no  means  uncommon,  and  I  have  never 
observed  it  unless  from  tubercle. 

Signs  of  Ulceration. — In  most  cases  the  signs  of  irritation 
precede  and  pass  into  these  phenomena.  In  some,  however, 
the  latter  appear  at  once,  unpreceded  by  any  active  auscultatory 
sign. 

In  general  nothing  can  be  more  gradual  than  the  transition 
from  the  crepitating  to  the  muco-crepitating  rales,  from  these  to 
a  large  mucous  rattle,  which  passes  into  the  rale  of  anfrac- 
tuosities,  and  ultimately  the  gurgling  0f  a  cavity.  This  is  the 
ordinary  course,  and  a  cavity  may  tbus  form,  complete  dulness 
having  never  existed.  In  other  cases,  however,  more  or  less  of 
dulness  having  existed,  the  signs  of  excavation  at  once  appear ; 


TUBERCLE    OF    TEE    LUNG.  435 

this  occurs  from  the  softening  of  a  large  tubercle  or  a  mass  of 
tubercular  infiltration. 

On  the  formation   of  a   cavity  in   the  upper  portion,  we  may 
often  detect  smaller  ulcerations,  or  the  earlier  stages  of  tubercle 
in  the  lower  part  of  the  affected  lung,  and  in  the  upper  lobe  of 
the  opposite.     So  rarely,  indeed,  is  tubercle  confined  to  one  lung, 
that  the  existence  of  a  cavity  almost  certainly  implies  disease  in 
the  opposite  side,  even  though  no  physical  sign  of  it  should  exist. 
The  signs  of  an  excavation  vary  according  to  its  situation, 
size,   contents,   bronchial  communication,  and  the   condition  of 
its  walls.      The   principal   are  cavernous  respiration,  rale,  and 
pectoriloquism ;  of  these  the  two  first  are  by  far  the  most  im- 
portant,   for   pectoriloquism,   about   which   so    much  has   been 
written,  and  on  the  discovery  of  which  so  much  importance  is 
placed,  is  of  all  the  physical  signs  of  phthisis,  the  least  constant, 
certain,  or  useful.     If  the  ear  be  well  accustomed  to  the  cavern- 
ous respiration  and  cough,  and  to  the  gurgling  rales  of  a  cavity, 
the  investigation  of  pectoriloquism  may  be  safely  neglected.     Of 
the  circumstances  which  modify  cavernous  respiration  and  rale, 
the  most  important  is  the  state  of  the  bronchial  communication ; 
the  fewer  and  larger  the  tubes  which  open  into  the  cavity  the . 
better  marked  will  the  signs  be,  while  the  communication  of  a 
great  number  of  smaller  orifices  obscures  the  cavernous  respira- 
tion, and  in  place  of  gurgling  produces  the  intense  mucous  rale 
of  a  cavity,  peculiar  indeed,  but  very  different  from  the  large 
cavernous  rale.     In  a  few  cases  the  temporary  obstruction  of  the 
tubes  obscures  the  cavernous  phenomena,  which  may  be  restored 
on  the  patient's  coughing  ;  and  we  thus  explain  the  variation  of 
the  physical   signs   according   to   the  position    of  the   patient. 
Cases  will  occur  in  which  the  recumbent  position  obscures  the 
signs  of  a  cavity  plainly  evident  when  the  patient  sits  up  ;  the 
reverse  of  this  is  also  observed. 

The  signs  are  rarely  perceptible  beyond  the  situation  of  the 
ulcer,  and  hence  the  removal  of  the  stethoscope  for  a  single 
intercostal  space  shall  make  us  lose  them.  In  the  same  way,  s«. 
cavity  may  be  plainly  perceptible  under  the  clavicle,  and  yet 
without  the  slightest  indication  of  it  posteriorly ;  nay,  we  may 
find  a  small  excavation  at  the  sternal  end  of  the  clavicle,  while 
below  the  humeral  the  signs  are  wholly  wanting. 

When  ulceration   commences   it   may  be   pointed  out   by  a 

f  f  2 


436  TUBERCLE    OF    THE    LUNG. 

single  but  well  defined  bubble,  occurring  in  a  situation  with 
feeble  or  puerile  respiration  and  some  dulness.  When  this  is 
constant  we  may  diagnosticate  a  cavity  of  the  size  of  a  Spanish 
nut.  As  new  ulcerations  form  the  rale  is  multiplied,  presents 
bubbles  of  various  sizes,  and  is  heard  over  a  greater  extent. 
The  sound  is  now  more  dull,  and  the  respiration  either  very 
feeble  or  semi-tracheal,  but  cavernous  respiration  and  pectori- 
loquism  are  absent,  and  we  make  the  diagnosis  of  anfractuo- 
sities.  At  this  period  the  dulness  is  often  very  considerable, 
but  the  tracheal  breathing  is  not  in  proportion  to  it.  In  some 
cases  the  bruit  de  'potfde  exists. 

A  well  defined  cavity  being  formed  with  sufficient  bronchial 
communication,  cavernous  respiration  is  produced.  This  must 
be  explored  during  ordinary  and  forced  breathing  and  cough. 
Upon  cavernous  respiration  and  gurgling  depend  the  diagnosis 
of  a  cavity. 

As  yet  we  know  little  of  the  conditions  which  regulate  pec- 
toriloquism,  but  as  a  sign  of  phthisis,  it  has  little  value.  Its 
occurrence  in  cavities  of  all  kinds,  ulcerous  or  not ;  its  varieties  ; 
its  similarity  to  morbid  bronchophonia,  often  so  great  as  to  make 
it  difficult  or  impossible  to  distinguish  them ;  its  existence  as  a 
natural  phenomenon  in  the  upper  portions  of  the  lungs  of  many 
individuals  ;  and  its  total  absence  in  cases  presenting  every 
apparent  physical  condition  for  its  existence,  have  long  made 
me  consider  it  as  the  least  important  and  most  fallacious  of 
all  the  physical  signs  of  phthisis.  Doctor  Forbes  has  long  come 
to  similar  conclusions.  Taken  alone,  it  is  absolutely  without 
value ;  but  when  in  combination  with  other  signs,  it  strengthens 
the  diagnosis.  It  is  to  be  explored  during  the  ordinary  and 
whispering  voice. 

In  certain  cases  the  existence  of  strong  pectoriloquism  is 
perceptible  to  the  patient,  who,  from  the  resonance  of  his  voice, 
can  point  out  the  situation  of  the  cavity. 

When  the  cavity  is  close  to  the  anterior  surface  of  the  lung, 
the  agitations  of  its  fluid  contents  are  often  perceptible  before 
we  apply  the  ear  to  the  chest.  In  this  way  sounds  are  produced 
by  the  respiration  and  the  action  of  the  heart.  In  the  first  case 
the  phenomena  are  twofold,  we  may  have  a  distinct  gurgling 
from  many  bubbles,  audible  during  inspiration  and  expiration — 
it  is  a  sort  of  churning,  or,  which  is  more  common,  we  hear  a 


TUBERCLE    OF    THE    LUNG. 


437 


single  bubble  corresponding  to  the  inspiration,  and  similar  to  the 
tick  of  a  small  clock,  or  watch.  In  some  cases,  upon  coughing, 
this  is  for  a  short  time  removed. 

But  a  more  curious  phenomenon  is  the  agitation  produced 
by  the  action  of  the  heart ;  it  is  the  rarer  of  the  two.  Each 
pulsation  is  accompanied  with  a  tick  in  the  cavity,  loud  enough 
to  enable  us  easily  to  reckon  the  pulse  ;  this  is  not  always  audible 
without  the  stethoscope,  but  where  the  cavity  is  large,  and  the 
chest  attenuated  and  elastic,  we  may  hear  it  at  a  distance  of  a 
foot  or  more  from  the  patient.  In  a  case  of  the  most  protracted 
consumption  with  extreme  emaciation,  this  sound  became  pain- 
fully loud,  and  of  a  metallic  character  on  the  patient  opening  the 
mouth. 

This  cardiac  gurgling  may  occur  in  both  lungs.  I  have  heard 
it  in  the  postero-superior  portion  of  the  right  lung,  while  it  is 
commonly  absent  even  when  the  cavity  lies  upon  the  pericardium , 

When  the  cavity  becomes  much  enlarged,  the  metallic 
character  may  be  communicated  to  the  gurgling,  cavernous 
respiration  and  voice  ;  of  these  the  metallic  gurgling  is  most 
common,  and  the  first  perceived,  for  the  bubbles  will  receive 
the  metallic  character  from  a  cavity  not  yet  sufficiently  large  to 
communicate  it  to  the  respiration  or  voice. 

These  characters  are  confined  to  the  situation  of  the  cavity, 
and  hence,  where  cavernous  respiration  and  gurgling  exist  under 
the  clavicle,  and  over  the  scapula,  yet  with  the  metallic  cha- 
racters only  audible  in  one  situation,  we  may  diagnosticate  two 
or  more  cavities,  one  much  larger  than  the  others. 

When  a  cavity  exists  in  the  lower  portion  of  the  left  lung, 
the  distention  of  the  stomach  with  air  may  cause  the  phenomena 
to  become  metallic. 

The  diagnosis  between  the  metallic  phenomena  of  a  large 
cavity,  and  those  of  pneumothorax  with  fistula,  is  not  difficult. 
I  shall  arrange  their  characters  in  opposite  pairs. 


LAEGE  CAVITY  WITHIN  THE  LUNG. 

1.  Metallic   phenomena   much 
less  developed. 

2.  Signs  supervening  gradually. 


PNEUMOTHORAX,      FISTULA,      EM- 
PYEMA. 

1.  Metallic  phenomena  intense. 

2.  Phenomena  suddenly  deve- 
loped. 


438  TUBERCLE    OF    THE    LUNG. 


3.  Side  not  dilated.    It  may  be 
contracted. 

4.  Sound  on  percussion  dull,  or 
with  the  resonance  of  a  cavity. 

5.  No    lateral  displacement  of 
the  heart. 

G.  Cavernous  rale  large. 

7.  Sound  of  fluctuation  absent, 
or  indistinct. 

8.  Pectoriloquisru  often  present. 


3.  Side  generally  dilated. 

4.  Percussion  exactlyindicating 
the  extent  of  air  and  liquid. 

5.  Lateral  displacement   com- 
mon. 

6.  Cavernous  rale  absent. 

7.  The  reverse. 

8.  Pectoriloquism  absent. 


With  respect  to  any  of  these  characters,  occasional  exceptions 
may  occur.  In  a  case  seen  for  the  first  time,  we  must  never 
neglect  percussion,  mensuration,  and  the  signs  of  cardiac  or 
hepatic  displacement. 

The  second  character  is  almost  always  available ;  yet  I  have 
known  of  an  instance  where  the  sudden  development  of  metallic 
signs  did  not  proceed  from  pneumothorax.*  The  ordinary 
signs  of  a  cavity  had  existed  for  some  time,  when,  during  a  fit 
of  coughing,  the  patient  was  seized  with  a  sudden  and  violent 
pain  in  the  side,  and  felt  as  if  something  had  given  way.  The 
signs  became  metallic,  and  the  patient  soon  afterwards  sank  ;  it 
was  found  that  there  had  been  two  cavities  divided  only  by  a 
thin  partition  ;  this  had  been  ruptured  during  the  fit  of  coughing, 
and  a  cavity  was  thus  produced  sufficiently  large  to  cause  metallic 
sounds. 

Laennec  has  given  two  cases  of  phthisical  cavities  producing 
metallic  phenomena.  In  the  first  there  was  distinct  pectorilo- 
quism, and  when  the  patient  coughed  or  spoke,  the  tinkling  was 
heard.  The  cavity  occupied  the  upper  half  of  the  lung,  and 
branched  into  many  anfractuosities.  It  contained  about  two 
spoonfuls  of  liquid. 

In  the  second  case  there  were  also  pectoriloquism,  and  the 
metallic  tinkling  on  coughing.  A  large  cavity  containing  a  very 
little  liquid  was  diagnosticated.  Three  cavities  Avere  found 
communicating  with  one  another,  none  of  them  larger  than  a 
pullet's  egg.  In  neither  of  these  cases  did  succussion  produce 
any  sound. 

I  have  found  the  metallic  signs  in  a  few  cases.     In  one  the 

*  This  case  did  not  occur  under  my  own  observation,  but  has  been  communicated 
to  me  by  a  gentleman  about  whose  accuracy  there  can  be  no  question. 


TUBERCLE    OF    THE    LUNG.  439 

patient  had  laboured  under  chronic  phthisis  of  the  right  lung, 
when  an  extensive  cavity  rapidly  formed  in  the  left.  The 
respiration  was  cavernous,  and  accompanied  by  a  tinkling  sound, 
similar  to  that  produced  by  the  falling  of  a  pin  into  a  cup  or 
glass.  A  vast  excavation  was  found  in  the  upper  portion  of  the 
left  lung,  communicating  with  many  smaller  ones  by  winding 
canals.  In  the  lower  lobe  there  was  another  cavity  of  the  size 
of  a  hen's  egg.* 

In  another  case,  the  left  side  sounded  everywhere  dull,  while 
over  the  infero-lateral  portion  the  metallic  tinkling  was  audible 
after  speaking,  when  a  succession  of  metallic  bubbles  could  be 
heard.  This  was  not  excited  by  the  cough,  nor  was  the  voice 
itself  metallic ;  there  was  no  amphoric  resonance  nor  sound  upon 
succussion,  nor  was  the  heart  displaced.  The  patient  soon  after 
sunk,  the  tinkling  having  more  than  once  subsided  and  re-appeared 
during  the  course  of  a  few  days. 

We  found  the  left  lung  universally  adherent,  and  so  excavated 
as  to  resemble  a  bag  of  liquid  more  than  a  lung.  Two  large 
cavities  existed,  one  in  the  upper,  the  other  in  the  lower  lobe ; 
these  communicated  by  a  fistula  into  which  the  finger  could  be 
introduced.  The  upper  cavity  extended  from  the  interlobular 
fissure  to  the  summit  of  the  lung  ;  the  lower  could  contain  a 
middle  sized  orange ;  both  presented  numerous  anfractuosities, 
and  the  lower  was  nearly  filled  with  a  grumous,  purulent  fluid. 
They  were  both  traversed  by  numerous  vessels  lined  with  a 
strong  cartilaginous  membrane,  and  had  the  most  extensive  and 
free  bronchial  communication.  In  the  upper  cavity  particularly, 
the  tubes  seemed  as  if  accurately  cut  across  with  a  knife.  The 
left  lung  contained  a  quantity  of  crude  tubercle. 

In  a  third  case,  the  metallic  tinkling  occurred  in  the  last 
stage  of  a  chronic  phthisis.  Gurgling  and  cavernous  respiration 
had  existed  over  the  left  mammary  region ;  but  during  the  last 
fortnight  of  existence,  an  occasional  metallic  tinkling  became 
audible.  The  cavity  extended  nearly  from  the  apex  of  the 
lung  to  its  base  ;  it  could  contain  more  than  a  pint  of  fluid ; 
its  anterior  Avail  was  formed  of  little  more  than  the  pleura, 
and  it  was  crossed  by  several  obliterated  blood-vessels.  The 
remainder  of  the  lung  was  nearly  solid  from  tubercle,  which  also 
existed  in  small  quantity  in  the  upper  portion  of  the  right  lung. 
*  See  Dublin  Hospital  Reports,  vol.  iv.,  a  Selection  of  Cases,  &c. 


440  TUBERCLE    OF    THE    LUNG. 

From  these  facts,  it  is  obvious  that  the  mechanism  of  the 
metallic  signs  is  not  yet  established.  These  sounds  may  be  inter- 
mittent, and  may  accompany  the  voice,  inspiration,  cough,  and 
action  of  the  heart,  or  exist  in  connexion  with  only  one  of  these 
actions  ;  further,  although  they  generally  indicate  a  large  cavity, 
yet  even  in  this  case  they  are  not  always  present,  and  may  even 
proceed  from  several  moderately  sized  excavations,  as  in  the  case 
recorded  byLaennec. 

It  is  remarkable  that  in  several  of  these  cases  the  cavities 
were  multilocular,  the  divisions  being  caused  by  septa  of  the 
pulmonary  tissue,  perforated  by  fistula?,  or  by  bands  of  obliterated 
vessels.  Can  this  condition  have  any  effect  in  producing  the 
metallic  sounds  ?  * 

Signs  from  Atrophy  of  the  Lung. — That  the  volume  of 
the  lung  is  diminished  in  phthisis  was  recognized  by  Bayle,  but 
the  subject  has  never  been  sufficiently  studied.  Laennec  states, 
that  a  contraction  of  the  chest  may  be  observed  in  very  chronic 
cases,  when  large  cavities  are  tending  to  cicatrize. 

Numerous  observations,  however,  have  convinced  me,  that 
the  contraction  Of  the  chest  resulting  from  atrophy  of  the  lung, 
begins  and  may  be  appreciated  at  a  much  earlier  period  than 
has  been  supposed ;  and  further,  that  in  chronic  cases,  great 
falling  in  of  the  chest  may  occur  from  interstitial  atrophy,  with- 
out the  formation  of  any  cavity  whatever.  Atrophy  of  the  lung 
I  believe  always  to  attend  the  earlier  stages  of  tubercle,  and 
is  probably  produced  by  the  operation  of  that  law,  by  which  an 
organ  loses  its  volume  when  its  functions  are  rendered  less 
energetic ;  and  thus  as  the  obliteration  of  the  minute  air  tubes 
described  by  Raynaud  advances,  the  cells  become  useless,  and 
ultimately  disappear.f 

But  whatever  be  the  mechanism  of  the  change  we  can. recog- 
nize it  at  an  early  period  by  accurate  measurement  of  the  antero- 
posterior diameter  of  the  thorax,  and  in  this  way  measurement 
is  found  a  most  important  means  of  diagnosis  in  the  earlier 

*  I  shall  recur  to  this  subject  when  on  Pneumothorax,  and  in  the  meantime  refer 
to  the  work  of  Dr.  Williams,  and  the  Memoir  of  M.  Beau,  Archives  Generales  de 
Medecine,  tome  iv.,  11  Serie,  Mars  1834. 

f  An  interesting  illustration  of  this  is  recorded  by  Andral.  In  dissecting  a  monkey, 
M.  Reynaud  found  that  one  bronchus  was  compressed  by  a  large  ganglion,  so  as 
greatly  to  diminish  its  calibre  ;  the  corresponding  lung  was  singularly  atrophied,  and 
the  side  fallen  in  as  in  the  absorption  of  pleuritic  effusion. — Precis  d' Anatomic 
Pathologique. 


TUBERCLE    OF   THE    LUNG.  441 

stages  of  phthisis.  It  should  never  be  neglected.  By  means  of 
a  spring  callipers,  one  knob  of  which  is  fixed  on  the  scapula, 
and  the  other  below  the  clavicle,  the  comparative  depths  of  the 
upper  lobes  can  be  at  once  determined  and  the  most  minute 
difference  detected.  The  circumference  of  the  chest  above  the 
mamma,  and  the  distance  of  the  clavicle  from  the  nipple, 
must  also  be  observed.  In  the  earlier  stages  the  difference 
varies  from  the  eighth  of  an  inch  to  half  an  inch,  and  there  is 
no  visible  alteration  except  a  flattening  or  slight  hollowing  under 
the  clavicle. 

But  in  the  more  chronic  cases  distinct  deformity  takes  place. 
The  antero-superior  region  becomes  extensively  flattened  or  con- 
cave, the  shoulder  depressed,  the  clavicle  flattened,  and  its  lower 
edge  everted,  the  ribs  closely  approximated  or  even  overlapping, 
and  the  apex  of  the  scapula  tilted  out  as  in  contraction  from 
empyema.  The  heart  ascends  in  the  thorax,  and  in  one  extreme 
case  I  have  found  it  to  pulsate  under  the  second  rib.  All  these 
signs  are  more  connected  with  the  chronic  solidity  than  the 
suppuration  of  the  lung,  for  the  latter,  by  permitting  some 
expansion  to  take  place,  may  delay  the  process  of  contraction. 

This  condition  may  exist  with  complete  dulness  of  sound 
and  bruit  de  pot  felt,  but  without  the  signs  of  cavities,  or  may 
coincide  with  gurgling  and  cavernous  respiration  in  their  different 
modifications. 

Signs  from  the  State  of  the  Circulating  System. — Active 
organic  disease  of  the  heart  and  aorta  being  among  the  rarest 
complications  in  phthisis,  it  happens  that  we  can  seldom  avail 
ourselves  of  signs  drawn  from  the  circulating  system  ;  Louis 
found,  out  of  a  hundred  and  twelve  cases,  only  three  in  which 
the  heart  was  enlarged.  It  is  more  often  diminished  in  volume, 
pale  and  flabby,  as  if  participating  in  the  general  muscular 
atrophy.  This  applies  to  the  chronic  cases,  for  in  the  acute  I 
have  often  found  the  heart  red,  and  in  no  way  altered  from  its 
natural  condition.* 

Notwithstanding  the  atrophied  state  of  the  heart  in  phthisis,  its 
action  is  occasionally  violent  and  distressing.  In  most  cases, 
indeed,  its    impulse   is    somewhat   increased,    and   if   there    be 

*  The  slowness  with  which  the  pulmonary  obstruction  occurs  in  chronic  cases 
explains  the  rarity  of  morbus  cordis ;  for  as  Louis  has  remarked,  the  fluids  diminish 
with  the  obstruction. — Recherches  sur  le  Phthisie  Pulmonaire.  See  also  Broussais' 
Histoire  des  Phlegmades  Chroniques,  torn.  i. 


442  TUBEECLE    OF    THE    LUNG. 

emaciation,  and  much  tubercle  of  the  left  lung,  the  impulse  is 
distinctly  double,  the  second  stroke  coinciding  with  the  second 
sound. 

In  a  few  chronic  apyrexial  cases  the  heart's  action  is  per- 
fectly tranquil,  while  in  a  still  rarer  class  the  palpitations  are 
violent  and  irregular,  so  as  to  lead  to  the  belief  of  great  organic 
disease.  Of  this  Dr.  Townsend  has  recorded  a  case,  in  which 
the  symptoms  were  almost  precisely  those  of  morbus  cordis  ; 
there  were  violent  palpitations  on  exertion ;  a  rapid,  full,  and 
bounding  pulse;  tremulous  motion  of  the  jugulars;  extreme 
dyspnoea  and  orthopncea  ;  lips  and  nails  of  a  dark  leaden 
colour ;  and  the  heart's  action  so  tumultuous,  as  to  cause  the 
whole  anterior  surface  of  the  chest  to  vibrate.  The  heart  was 
found  perfectly  well  proportioned ;  the  foramen  ovale  not  com- 
pletely closed ;  both  lungs  were  extensively  tubercular  with 
intercurrent  pneumonia,  which  had  been  diagnosticated  before 
death.* 

How  far  the  open  state  of  the  foramen  ovale  may  have  influ- 
enced the  symptoms  in  this  case  is  still  to  be  determined.  I 
have  seen  a  case  of  tuberculization  of  both  lungs,  where  the 
inter-ventricular  septum  was  deficient,  the  aorta  arising  from 
both  ventricles  ;  the  cardiac  symptoms  were  severe,  but  there 
was  no  permanent  cyanosis.f 

But  one  of  the  most  interesting  signs  connected  with  the 
circulating  system,  is  an  increased  action,  often  accompanied 
with  bruit  cle  souffiet,  which,  when  the  upper  lobe  is  diseased, 
may  be  occasionally  observed  in  the  corresponding  subclavian 
artery,  and  which  has  not  been  noticed  by  any  author. 

*  Transactions  of  the  Association  of  the  King  and  Queen's  College  of  Physicians, 
vol.  v. 

f  The  particulars  of  this  case  were  communicated  by  Dr.  Graves  to  Dr.  Houston  ; 
the  boy,  aged  three  years,  had  had  frequent  attacks  of  bronchitis,  and  was  admitted 
into  hospital  with  signs  of  tubercular  cavities  and  bronchitis  ;  the  heart's  action  was 
violent,  the  pulse  feeble,  and  the  skin  cold.  The  face,  hands,  and  feet  were  of  a  dark, 
livid  hue  ;  but  it  appeared  that  this  colour  was  not  habitual,  and  only  came  on  when  he 
laboured  under  pectoral  affections. 

On  dissection,  besides  the  usual  appearances  of  phthisis,  the  heart  was  found 
malformed  ;  a  well  defined  opening,  sufficiently  large  to  admit  the  little  finger,  led 
from  the  right  ventricle  through  the  septum  into  the  upper  part  of  the  left ;  this 
passage  was  twice  as  wide  as  that  leading  into  the  pulmonary  artery  ;  the  left  auricle 
was  small,  the  right  large  ;  the  left  ventricle  of  the  same  size  and  thickness  as  the 
right ;  the  aorta  was  unusually  capacious ;  and  the  ductus  arteriosus  diminished  in 
size,  but  not  obliterated. — Pathological  Observations,  by  John  Houston,  M.D.  Dublin 
Hospital  Reports,  vol.  v. 


TUBERCLE    OF    THE    LUNG.  443 

Two  causes  obviously  exist  for  this  increased  action  of  the 
subclavian  in  phthisis  ;  viz.,  the  falling  in  of  the  subclavicular 
region,    and   the  consolidation  of  the  lung  ;    but  I  have   little 
doubt   that   there   is   a   third,    namely,   sympathetic   irritation, 
something  similar  to  the  sympathy  of  contiguity  of  Hunter,  for 
I  have  found  that  in  certain  cases  it  was  distinctly  remittent, 
its  appearance  coinciding  with  signs  of  pulmonary  excitement 
and  irritation  ;  I  observed  it  to  subside  after  a  copious  luemop- 
tysis,  and  have  repeatedly  removed  it  by  leeching  the  subclavi- 
cular or  axillary  regions  :   and  the  fact  of  its  being  often  accom- 
panied by  the  bellows  murmur,  inaudible  in  any  other  part  of 
the  circulatory  system;  and,  like  the  pulsation,  capable  of  being 
modified  by   the  antiphlogistic   treatment,  leaves  little  doubt  of 
the  correctness  of  my  view.    Under  these  circumstances  it  occurs 
in  cases  with   but  little  contraction  or  consolidation  ;  and  the 
bellows  sound  is  often  exceedingly  sharp,  though  ceasing  in  the 
brachial    artery,    and    altogether  wanting   in    the   heart,   aorta, 
carotid,  or  opposite  subclavian. 

Varieties  of  Phthisis. — Under  this  head  we  shall  study  the 
symptoms  in  connexion  with  the  physical  signs,  of  the  more 
prominent  varieties  of  the  disease.  The  following  cases  may  be 
enumerated : — 

1st.  Acute  inflammatory  tuberculization  of  the  lung  without 
suppuration. 

2nd.  Acute  suppurative  tuberculization. 

3rd.  Chronic  progressive  tubercle,  with  signs  of  local  and 
general  irritation  ;  pulmonary  ulceration. 

4th.  Chronic  progressive  ulceration  succeeding  to  an  unre- 
solved pneumonia. 

5th.  Tuberculous  ulceration  succeeding  to  chronic  bronchitis. 

6th.  Tubercle  consequent  on  the  absorption  of  an  empyema. 

7th.  Chronic  phthisis  complicated  with  pneumothorax  from 
fistula. 

8th.  Tubercle  complicated  with  disease  of  the  larynx. 

9th.  Latent  progressive  phthisis. 

10th.  Chronic,  latent  but  partial  tuberculization. 

11th.  Chronic  general  tuberculization. 

l'2th.  Cicatrization  of  cavities. 

Acute  Inflammatory  Tubercle  without  Suppuration. — 
All  the  cases  of  this  which  I  have  seen,  occurred  as  sequehe  or 


444  TUBERCLE    OF    THE    LUNG. 

complications  of  the  fever  of  this  country.  In  most  the  symp- 
toms supervened  after  the  fever,  an  interval  existing-  between  the 
crisis  and  the  new  attack.  In  others,  the  disease  commencing 
with  the  symptoms  of  the  ordinary  gastro-catarrhal  fever  pro- 
ceeded uninterruptedly  to  its  fatal  termination. 

The  symptoms  are  undistinguishable  from  the  more  violent 
forms  of  bronchitis.  High  inflammatory  fever,  with  severe 
cough  and  extremely  hurried  respiration,  sets  in  ;  the  expectora- 
tion is  scanty,  viscid,  and  often  tinged  with  blood ;  the  face  is 
swollen  and  livid,  and  the  nares  dilate,  the  action  of  the  heart  is 
violent,  and  the  pulse  extremely  rapid ;  there  are  shooting  pains 
in  the  side,  and  the  patient  has  often  copious  sweatings  and 
delirium.  In  some  instances  these  symptoms  are  complicated 
with  others  referrible  to  the  abdomen ;  the  tongue  is  dry  and 
red,  the  abdomen  swollen  and  tender,  extreme  thirst,  drawing 
up  of  the  knees,  and  diarrhoea.  It  is  singular  that  in  a  case 
where  these  symptoms  were  best  marked  we  found  the  gastro- 
intestinal tube  healthy,  while  all  the  parenchymatous  organs 
were  filled  with  granular  and  miliary  tubercles.  In  another 
instance,  peritonitis  from  numerous  perforations  had  occurred, 
yet  the  abdominal  were  nearly  masked  by  the  thoracic  symptoms.* 

In  a  second  class,  the  symptoms  are  more  pneumonic,  while 
in  a  third,  which  may  be  termed  the  haBmoptysical  variety,  the 
first  symptom  is  a  copious  discharge  of  blood,  followed  by  a 
rapid  development  of  tubercle,  but  without  the  violent  signs  of 
irritation  which  occur  in  the  two  former  instances. 

In  the  two  first  cases  the  diagnosis  is  difficult,  for  the  tubercle 
being  often  equably  developed,  comparison  cannot  be  employed, 
and  the  want  of  the  signs  of  ulceration  adds  to  the  difficulty. 
There  is  nothing  characteristic  in  the  symptoms,  and  the  stetho- 
scopic  signs,  taken  alone,  or  considered  without  reference  to 
time,  are  insufficient.  In  the  first  variety  we  have  the  most 
intense  sonorous,  sibilous,  and  muco-crepitating  rales  ;  every 
part  of  the  bronchial  system  seems  engaged.  In  the  second  the 
musical  rales  are  comparatively  wanting,  while  the  crepitating 
and  muco-crepitating  are  extensively  audible  ;  yet,  by  successive 
observations,  and  considering  the  phenomena  with  reference  to 
time,  the  diagnosis  can  be  made. 

*  See  Transactions  cf  the  Association,  &c,  vol.  iv. ;  also  the  Clinical  Report  of 
the  Meath  Hospital,  Dublin  Hospital  Reports,  vol.  v. 


TUBERCLE    OF    THE    LUN1.  445 

I  published  the  first  instance  of  this  diagnosis  as  far  back 
as  1828.  The  case  was  one  of  a  young  female  who  became 
attacked  with  violent  symptoms  of  gastro-catarrhal  fever,  which 
resisted  all  means  of  relief.  The  stethoscopic  signs  were  of 
intense  bronchitis ;  yet  we  found  that  the  chest  became  rapidly 
and  extensively  dull.  This  could  only  be  explained  on  the  sup- 
position of  an  extensive  crop  of  tubercle,  which  diagnosis  was 
made  at  the  time. 

On  dissection,  both  lungs  were  found  completely  stuffed  with 
small  granular  and  miliary  tubercles,  in  such  quantity  as  to 
obscure  the  condition  of  the  intervening  tissue,  but  they  were 
generally  crepitating,  and  nowhere  presented  complete  solidity. 
This  progressive  general,  though  not  complete  dulness  conse- 
quent on  the  signs  of  bronchitis,  has  led  me  in  many  cases  to 
announce  the  acute  general  development  of  tubercle. 

In  the  second  or  pneumonic  variety  the  patient,  though  not 
suffering  so  much  from  dyspnoea,  is  in  equal  danger.  The 
musical  rales  are  either  absent  or  very  slight ;  but  an  intense 
and  extensive  crepitating  rale  is  to  be  heard.  As  in  the  former 
case,  dulness  advances,  and  the  phenomena  are  only  distin- 
guishable from  those  of  ordinary  pneumonia  by  the  absence  of 
the  signs  of  hepatization.  The  rale  continues  to  the  end,  and 
bronchial  respiration  is  not  observed. 

The  third  or  hsernoptysical  variety  is  never  so  rapid  as  the 
two  former,  and  hence  we  can  often  avail  ourselves  of  the  signs 
of  ulceration. 

A  remarkable  feature  in  the  inflammatory  cases  is  the  resist- 
ance of  the  symptoms  and  signs  to  treatment  even  of  the  most 
active  and  varied  description.  The  disease  seems  to  defy  all 
medical  treatment. 

We  may  now  state  the  general  principle  of  diagnosis. 
If  in  a  case  presenting  the  symptoms  and  signs  of  intense 
bronchitis,  or  if  crepitating  rale  has  been  present,  yet  persisting 
to  the  last,  tee  find  the  chest  becoming  dull ;  if  this  dulness  be 
extensive,  yet  incomplete,  without  bronchial  respiration,  the 
stethoscope  showing  that  the  lung  is  everywhere  permeable,  the 
solidity  only  occurring  in  jwints ;  or  if  the  crepitus  be  so  slight 
as  not  to  account  for  the  dulness,  we  may  make  the  diagnosis  of 
the  acute  inflammatory  development  of  tubercle. 

Acute  suppurative  Phthisis. — In  the  preceding  variety,  the 


446  TUBERCLE    OF    THE    LUNG. 

absence  of  suppuration  is  owing  not  to  any  inherent  character  of 
the  disease,  but  arises  simply  from  the  rapidity  of  the  asphyxia.' 
The  cases  now  under  consideration  are  those  described  by  Louis 
as  the  acute  phthisis  ;  one  case  only  of  the  first  variety  is  given 
by  him. 

In  this  affection  the  symptoms  set  in  as  in  the  former  case  ; 
they  continue  with  great  violence,  and  resist  treatment.  The 
expectoration  soon  becomes  purulent ;  the  fever  is  high,  but 
after  a  time  becomes  a  sort  of  mixture  of  the  inflammatory  and 
hectic  forms. 

The  stethoscopic  signs  of  the  earlier  stages  are  the  same  as 
in  the  last  variety,  but  the  deep  toned  rales  are  not  so  often 
observed.  After  the  tubercles  suppurate,  mucous  rales  passing 
into  gurgling  are  heard.  The  musical  rales,  however,  are  not 
removed ;  a  sibilous  sound  during  inspiration  and  expiration 
is  audible,  and  this,  when  the  action  of  the  heart  is  strong,  is 
influenced  by  it  so  as  to  produce  a  distinct  musical  rhythm  :  of 
course  dulness  rapidly  advances. 

In  the  cases  given  by  Louis,  death  occurred  in  three,  four, 
five,  six,  and  seven  weeks.  I  have  seen  two  cases  in  which  no 
pulmonary  symptoms  existed  before  the  occurrence  of  fever,  yet 
in  which  death  occurred  within  three  weeks  from  the  first 
invasion,  and  the  lungs  were  found  full  of  tuberculous  anfrac- 
tuosities. 

Louis  remarks,  that  notwithstanding  its  rapid  development 
this  disease  is  accompanied  by  those  secondary  lesions  which  we 
see  in  the  more  chronic  forms ;  ulcerations  of  the  epiglottis, 
trachea,  oesophagus,  and  small  intestine  have  been  observed. 
In  one  case  he  found  the  mucous  membrane  of  the  stomach 
softened  and  thinned ;  in  another  the  liver  was  fatty ;  and  in  a 
third  the  lymphatic  glands  of  the  neck  and  mesentery  contained 
tuberculous  matter.* 

The  diagnosis  of  this  affection  has  been  in  part  given  by 
Louis.  By  combining  his  observations  with  mine,  we  may  state 
it  to  be  the  following. 

If  in  a  case  which  has  presented  violent  and  generally  uncon- 
controllable  symptoms  and  signs  of  bronchitis,  or  of  pneumonia 
continuing  in  its  first  stage;  with  a  fever  at  first  inflammatory, 
and  afterwards  passing  into  severe  hectic,  ice  find  an  extensive 

*  Op.  cit.,  p.  439. 


TUBERCLE    OF    THE    LUNG.  447 

dulness  to  supervene,  more  partial,  but  more  complete  than  in 
the  preceding  form,  accompanied  with  a  large  mucous  rale,  and 
supervening  in  a  few  tveeks  from  the  first  invasion  of  the  disease  ; 
ice  may  diagnosticate  the  acute  suppurative  phthisis. 

In  the  third  or  haemoptysical  variety,  the  disease  is  not  so 
rapid,  nor  are  the  signs  of  irritation  at  all  so  violent.  There  is 
sometimes  an  absence  of  rale,  although  the  dulness  seems  as  it 
were  to  grow  daily,  and  advance  downwards.  The  hemoptysis 
seems  to  relieve  the  mucous  irritation,  but  the  tubercle  advances. 
In  this  form  I  have  observed  the  contraction  of  the  chest  at  a 
very  early  period ;  it  would  seem  as  if  the  terminal  tubes  being 
plugged  up  by  minute  coagula,  atrophy  of  the  cells  occurred 
long  before  ulceration. 

Chronic  progressive  Tubercle,  with  local  and  general 
Irritation,  Pulmonary  Ulceration. — This  is  the  common 
form  of  consumption,  properly  so  called.  Its  symptoms  have 
been  stated  so  often,  that  their  description  here  would  be 
unnecessary ;  we  shall,  however,  take  a  brief  view  of  the 
symptoms  and  signs  conjointly,  in  three  stages  of  the  affection, 
it  being  always  understood  that  their  combinations  and  charac- 
ters are  capable  of  great  modification. 

We  may  divide  the  disease  into  three  stages  ;  in  the  first  the 
tubercle  is  developed,  but  not  yet  suppurated  ;  in  the  second 
small  ulcerations  are  formed  ;  and  in  the  third  we  have  vast 
caverns  excavating  great  portions  of  the  lung.  Between  these 
stages  there  is  no  exact  line  of  demarcation,  but  when  estab- 
lished, they  have  each  symptoms  and  signs  which  are  somewhat 
peculiar. 

First  stage. — The  more  prominent  symptoms  are  those  of 
irritation  ;  cough,  pain,  and  quickness  of  pulse,  which  in  certain 
cases  are  preceded,  but  in  the  greater  majority  followed,  by  an 
unaccountable  emaciation ;  the  cough  is  almost  always  dry 
during  the  first  few  weeks,  unless  where  the  tubercle  has  suc- 
ceeded to  catarrh  ;  it  may  occur  in  every  variety,  but  is  most 
commonly  a  slight,  frequent,  and  irritating  cough,  referred  by 
the  patient  to  a  tickling  sensation  in  the  trachea.  The  ex- 
pectoration, when  occurring,  is  scanty,  and  consisting  of  a  thready, 
greyish,  and  nearly  transparent  mucus,  occasionally  dotted  with 
blood ;  a  slight  wheezing  sometimes  accompanies  the  cough. 
With    these    symptoms  the  patient  frequently  complains   of 


448  TUBERCLE    OF    THE    LUNG. 

pain,  -which  may  be  situated  in  any  part  of  the  side.  In  some 
instances  it  is  only  felt  in  the  lower,  while  in  others  it  occupies 
the  upper  part  of  the  chest,  shooting  from  the  clavicle  to  the 
subscapular  regions,  and  often  occupying  the  articulation  of  the 
shoulder,  when  it  is  often  mistaken  for  rheumatism,  or  the  pain 
of  hepatic  disease  ;  it  occurs  with  various  intensities,  is  generally 
remittent,  and  often  relieved  by  anodyne,  or  slightly  stimulating 
applications.  I  have  known  it  to  be  regularly  intermittent, 
coinciding  with  the  paroxysms  of  hectic,  so  that  the  disease  was 
taken  for  ague,  and  treated  accordingly.  This  pain  is  commonly 
accompanied  with  tenderness  of  the  subclavicular  region,  and 
often  with  that  irritation  of  the  muscular  fibres  which  causes 
their  contraction  on  percussion ;  the  respiration  is  slightly 
hurried,  and  the  first  approaches  of  hectic  can  be  perceived. 
The  continuation  of  pain  in  the  shoulder  with  quickness  of 
pulse  should  always  excite  alarm. 

Under  these  circumstances  wre  may  have  one  of  two  results 
from  a  physical  examination  ;  we  shall  either  find  that  there 
is  no  sign  of  disease,  or  that  some  of  the  various  phenomena 
of  tuberculous  irritation  may  be  discovered. 

In  the  first  case  the  absence  of  physical  signs  has  no  value 
unless  considered  in  relation  to  time  ;  thus  if  the  duration  of 
the  symptoms  be  only  a  few  weeks,  the  absence  of  commensu- 
rate signs  would  be  rather  an  argument  in  favour  of  tubercle, 
while  if  they  had  continued  for  months,  and  particularly  if  there 
existed  any  other  local  or  constitutional  cause  of  hectic,  the 
absence  of  signs  would  so  far  justify  the  opinion  that  the  disease 
was  not  pulmonary  tubercle. 

But  in  the  second  case  the  existence  of  any  of  the  following 
signs  is  almost  enough  to  reveal  the  too  fatal  disease : — 

Comparative  dulness  of  the  clavicle,  scapular  ridge,  or  inter- 
scapular region. 

Feebleness  of  respiration,  most  valuable  when  occurring  on  the 
left  side,  and  occurring  with  or  without  puerile  breathing  in  the 
other  portions  of  the  lung.* 

The  interrupted  respiration. 

The  various  rales  combined  with  a  feeble  or  puerile  respiration 
and  confined  to  the  upper  portion  of  the  lung. 

*  To  which  should  be  added  the  valuable  sign  of  exaggerated  and  prolonged 
expiration  murmur,  first  observed  by  Dr.  Jacksou.     (Ed.) 


TUBERCLE    OF    THE   LUNG.  449 

Increased  resonance  of  the  voice,  most  valuable  on  the  left 
side. 

Loudness  of  the  sounds  of  the  heart  in  the  upper  portions, 
most  valuable  at  the  right  side. 

The  friction  sound  audible  in  the  antero-superior  portions.* 

If  we  now  compare  the  symptoms  with  the  physical  signs  we 
must  be  struck  with  their  agreement  in  pointing  out  a  progressive 
irritation  and  disposition,  but  without  further  destruction,  or  any 
supersecretion  from  the  part. 

Second  stage. — This  is  characterized  by  the  establishment  of 
decided  symptoms  ;  the  emaciation  increases;  the  pulse  continues 
quick ;  the  countenance  becomes  characteristic ;  the  sweatings 
are  more  profuse  ;  the  cough  looser,  the  expectoration  becoming 
puriform,  tubercular,  and  often  bloody.  The  digestive  system 
now  begins  to  suffer  ;  thirst,  loss  of  appetite,  and  abdominal 
pains  torment  the  patient,  and  the  first  indications  of  the 
wasting  and  persistent  diarrhoea  appear  ;  the  patient  feels  that  he 
can  lie  better  on  one  side  than  the  other,  and  begins  to  feel  pain 
in  the  opposite  side  of  the  chest,  a  sure  sign  that  his  terrible 
disease  has  invaded  the  remaining  lung.t 

The  physical  signs  are  the  following  : — 

Increase  and  extension  downwards  of  the  dulness  on  percus- 
sion. 

The  respiratory  murmur  is  feeble  or  changed  into  a  semi- 
tracheal  breathing,  most  audible  in  the  erect  position.     This  is 

*  As  this  is  the  rarest  of  the  physical  signs,  I  have  placed  it  last  in  the 
catalogue. 

f  Notwithstanding  all  this,  it  will  commonly  be  found  that  this  is  the  period  at 
which  the  patient  seems  to  feel  the  greatest  relief,  and  shews  the  greatest  confidence 
in  recovery  ;  two  causes  seem  to  concur  towards  this  result ;  the  first,  that  the  gastro- 
intestinal disease  acts  as  a  revulsive,  and  relieves  the  pulmonary  irritation  to  a 
certain  degree,  as  in  the  case  of  fistula  in  ano,  and  we  have  a  painless  but  yet 
revulsive  discharge. 

In  the  next  place,  the  pulmonary  irritation  is  relieved  to  a  certain  degree  by 
the  secretion  of  pus  from  the  ulcers  and  bronchial  tubes,  and  thus  if  no  new 
inflammatory  crop  of  tubercle  is  developing  a  period  of  comparative  ease  is 
produced. 

But  there  is  a  third  and  mechanical  cause  to  be  noticed ;  according  as  the  suppu- 
ration of  the  tubercles  extends,  and  the  excavations  enlarge,  the  cough  often  becomes 
much  less  frequent  and  troublesome  ;  it  no  longer  occurs  in  tits,  but  singly,  followed 
by  the  easy  expectoration  of  a  mass  of  muco-puriform  and  tuberculous  matter ; 
this  is  traceable  to  the  free  bronchial  communication  with  the  ulcerous  cavities.  The 
destruction  of  the  lung  causes  a  relief  to  the  patient,  and  too  often  may  we  hear 
the  voice  of  hope  and  confidence  reverberating  in  the  cavity  which  seals  the  patient's 
doom. 

G  G 


450  TUBERCLE    OF    THE    LUNG. 

often  combined  with  deep  seated  or  superficial  cavernous 
breathing ;  the  bruit  de  soupape  and  cavernous  rales.  When 
the  ulcerations  are  small  and  numerous,  the  cavernous 
phenomena  are  indistinct ;  and  dulness  of  sound,  with  a  large 
mucous  rale,  increased  by  coughing,  and  a  semi-tracheal  breath- 
ing, are  the  principal  signs. 

When  the  cavities  are  sufficiently  large,  some  form  of  pectori- 
loquism  may  occur  ;  but  most  commonly  there  is  nothing  but  an 
increased  and  undefined  resonance  of  the  voice.  These  signs  are 
most  distinct  in  the  postero-superior  portions. 

All  varieties  of  the  crepitating,  mucous,  and  cavernous  rales 
occur,  the  size  of  the  bubbles  generally  diminishing  from  above 
downwards ;  and  in  certain  cases  the  rales  are  modified  by  the 
action  of  the  heart,  or  occasionally  suspended  by  bronchial 
obstruction. 

The  respiration  in  the  lower  lobe,  or  opposite  lung,  is  puerile ; 
and  we  have  the  signs  of  atrophy,  evident  generally  in  pro- 
portion to  the  chronioity  of  the  case. 

Third  stage. — In  this  condition  the  patient  is  often  apyrexial, 
and  the  perspirations  cease,  particularly  if  the  digestive  system 
remains  healthy :  the  pulse  may  be  slow,  though  generally 
becoming  again  accelerated  before  death  :  emaciation  proceeds  to 
the  last  extremity.  The  voice  is  sometimes  lost ;  at  others 
hollow  and  melancholy :  the  cough  is  loose ;  the  respiration 
tranquil  and  expectoration  easy :  apthae  appear  on  the  tongue, 
and  spread  over  the  cavity  of  the  mouth  :  the  limbs  become  cold  : 
the  breath  gets  a  heavy  odour,  and  the  appetite  in  general  fails. 
Yet  the  painful  tenacity  of  life  continues  for  a  length  of  time, 
as  if  the  patient  wanted  strength  to  die.  The  physical  signs 
of  this  condition  are  so  graphically  described  by  Sir  James 
Clark,  that  I  cannot  do  better  than  give  them  in  his  own  words. 

"  The  chest,  at  this  advanced  period  of  the  disease,  is  found 
to  be  remarkably  changed  in  its  form;  it  is  flat,  instead  of 
being  round  and  prominent :  the  shoulders  are  round,  and 
brought  forward  and  the  clavicles  are  unusually  prominent,  leaving 
a  deep  hollow  space  between  them  and  the  upper  ribs.  The 
subclavicular  regions  are  nearly  immoveable  during  respiration  ; 
and  when  the  patient  attempts  to  make  a  full  inspiration,  the 
upper  part  of  the  thorax,  instead  of  expanding  with  the  sponta- 
neous ease  peculiar  to  health,   seems   to   be   forcibly   dragged 


TUBERCLE    OF    THE    LUNG.  451 

upwards.  Percussion  gives  a  dull  sound  over  the  superior  parts 
of  the  chest,  although  the  caverns  which  partially  occupy  this 
part  of  the  lungs,  and  the  emaciated  state  of  the  parietes,  may 
render  the  sound  less  dull  than  in  the  preceding  stage.  The 
stethoscope  affords  more  certain  signs,  the  respiration  is  obscure, 
and  in  some  places  inaudible ;  while  in  others  it  is  particularly 
clear,  but  has  the  character  of  the  bronchial,  or  tracheal,  or 
even  cavernous  respiration  of  Laennec.  There  is  a  mucous 
rhonchus ;  coughing  gives  rise  to  a  gurgling  sound  (gargouille- 
ment)  ;  and  pectoriloquism  is  generally  more  or  less  distinct,  for 
the  most  part  on  both  sides,  though  more  marked  on  one  than 
the  other.  In  this  state  the  patient  may  still  linger  for  weeks, 
or  even  months,  reduced  almost  to  a  skeleton,  and  scarcely  able 
to  move,  in  consequence  of  debility  and  dyspnoea."  :;: 

To  this  succinct  but  lucid  description  there  is  but  little  to 
be  added.  When  the  cavities  are  large,  there  is  often  an  absence 
of  pectoriloquism  ;  and  the  cavernous  respiration,  whether  from 
the  size  of  the  cavern  or  the  feebleness  of  breathing,  becomes 
often  indistinct,  and  as  it  were  distant.  It  is  at  this  period 
that  the  metallic  phenomena  are  generally  audible,  while  the 
respiratory  murmur  which  had  been  puerile  in  the  healthier 
portions  of  the  lung,  at  length  loses  this  character. 

Chronic  Tuberculous  Ulceration,  succeeding  to  an 
unresolved  Pneumonia. — In  this  case  the  progress  of  the 
tubercle  is  insidious  ;  and  where  the  seat  of  pneumonia  has  been 
in  the  lower  tube,  it  is  reversed,  beginning  below  and  proceeding 
upwards.  Tubercle  may  supervene  on  the  sthenic  or  asthenic 
pneumonia,  but  much  more  frequently  on  the  latter.  Indepen- 
dent, however,  of  any  constitutional  tendencies,  there  are  three 
cases  in  which  this  termination  may  be  observed, — the  first  in 
which  a  sthenic  pneumonia  has  been  neglected,  or  exasperated 
in  its  early  stage ;  the  second,  a  case  in  which  auscultation  has 
not  been  employed,  and  the  disease  only  rendered  latent  by 
treatment ;  and  the  third,  the  typhoid  variety,  when  the  strength 
is  profoundly  injured. 

In  such  cases  the  lung  remains  solid,  or  we  may  observe 
attempts  at  resolution  to  occur  more  than  once.  A  considerable 
portion  of  the  lung  may  resolve,  yet  the  process  be  arrested,  and 
one  part  continue  dull  on  percussion. 

*  Treatise  on  Pulmonary  Consumpt'on.    Lon'on:  1835. 

G    G2 


452  TUBERCLE    OF    THE    LUNG. 

Under  these  circumstances,  the  patient  seems,  for  an  indefi- 
nite period,  in  a  state  of  imperfect  convalescence  :  his  pulse 
may  have  become  slow,  hut  it  begins  to  rise  :  he  does  not  gain 
flesh ;  some  cough  remains ;  obscure  fever  manifests  itself ;  the 
breathing  becomes  hurried;  and  by  degrees  the  usual  symptoms 
appear  :  and  he  generally  sinks  in  from  three  to  six  months  from 
the  first  attack  of  pneumonia. 

When  the  lower  lobe  is  engaged,  the  physical  signs  are  the 
following : — 

Hepatization  continuing  for  about  a  month,  we  find  a  mucous 
rattle  generally  near  to  the  root  of  the  lung :  the  respiration 
of  the  upper  lobe,  which  had  been  puerile,  gradually  becomes 
feebler,  from  below  upwards,  either  without  rale  or  with  a  few 
mucous  or  muco-crepitating  bubbles  :  every  day  we  observe  the 
dulness  to  advance  ;  the  bubbles  at  the  root  of  the  lung  become 
larger,  and  ultimately  a  cavity  appears  :  then  the  ulcerative 
process  stretches  upwards,  and  new  excavations  appear  in  various 
portions. 

When  the  upper  lobe  has  been  engaged,  the  same  circumstances 
occur ;  and  vacillations  in  resolution  may  be  observed  even  after 
ulcerations  have  formed.  After  middle  age,  the  process  is 
extremely  slow,  and  may  coincide  with  a  singularly  tranquil  state 
of  the  heart. 

Tubercle  consequent  on  a  chronic  Bronchitis. — This 
combination  is  much  more  frequent  than  has  been  supposed  : 
a  great  number  of  cases,  called  bronchitis,  occurring  after  the 
meridian  of  life,  are  of  this  nature. 

The  cases  may  be  divided  into  two  classes,  according  to  the 
expectoration.  In  the  first  it  has  been  for  years  concocted,  or 
muco-puriform.  In  the  second,  it  consists  of  a  scanty  serous,  or 
sero-mucous  fluid.  Tubercle  may  supervene  in  both  cases,  but 
is  more  common  in  the  first  than  the  second  form. 

In  the  first  case,  a  chronic  catarrh  having  existed  for  many 
months  or  years,  passes  insidiously  into  phthisis  :  or,  what  is 
more  common,  a  peculiar  change  of  symptoms  marks  the  com- 
mencement of  the  tuberculous  disease.  A  patient  shall  have  had 
cough  and  expectoration  for  three  or  four  years,  yet  preserving  his 
flesh  and  appearance,  and  with  a  quiet  pulse.  He  may  then  be 
attacked  with  haemoptysis ;  his  pulse  becomes  quickened,  and 
emaciation  advances  slowly,  and  he  by  slow  degrees  passes  into 


TUBERCLE    OF    THE   LUNG.  453 

phthisis :  or  a  tuhercular  complication  may  supervene,  without 
any  apparent  change  in  symptoms.  The  pulse  may  continue 
tranquil,  and  hectic  he  absent ;  and  the  disease  he  only  detected 
by  physical  signs. 

It  is  in  these  cases,  but  particularly  the  last,  that  we  observe 
the  extreme  chronicity  of  phthisis.  It  may  be  advancing  from 
five  to  fourteen  years,  or  even  longer ;  a  fact  to  be  explained,  in 
part  at  least,  by  the  copious  expectoration  which  acts  as  an 
issue,  and  the  healthy  state  of  the  digestive  system.  To  these 
must  be  added  the  important  conditions  stated  by  Sir  James 
Clark,  of  the  absence  of  constitutional  disposition,  rendering  the 
progress  of  disease  slower.*  In  some  instances,  the  disease 
advances  steadily,  and  almost  imperceptibly ;  while  in  others 
there  are  frequent  exacerbations  with  haemoptysis,  and  great 
increase  of  dyspnoea  and  expectoration. 

I  have  no  observations  to  illustrate  the  early  stages  of  the 
transition  from  bronchitis  to  phthisis.  In  all  cases  which  I  have 
seen,  the  disease  was  local,  and  comparison  could  be  employed. 
We  may  then  apply  the  diagnostics  as  in  the  third  variety. 
Dulness  and  signs  of  anfractuosities  are  found,  and  the  diagnosis 
will  lie  between  dilated  tubes  and  phthisical  ulcerations.  The 
progression  of  the  signs,  the  rale,  and  the  absence  of  the  bronchial 
respiration,  and  resonance  of  the  voice  as  in  dilated  tubes,  will  in 
general  suffice  for  diagnosis.  Of  these  principles,  the  first  is  the 
most  important.  In  some  advanced  cases,  great  deformity  is 
produced  by  the  contraction  of  the  chest. 

Tuberculization  of  the  Lung,  consequent  on  the  Ab- 
sorption of  an  Empyema. — We  may  suspect  this  occurrence  in 
all  cases  where,  after  the  absorption  of  an  empyema,  the  cough 
is  renewed,  and  the  pulse  becomes  permanently  accelerated.  In 
neglected  cases,  yet  in  which  absorption  occurs,  independent,  or 
nearly  so,  of  treatment,  it  is  a  common  termination.  In  a  few 
instances  an  interval  of  quiescence  intervenes  between  the  sub- 
sidence of  the  first  and  the  commencement  of  the  second  disease : 
while  in  others,  the  phthisical  symptoms  and  signs  supervene 
immediately  on  the  removal  of  the  effusion.  Without  possessing 
a  sufficient  number  of  cases  to  determine  the  point,  I  would  say 
that  the  rapid  absorptions  are  more  likely  to  be  followed  by  a 
fatal  development  of  tubercle  than  those  more  chronic.     And  it 

*  Op.  cit,  p.  52. 


454  TUBERCLE    OF    THE    LUNG. 

may  be  inquired,  whether  the  "  doubtful  convalescence  "  of 
Laennec  is  not  often  produced  by  the  formation  and  evacuation 
of  a  small  quantity  of  this  consecutive  tubercle.  I  have  often,  in 
such  instances,  been  kept  in  a  state  of  great  apprehension,  by  the 
recurrence  of  rale  and  feeble  respiration  several  times  in  the 
upper  portion  of  the  lung.  In  two  cases  I  found  that  although 
tubercle  existed  in  both  lungs,  it  was  in  much  greater  quantity 
in  the  side  opposite  to  that  where  the  pleurisy  had  occurred,  as 
if  the  pressure  had  diminished  the  liability  to  tubercle.  It  is  a 
curious  fact,  but  not  without  analogies,  that  the  occurrence  of  an 
empyema  and  pneumothorax  from  fistula,  suspends  the  progress 
of  tubercle  in  a  remarkable  manner. 

The  physical  diagnosis  is  often  difficult  from  our  inability  to 
apply  comparison.  The  pleurisy  has  altered  the  symmetry  of 
the  chest,  and  has  caused  physical  phenomena,  depending  on 
the  contraction  ;  hence  in  the  earlier  periods,  the  dulness  and 
feebleness  of  respiration  may  not  be  tubercular,  and  may  even 
occur  on  the  side  where  least  tubercle  exists.  This  I  have  more 
than  once  verified  :  but  when  with  the  symptoms  of  a  new  pul- 
monary disease,  with  hectic,  and  a  quickened  pulse,  we  find  the 
opposite  clavicle  or  scapular  ridge  becoming  dull,  and  with  some 
of  the  active  signs  of  irritation,  we  may  diagnosticate  tubercle. 
When  the  disease,  however,  predominates  in  the  affected  lung, 
a  curious  change  of  phenomena  is  observed  :  the  dulness  and 
feebleness  of  respiration,  as  it  were,  change  seats,  and  in  place 
of  existing  inferiorly,  are  perceived  in  the  upper  portion, 
while  the  lower  becomes  not  really  clearer  than  it  was,  but 
comparatively  so. 

But  tubercle  may  supervene,  even  although  the  empyema  is 
not  absorbed.  The  opposite  lung  is  then  the  seat  of  disease, 
which  may  pass  into  ulceration.  In  this  way  large  cavities  may 
exist  in  one  lung,  with  an  original  empyema  of  the  other.  In 
some  of  these  cases  the  puerile  respiration  of  the  tuberculous 
lung  is  beyond  everything  intense,  so  that  a  large  cavity  may 
exist,  yet  without  our  being  able  to  detect  either  the  cavernous 
respiration  or  gurgling.  This  must  be  borne  in  mind,  in  all 
examinations  of  the  lung,  previous  to  the  operation  for  empyema. 
In  more  chronic  cases,  however,  with  great  emaciation,  and 
less  puerility  of  breathing,  the  progress  of  tubercle  in  the  oppo- 
site lung  can  be  easily  recognised  by  the  usual  signs. 


tubercle  of  the  lung.  455 

Phthisis  complicated  with  Empyema  and  Pneumothorax 
from  Fistula. — I  shall  not  enter  here  into  the  history  of  this 
triple  lesion,  hut  remark,  in  the  first  place,  on  the  interesting 
fact,  that  the  proper  symptoms  of  phthisis  are  in  many  cases 
arrested,  and  singularly  modified,  hy  the  occurrence  of  the  new 
disease.  I  have  often  found  that  after  the  first  violent  symptoms 
had  subsided,  the  hectic  ceased,  the  phthisical  expression  dis- 
appeared, the  flesh  and  strength  returned ;  and  in  this  way  the 
patient  has  enjoyed  many  months  of  comfortable  existence,  and 
was  only  disturbed  by  dyspnoea  and  the  sound  of  fluctuation  on 
exercise. 

To  explain  this,  we  must  recollect  the  compression  exercised 
on  the  lung,  which  by  diminishing  its  vascular  supply,  causes  its 
atrophy,  and  arrests  its  disease.  The  pleuritis,  too,  may  have  a 
revulsive  effect ;  and  perhaps  the  increased  action  of  the  opposite 
lung,  by  preventing  the  obliteration  of  the  minute  tubes,  may 
hinder  the  accumulation  of  tubercle. 

In  chronic  cases,  where  the  lung  is,  as  it  were,  anchored  to 
the  parietes  of  the  chest  by  adhesions,  the  cavity  from  which  the 
fistula  has  passed  can  be  easily  detected.  With  respect  to  the 
opposite  lung,  there  is  nothing  to  interfere  with  direct  diagnosis, 
unless  it  be  the  puerility  of  respiration.  Under  the  circum- 
stances, however,  any  sign  of  irritation  of  the  opposite  lung  is 
sufficient  to  point  out  tubercle. 

Phthisis,  complicated  with  Laryngeal  Disease. — I  have 
already  stated  the  frequent  combination  of  ulceration  of  the 
larynx  with  tubercle  of  the  lung.*  The  common  case  of  phthisis 
laryngea  is  in  most  instances  pulmonary  consumption,  with 
ulcerations  of  the  larynx,  either  preceding  or  following  the  tuber- 
cular disease. 

With  respect  to  diagnosis,  the  early  history  must  be  examined, 
so  as  to  discover  whether  pulmonary  as  well  as  laryngeal  disease 
exists.  If  there  have  been  cough,  pain  of  the  chest  or  shoulder, 
haemoptysis,  difficulty  of  lying  on  one  side,  copious  expectoration, 
any  degree  of  emaciation,  quickness  of  pulse,  or  hectic  fever 
before  the  laryngeal  symptoms,  there  is  the  greatest  probability 
of  tubercle  existing  ;  or  if  these  symptoms  distinctly  supervened 
on  the  laryngeal  affection,  forming  a  new  train  of  sufferings, 
the  same  conclusion  may  be  come  to.      Many  cases  also  will 

*  See  the  Section  on  Diseases  of  the  Larynx  and  Trachea. 


456  TUBERCLE    OF    THE    LUNG. 

be  found  to  have  commenced  by  an  influenza,  a  bronchitis, 
or  pneumonia — in  all  of  which  the  complication  commonly 
exists. 

The  physical  diagnosis  is  in  general  easy,  except  in  old 
persons,  or  when  great  stridor  exists.  A  certain  degree  of  stridor 
does  not  prevent  a  stethoscopic  examination  ;  and  when  the 
obstruction  is  great  (a  rare  case),  we  can  use  percussion  and 
measurement.  In  most  cases  the  tubercle  predominates  on  one 
side,  and  comparison  can  be  employed. 

Acute  affections  of  the  larynx  are  rare  in  phthisis.  The  fol- 
lowing case  presents  symptoms  which  are  somewhat  difficult 
of  explanation  : — 

A  gentleman  in  the  last  stage  of  chronic  phthisis,  with  dulness 
of  the  upper  lobe  of  the  left  lung,  and  the  signs  of  a  cavity  under 
the  clavicle,  was  suddenly  seized  with  dreadful  dyspnoea,  followed 
by  a  slight  convulsive  fit.  The  respiration  was  tracheal,  but  the 
obstruction  seemed  to  be  low  down.  In  this  state  he  continued 
for  twenty-four  hours,  with  occasional  slight  remissions.  The 
difficulty  of  breathing  then  increased  so  much  that  the  opening 
of  the  trachea  was  contemplated  as  a  means  of  temporary  relief. 
The  operation,  however,  was  not  performed.  Next  morning  the 
symptoms  being  somewhat  relieved  by  a  blister  and  other  treat- 
ment, I  was  enabled  to  make  an  examination.  The  right  lung 
sounded  everywhere  clear,  but  respiration  was  unusually  feeble  ; 
while  the  left,  which  before  presented  feeble  respiration  and  the 
signs  of  a  cavity,  now  gave  the  most  intense  puerile  murmur, 
masking  the  cavernous  signs.  In  fact  the  phenomena  of  the 
chest  were  completely  reversed.  By  degrees  the  tracheal 
breathing  subsided  ;  the  signs  of  a  cavity  returned  ;  the  right 
lung  expanded  as  before,  but  a  general  bronchial  rale  preceded 
death  for  a  few  days. 

These  phenomena  can  only  be  explained  by  the  temporary 
obstruction  of  the  right  bronchus. 

Chronic  latent  Forms. — Cicatrization  of  Cavities. — I  shall 
not  dwell  at  any  length  on  the  remaining  varieties  of  phthisis. 
Like  other  diseases,  pulmonary  tubercle  is  occasionally  a  latent 
disease ;  but  I  have  never  known  it  latent  when  considered  as 
to  local  symptoms,  general  symptoms,  and  physical  signs, 
combined.  The  first  may  be  wanting,  the  second  absent  or 
anomalous,  and  the  physical  signs  obscure  ;  but  by  combining  all 


TUBERCLE    OF    THE    LUNG.  457 

the  phenomena  the  disease  can  be  detected  in  almost  every  case. 
What  has  been  already  said  is  sufficient  to  guide  the  diagnosis 
in  most  cases  of  the  senile  phthisis. 

On  the  signs  of  cicatrization  I  have  nothing  to  add  to  what 
has  been  already  stated  by  Laennec.  A  certain  feebleness  of 
respiration,  a  little  dulness  of  sound,  and  a  somewhat  tracheal 
character  of  the  vesicular  murmur  are  the  phenomena  commonly 
observed. 

In  the  examination  of  a  patient  supposed  to  be  phthisical, 
the  following  points  demand  attention  before  proceeding  to  the 
physical  signs  : — 

1st.  The  age,  habit,  and  diathesis  of  the  patient,  and  whether 
phthisis  or  scrofula  have  existed  in  his  family. 

'2nd.  The  exact  date  of  his  illness. 

3rd.  Whether  this  has  been  the  first  attack,  and  how  far  he 
has  been  liable  to  bronchitis. 

4th.  Whether  the  disease  commenced  by  laryngeal,  tracheal, 
or  bronchial  irritation,  or  followed  a  pneumonia,  a  pleurisy,  or  a 
continued  fever. 

5th.  Whether  there  has  been  haemoptysis,  and  if  so,  its  nature, 
repetitions,  and  whether  it  preceded  or  followed  the  other  pul- 
monary symptoms. 

6th.  Whether  the  cough  was  at  first  dry  or  followed  by  ex- 
pectoration.* 

7th.  The  nature  and  quantity  of  expectoration,  and  whether 
there  has  been  a  change  from  a  mucous  to  a  purulent  character, 
coinciding  Avith  the  symptoms  of  ulceration  ;  whether  any  cal- 
culous matter  has  been  expectorated. 

8th.  Whether  there  has  been  pain  ;  if  so,  its  seat  and 
nature ;  whether  it  has  affected  the  shoulder,  side,  or  calf  of 
the  leg. 

9th.  The  existence  of  hectic,  emaciation,  and  acceleration  of 
breathing ;  the  state  of  the  pulse,  and  decubitus. 

10th.  The  condition  of  the  digestive  system. 

11th.   The  state  of  the  pharynx,  larynx,  and  trachea. 

12th.  Whether  there  be  any  syphilitic  taint;  if  so,  examine  for 
periostitis  of  the  chest.i- 

*  To  which  we  may  add,  whether  it  leads  to  retching  or  vomiting. 

t  Secondary  syphilis  simulates  phthisis  when  the  syphilitic  hectic  exists  with  the 
bronchial  irritation  which  I  have  described.  If,  as  is  often  the  case,  there  be  also 
periostitis  of  the  ribs  or  sternum,  the  symptoms  are  almost  identical. 


458  TUBERCLE    OF    THE    LUNG. 

13th.  Whether  the  patient  (if  a  female)  be  hysterical ;  *  the 
state  of  the  uterine  system. f 

14th.  Whether  if  there  has  been  any  external  disease  of  a 
scrofulous  nature,  the  symptoms  have  succeeded  to  its  removal 
or  diminution. 

With  the  information  thus  obtained  we  may  proceed  to  the 
physical  examination,  which  must  be  conducted  in  as  delicate 
and  rapid  mode  as  possible.  It  is  almost  never  necessary  to 
uncover  the  whole  chest,  the  baring  of  the  upper  portion  is 
sufficient.  Before  percussion,  gentle  pressure  should  be  made 
on  the  subclavicular  regions,  to  discover  whether  any  tenderness 
exists,  which  would  render  its  use  painful.  Percussion  must 
then  be  performed,  the  patient  being  in  the  erect  position,  and 
without  the  head  being  inclined  to  either  side.  It  is  always  to 
be  comparative  and  strictly  so,  and  we  get  much  better  results 
by  the  most  delicate  than  by  forcible  percussion.  The  best 
pleximeter  is  the  index  finger,  the  back  of  which  is  laid  on  the 
chest.  In  this  way  the  clavicles,  subclavicular  regions,  and 
ridges  of  the  scapulte  are  to  be  explored.  If  necessary,  we  may 
use  percussion  at  the  end  of  a  forced  inspiration,  and  compare 
the  sound  of  the  upper  and  lower  portions  J  For  the  active 
signs  the  stethoscope  is  absolutely  necessary,  for  the  results  of 
immediate  auscultation  are  not  sufficiently  accurate  ;  the  respira- 
tion, cough,  voice,  and  sounds  of  the  heart,  are  to  be  explored 
rapidly ;  and  an  observation  being  made  of  the  external  appearance 
of  the  chest  as  to  contraction,  the  examination  is  completed. 

*  The  practitioner  must  not  build  too  much  on  the  complication  with  hysteria. 
Nothing  is  more  common  than  to  attribute  the  symptoms  of  tubercle  to  this  affection  ; 
an  error  injurious  to  the  patient  and  to  the  reputation  of  the  physician.  The  com- 
plication of  the  hysterical  cough  with  fever  should  always  excite  alarm.  In  phthisis, 
if  there  be  any  cause  for  spasmodic  cough,  this  character  often  continues  to  the  end. 
Thus  where  tubercle  succeeds  to  pertussis,  the  original  character  of  cough  may  con- 
tinue long  after  great  cavities  are  formed.  There  is,  however,  a  singular  hysterical 
affection  with  violent  cough  and  hemoptysis,  excitement  of  the  pulse  and  respira- 
tion, and  copious  sweatings.  The  respiration  is  intensely  puerile ;  but  though  the 
symptoms  continue  for  months,  defying  all  treatment,  there  are  no  signs  of  con- 
solidation. 

f  "  The  origin  of  phthisis  in  pregnancy,  after  delivery,  or  in  the  course  of  lactation, 
lias  been  found  to  exercise  a  peculiar  influence  on  the  disease,  and  to  generate  a  form 
of  tuberculosis,  fraught  with  peculiar  danger,  and  attended  often  from  the  beginning 
with  symptoms  of  urgency  and  rapidity."  (See  Pollock  on  Prognosis  in  Consumption, 
p.  63.)     (Ed.) 

X  A  difference  of  tone  not  otherwise  appreciable  may  be  easily  detected  if  the 
patient's  mouth  be  kept  open. 


TUBERCLE    OF    THE    LUNG.  459 

In  the  nervous  female,  and  in  cases  in  which  there  has  been 
recent  haemoptysis,  the  examination  must  he  performed  as  ex- 
peditiously as  possible  ;  and  in  the  latter  case,  all  fatigue  to  the 
patient  and  forced  inspirations  are  to  be  avoided,  lest  a  new 
haemorrhage  should  be  induced. 

Before  considering  the  treatment,  we  shall  recapitulate  the 
facts  of  the  physical  diagnosis.  Of  course  many  of  these  have 
been  already  observed  by  authors. 

1st.  That  there  are  no  physical  signs  peculiar  to  tubercle. 
2nd.  That  every  known  auscultatory  sign,   active  or  passive, 
may  be  met  with  in  phthisis. 

3rd.  That  in  the  great  majority  of  cases  comparison  can  be 
used,  in  consequence  of  the  predominance  of  disease  in  one 
portion  of  the  lung. 

4th.  That  where  comparison  cannot  be  employed,  there  is 
much  greater  difficulty  of  diagnosis. 

5th.  That  the  earliest,  and  consequently  most  important,  signs 
are  in  the  great  majority  of  cases  those  of  irritation. 

6th.  That  these  may  exist  in  any  of  the  tissues  of  the  lung. 
7th.   That  the  bronchitic  signs  derive  their  value  principally 
from  their   localization  and  combination  with    dulness  on  per- 
cussion. 

8th.  That  the  crepitating  rale  of  pneumonia  is  rarely  observed 
in  the  portion  of  the  lung  first  tuberculated. 

9th.  That  when  it  occurs  it  is  either  recurrent  or  continued, 
and  in  the  latter  case  it  persists  much  longer  than  in  ordinary 
pneumonia. 

10th.  That  feebleness  of  respiration  is  one  of  the  most  com- 
mon physical  signs. 

11th.  That  though  commonly  combined  with  other  signs,  it 
may  occur  as  the  sole  phenomenon. 

12th.  That  the  interrupted  respiration  receives  its  value  solely 
from  its  localization  and  co-existence  with  other  signs. 

13th.  That  of  the  signs  of  irritation,  those  of  the  serous  mem- 
brane are  the  rarest. 

14th.  That  complete  solidity  of  the  lung  is  rare  in  phthisis. 
15th.  That  in  the  early  stages  it  can  often  only  be  ascertained 
by  comparison ;  it  proceeds  from   above    downwards,   and  may 
exist  with  a  feeble  or  puerile  respiration. 

16th.  That  perfect  tracheal  respiration  is  rare  in  phthisis. 


460  TUBERCLE    OF    THE    LUNG. 

17th.  That  when  it  exists  it  is  most  evident  in  the  erect 
position. 

18th.  That  one  side  is  rarely  observed  to  be  equally  dull. 

19th.  That  the  formation  of  cavities  gives  a  tympanitic  cha- 
racter to  the  sound  on  percussion. 

20th.  That  in  cases  of  solidity  of  the  left  lung  a  somewhat 
similar  character  is  given  by  the  distention  of  the  stomach  with 
air. 

21st.  That  in  the  universal  development  of  tubercle  the  sound 
is  generally  but  not  completely  dull. 

22nd.  That  a  great  quantity  of  tubercle,  when  equally  diffused, 
may  coincide  with  but  little  dulness  on  percussion. 

23rd.  That  in  ordinary  phthisis  the  greatest  variety  may  exist 
as  to  dulness. 

24th.  That  the  signs  of  irritation,  and  of  solidification  in  its 
early  stages,  may  be  modified  or  even  removed  by  an  antiphlo- 
gistic or  revulsive  treatment. 

25th.  That  in  the  early  stages  of  the  case  these  phenomena 
only  shew  that  tubercle  is  about  to  form. 

26th.  That  the  signs  of  ulceration  may  imperceptibly  succeed 
those  of  irritation,  or  appear  at  once. 

27th.  That  they  rarely  exist  without  the  signs  of  the  earlier 
stages  of  tubercle  in  other  parts  of  the  lung. 

28th.  That  they  may  be  temporarily  obscured  by  obstruction 
of  their  bronchial  communications. 

29th.  That  they  are  not  audible  to  any  distance  beyond  their 
actual  situation. 

30th.  That  the  action  of  the  heart  may  produce  an  audible 
agitation  of  the  fluid  contents  of  a  cavity. 

31st.  That  the  metallic  phenomena  are  generally  perceived 
when  the  cavity  is  large,  but  may  occur  from  several  small  but 
inter-communicating  ulcerations,  and  may  be  absent  even  in  very 
large  cavities. 

32nd.  That  atrophy  of  the  lung  causes  contraction  of  the 
chest  at  an  early  period,  and  independent  of  the  formation  of 
cavities.* 

33rd.  That  in  very  chronic  cases  it  may  produce  a  deformity 
greater  than  what  occurs  from  the  cure  of  empyema. 

*  On  the  other  hand,  as  Dr.  Walshe  has  pointed  out,  the  contrary  condition  of  the 
paiietes  is  sometimes  seen  in  the  early  stage  of  phthisis.     (Ed.) 


TUBERCLE    OF    THE    LUNG.  461 

34th.  That  the  action  of  the  heart  seldom  furnishes  signs  of 
value  in  phthisis.* 

35th.  That  in  cases  of  tubercular  deposit  in  the  upper  portion 
of  the  right  lung,  the  sounds  of  the  heart  are  often  heard  more 
loudly  in  this  situation  than  under  the  left  clavicle. 

36th.  That  in  certain  cases  the  sounds  of  the  heart  and  those 
produced  by  its  impulses  on  the  diseased  lung  cause  a  distinct 
rhythm. 

37th.  That  in  cases  of  extreme  atrophy  of  the  upper  lobe  of 
the  lung,  the  heart  ascends  high  in  the  thorax. f 

38th.  That  the  subclavian  artery  corresponding  to  the  affected 
side  occasionally  presents  an  increased  pulsation  with  bruit  de 
souffle  t,  which  can  only  be  explained  by  some  sympathetic  irrita- 
tion of  the  vessel. 

39th.  That  the  supervention  of  dulness,  with  the  stethoscopic 
signs  of  bronchitis,  indicates  tubercle. 

40th.  That  in  this  way  we  may  discover  tubercle  in  cases 
not  localized,  and  consequently  not  admitting  of  comparison. 

41st.  That  the  crepitating  rale  of  acute  phthisis  is  not  suc- 
ceeded by  signs  of  hepatization,  as  in  pneumonia. 

42nd.  That  the  dulness  of  the  acute  suppurative  phthisis  is 
greater  than  in  the  non-suppurative  cases. 

43rd.  That  in  the  haemoptysical  variety  of  acute  phthisis  there 
is  often  a  want  of  proportion  between  the  signs  of  solidification 
and  those  of  pulmonary  irritation.  The  first  being  well  marked, 
and  the  latter  comparatively  wanting. 

44th.  That  in  the  ordinary  progressive  phthisis  the  physical 
signs  accurately  correspond  with  the  successive  changes. 

*  This  observation  by  no  means  applies  to  the  right  side  of  the  heart.  On  the  contrary, 
there  is  perhaps  no  more  certain  or  valuable  sign  of  irritation  or  of  obstruction  from 
copious  deposit  of  tubercle  than  augmented  accentuation  of  the  sounds  of  the  pul- 
monary valves,  as  compared  with  those  of  the  aortic.  It  is  in  cases  of  intercurrent 
pneumonia  and  of  haemoptysis  that  this  sign  is  of  most  value.  I  have  known  it  to 
be  the  only  one  portending  danger,  as  in  a  recent  case  in  which  sudden  and  fatal 
haemorrhage  occurred  within  three  days  after  I  had  observed  and  pointid  it  out  to 
the  patient's  medical  attendant.  On  the  other  hand,  the  most  hopeful  cases  are  those 
in  which  this  sign  is  absent  and  the  pulmonary  sounds  duly  proportioned  in  intensity 
to  those  of  the  aorta.     (Ed.) 

f  This  observation  applies  to  the  left  lung  especially,  since  the  heart  does  not  seem 
to  suffer  that  displacement  in  tubercle  of  the  right  lung,  which  is  so  remarkable  in 
cases  of  absorbed  empyema  and  of  cirrhosis.  In  fact,  the  differential  diagnosis 
between  cirrhosis  and  tubercle  is  very  much  determined  by  the  presence  or  absence 
of  dexiocardia,  it  being  so  much  more  marked  in  the  former  affection.     (Ed.) 


462  TUBERCLE    OF    THE    LUNG. 

45th.  That  where  tubercle  succeeds  to  an  unresolved  pneu- 
monia of  the  lower  lobe,  there  are,  coincident  with  the  signs  of 
softening  in  the  unresolved  portion,  evidences  of  the  spreading 
upwards  of  condensation. 

46th.  That  the  supervention  of  dulness  in  a  case  of  chronic 
bronchitis,  followed  by  the  signs  of  anfractuosities,  points  out  that 
tubercle  is  developed.* 

47th.  That  where  the  expectoration  is  scanty,  and  the  disease 
very  chronic,  the  occurrence  of  dilated  cells  may  obscure  the 
signs  of  tubercle. 

48th.  That  where  anfractuosities  form,  we  may  distinguish 
them  from  dilated  tubes,  by  the  dulness  which  has  preceded 
them,  by  the  signs  of  their  extension, f  and  by  reference  to  time. 

49th.  That  the  discovery  of  tubercle,  in  cases  of  absorbed 
empyema,  is  often  difficult  from  the  condition  of  the  lungs  having 
been  altered. 

50th.  That  where  a  great  empyema  exists,  the  intensity  of 
the  puerile  respiration  in  the  opposite  lung  may  obscure  the 
signs  of  disease  of  its  substance. 

51st.  That  in  cases  with  empyema  with  pneumothorax,  where 
adhesions  prevent  the  collapse  of  the  lung,  the  original  cavity 
may  be  still  detected. 

52nd.  That  in  this  complication,  the  signs  of  irritation  of  the 
opposite  lung  are  almost  always  indicative  of  tubercle. 

53rd.  That  in  the  laryngeal  complication,  the  physical 
diagnosis  is  in  general  easy,  unless  where  great  stridor  exists. 


TREATMENT    OP   PHTHISIS. 

We  may  consider  this  treatment  under  two  heads,  viz. — the 

*  Here  it  is  necessary  to  observe,  that  in  certain  cases  of  bronchitis,  where  the 
minute  tubes  are  engaged,  and  with  profuse  puriform  expectoration,  the  lodgment  of 
the  secretion  causes  occasionally  a  dulness  of  sound.  But  this  cannot  be  confounded 
with  that  of  tubercle,  for  it  almost  always  occurs  in  the  lower  portions,  is  constantly 
varying,  and  may  be  removed  (for  a  time)  by  an  emetic,  or  a  blister.  I  have  only 
seen  one  case  in  which  this  lodgment  caused  a  temporary  dulness  of  the  upper  lobe. 
It  was  evident  in  the  morning,  but  disappeared  in  a  few  hours,  leaving  the  respiratory 
mnimur  natural. 

f  When  I  wrote  the  article  on  dilatation  of  the  tubes,  I  was  not  aware  that 
Dr.  Williams  had  already  stated  the  differential  diagnosis  between  this  disease  and 
tubercular  cavities,  as  drawn  from  the  signs  of  extension. — Rational  Exposition  of  the 
Signs  of  Diseases  of  the  Lung  and  Pleura,  also  Encyclopaedia  of  Practical  Medicine 
Art.  Bronchitis. 


TUBERCLE    OF    THE    LUNG.  463 

curative  and  the  palliative  :  the  first,  the  attempt  to  eradicate 
the  disease  by  active  treatment ;  the  second,  the  relieving  the 
various  distressing  symptoms  of  a  hopeless  consumption.  And 
however  differing  in  detail,  the  principle  of  both  methods  is  the 
same,  namely,  the  removal  of  irritation  from  the  lung,  and  the 
improvement  of  the  general  health. 

It  unfortunately  happens  that  the  palliative  treatment  is  that 
which  we  must  generally  follow  ;  but  there  can  be  no  doubt  that 
as  medicine  advances,  the  cures  of  consumption  will  be  much 
more  frequent ;  its  nature  will  be  better  understood,  its  first 
stages  more  commonly  recognized,  and  the  disease  prevented 
from  proceeding  to  incurable  disorganization. 

The  first,  the  most  important  point  in  preparing  ourselves  for 
the  successful  treatment  of  phthisis,  is  to  have  clear  notions  as 
to  its  connexion  with  irritation. 

Without  adopting  the  opinion  of  Broussais,  that  phthisis  is 
nothing  but  a  chronic  pneumonia,*  but  rather  holding  with 
Andral,  Carswell,  Forbes,  and  Clark,  that  the  tubercular  matter 
results  from  a  lesion  of  secretion,  we  must  admit  its  connexion 
with  a  state  of  irritation  in  most  cases.  There  are  some,  indeed, 
where  the  matter  seems  deposited  without  any  such  action,  but 
these  are  comparatively  rare. 

Before  entering  on  this  subject,  I  shall  state  the  division  of 
cases  of  phthisis  which  I  have  generally  followed  with  relation 
to  treatment.  They  may  be  separated  into  two  classes,  the  con- 
stitutional and  accidental  phthisis.  In  the  first,  tubercle  super- 
venes either  with  or  without  precursory  irritation,  in  persons 
strongly  predisposed  to  it  by  hereditary  disposition  or  original 
conformation.  In  these  the  disease  is  generally  rapid,  invades 
both  lungs,  and  is  complicated  with  lesions  of  other  systems. 
The  disease  is  constitutional,  and  the  affection  of  the  lung, 
though  the  first  perceived,  seems  but  a  link  in  the  chain  of 
morbid  actions. 

In  the  second,  we  meet  the  disease  in  persons  not  of  the 
strumous  diathesis,  and  who  have  no  hereditary  disposition  to 
tubercle.  The  disease  results  from  a  distinct  local  pulmonary 
irritation,  advances  slowly,  and  the  digestive  and  other  systems 
show  a  great  immunity  from  disease. 

*  Histoire  des  Phlegmasies  Chroniques,  vol.  ii.  See  also  his  Commentaires  sur  les 
Propositions  de  Pathologic 


464  TUBERCLE    OF    THE    LUNG. 

In  both  cases  we  may  effect  a  cure  ;  but  this  result  will  be 
more  often  obtained  in  the  latter  than  in  the  former  class.  The 
value  of  early  treatment  is  of  course  greater  in  the  constitutional 
than  the  accidental  case.  In  the  early  stages  of  the  constitu- 
tional disease,  recovery  is  only  to  be  effected  by  treatment ;  in 
the  advanced  cases,  when  it  does  occur,  it  seems  almost 
independent  of  treatment. 

In  the  accidental  phthisis,  the  lesser  tendency  to  abdominal 
and  other  complication,  allows  time  for  the  vital  powers  to  act ; 
while  in  the  constitutional  variety,  tubercle  is  commonly  deposited 
throughout  the  body,  and  the  patient  dies  rapidly  in  consequence 
of  such  extent  of  disease. 

But  to  return  to  the  connexion  with  irritation,  we  find  it  in 
the  great  majority  of  cases  to  precede,  accompany,  and  accelerate 
the  disease  ;  and  further,  that  within  certain  limits,  it  is  by 
removing  irritation  that  we  best  succeed  in  effecting  a  cure. 
Without  this  principle  we  have  no  key  to  the  treatment  of 
phthisis.  Tubercle  is  preceded  by  irritation.  This  is  seen  in 
the  history  of  almost  every  case ;  an  ordinary  cold,  an  attack  of 
influenza,  a  pneumonia,  a  pleurisy,  the  bronchial  irritation  of 
hooping  cough,  or  the  exanthemata — these  admitted  conditions 
of  irritation  are  commonly  the  first  links  in  the  chain  of  con- 
sumptive symptoms.  How  commonly  in  the  strumous  diathesis 
do  we  see  individuals  continuing  free  from  phthisis  for  many 
years,  till  an  attack  of  pulmonary  irritation  occurs,  and  then  we 
can  trace  the  first  growth,  and  progress  of  tubercle.  And,  if 
further  evidence  is  necessary,  let  us  recollect  the  effect  of  injuries 
of  the  chest,  and  the  phenomena  of  the  acute  inflammatory 
tubercle. 

That  tubercle  is  accompanied  by  irritation  hardly  demands 
proof.  Fever,  cough,  excitement  of  the  lung,  and  acute  pain, 
declare  the  inward  disease.  Or  if  we  turn  to  anatomy,  we  find 
actual  inflammation  of  the  tissues  of  the  lung,  redness,  thickening, 
softening,  and  ulceration  of  the  mucous  membrane,  purulent 
secretions,  vermilion  redness  of  the  inter-tubercular  tissue, 
solidification  of  the  lung,  and  lymph  on  the  pleura.  Finally, 
it  is  not  uncommon  to  see  the  patient  suddenly  cut  off  by 
some  violent  inflammation,  pneumonia,  pleurisy,  cerebritis,  or 
enteritis. 

But  tubercle  is  not  only  preceded  and  accompanied  by  irrita- 


TUBERCLE    OF    THE    LUNG.  465 

tion,  but  it  is  hastened  by  it.  Every  new  attack  of  irritation 
is  followed  by  increase  of  the  tubercular  symptoms,  unless  it  be 
of  the  surface,  when  a  revulsive  action,  proving  the  general 
proposition,  is  occasionally  seen. 

Lastly,  experience  shews,  that  it  is  by  means  calculated  to 
diminish  irritation  of  the  lung  at  the  least  expense  to  the  con- 
stitution, that  we  can  best  palliate  or  delay  the  progress  of 
phthisis ;  and  I  trust  to  be  able  to  shew  that  the  antiphlogistic 
treatment  is  the  true  mode  of  arresting  the  disease  in  its  early 
periods. 

Thus  the  proposition  is  proved  by  the  study  of  symptoms,  by 
the  results  of  anatomy,  and  by  the  experience  of  treatment.  It 
is  hardly  necessary  to  repeat  that  there  are  cases  of  extensive 
tubercular  formation,  in  which  irritation  is  either  absent,  or 
but  little  marked.  These  are  always  incurable,  happily  they 
are  rare. 

On  being  called  to  a  case  of  phthisis,  the  practitioner  has  to 
decide  whether  to  adopt  the  curative  or  palliative  treatment. 
The  following  are  the  circumstances  which  may  induce  him  to 
attempt  the  cure. 

1st.  The  absence  of  the  strumous  diathesis,  or  an  hereditary 
disposition. 

2nd.  The  fact  of  the  disease  being  recent,  for  where  physical 
signs  of  tubercle  exist,  the  chance  of  recovery  is  inversely  as  the 
duration  of  symptoms. 

3rd.  The  want  of  proportion  between  the  extent  of  disease  as 
indicated  by  physical  signs,  and  the  duration  of  symptoms.  If 
the  extent  be  slight,  although  symptoms  have  existed  for  months, 
it  shows  a  power  of  resistance  in  the  economy. 

4th.  The  calmness  of  the  pulse. 

5th.  The  absence,  or  slight  degree  of  emaciation  or  hectic. 

6th.  The  healthy  state  of  the  digestive  system.* 

7th.  The  fact  of  the  disease  having  distinctly  supervened  on  a 
pneumonia  or  bronchitis. 

8th.  The  occurrence  of  free  expectoration  from  the  first 
period  of  the  cough.  + 

*  In  all  the  extremely  chronic  cases  which  I  have  observed,  the  digestive  system 
continued  healthy,  and  I  have  never  heard  of  a  recovery  after  diarrhoea  had  oc- 
curred. 

t  An  important  character,  as  shewing  an  early  attempt  to  relieve  the  irritation  by 
secretion. 

H    H 


466  TUBERCLE    OF    THE    LUNG. 

9th.  The  healthy  state  of  the  larynx.* 

10th.  The  disease,  as  shewn  by  physical  signs,  being  confined 
to  one  lung,  and  to  a  small  portion  of  that  lung. 

11th.  The  absence  of  the  signs  of  cavities. f 

12th.  The  absence  of  puerile  respiration  in  the  healthy 
portions  of  the  lung.]: 

13th.  The  absence  of  the  signs  of  atrophy. 

It  is  not  meant  that  a  case  should  present  all  these  characters 
in  order  to  justify  our  hopes  and  attempts  of  cure  :  any  of  them 
are  of  value.  Of  course  the  more  of  them  present  the  better ; 
and,  excluding  the  first  character,  they  may  be  all  available  in 
any  case  of  phthisis,  whether  constitutional  or  not. 

Incipient  curable  phthisis  is  met  with  in  one  of  three  forms, 
which  may  be  designated  as  the  Localized  Bronchitic,  the 
Tracheal,  the  Hsemoptysical,  and  the  Pneumonic  varieties.  "We 
shall  discuss  the  treatment  of  these  separately. 

Localized  Bronchitic  Variety. — This  is  shewn  by  the 
existence  of  the  signs  of  bronchial  irritation  already  described. 
They  occur  in  the  upper  portion,  are  combined  with  vesicular 
murmur,  and  with  slight  dulness.  The  pulse  is  quickened,  the 
cough  is  generally  dry,  but  the  hectic  is  not  yet  confirmed,  nor 
is  emaciation  decided. 

At  this  stage  the  experience  of  a  great  number  of  cases 
enables  me  to  say  that  a  cure  can  be  performed.  This  is  the 
period  for  exertion  on  the  part  of  the  physician,  but  that  in 
which  precious  time  is  commonly  lost. 

There  is  a  local  irritation  to  be  subdued;  tubercle  may  or 
may  not  have  formed.  In  the  first  case  its  quantity  is  so  small, 
that  nature  often  is  able  to  throw  it  off;  in  the  second  case,  it 
is  threatened,  and  every  day,  by  promoting  irritation,  increases 
the  chance  of  its  deposition. 

The  patient  must  be  confined  to  his  room,  and  all  exertions 
of  the  lung  forbidden.  If  he  be  of  a  robust  habit,  and  that 
the  pulse  is  inflammatory,  a  single  bleeding  from  the  arm  is  to 

*  Most  importint.  The  combination  of  even  a  small  quantity  of  pulmonary 
tubercle,  in  laryngeal  disease,  is  always  fatal. 

f  This  requires  explanation.  We  know  that  recovery  happens  after  the  formation 
of  cavities,  but  in  most  cases  their  existence  implies  that  of  tubercle  in  great  quantity, 
occupying  other  portions  of  the  lung. 

J  This  character  is  of  value  as  shewing  that  a  small  part  of  the  lung  is  obliterated, 
and  indicating  a  quiescent  btate  of  the  other  portions. 


TUBERCLE    OF    THE    LUNG.  4G7 

be  performed ;  the  bowels  must  be  kept  gently  open,  and  the 
diet  consist  of  milk,  farinaceous  substances,  and  light  vegetables. 

Leeches  are  to  be  applied  in  small  numbers  alternately  to 
the  subclavicular  and  axillary  regions  of  the  affected  side.  This 
depletion  is  to  be  repeatedly  performed,  the  cupping-glass  being 
occasionally  used  over  the  bites.  Under  this  treatment  the  rale 
Avill  be  commonly  removed,  the  vesicular  murmur  increased  in 
strength,  and  the  dulness  diminished,  and  all  this  with  corres- 
ponding relief  to  the  symptoms.  We  are  now  to  commence  the 
use  of  blisters,  which  are  to  be  continually  applied  under  the 
clavicle  and  over  the  scapular  ridge.  Their  size  should  not  ex- 
ceed that  of  a  dollar,  and  thej  must  in  all  cases  be  covered  with 
silver  paper.  A  blister  is  to  be  applied  about  every  three  days. 
This  counter-irritation  is  to  be  persevered  in  for  several  weeks, 
when  the  blister  under  the  clavicle  may  be  converted  into  a 
superficial  issue,  by  dressing  the  surface  with  a  disc  of  felt,  and 
a  combination  of  mercurial  and  savine  ointments.  During  this 
treatment  the  cough  is  to  be  allayed  by  mild  sedatives.* 

As  soon  as  the  issue  is  established,  the  regimen  may  be  im- 
proved. The  patient  may  now  commence  the  friction  with  the 
turpentine  liniment, f  and  if  necessary,  use  inhalations  of  the 
vapour  of  water,  impregnated  with  a  narcotic  extract.  From 
twelve  to  fifteen  grains  of  the  extract  of  cicuta  may  be  employed, 
at  each  time  of  inhalation.  In  mild  weather,  horse  exercise 
should  be  taken,  and  the  invalid,  to  perfect  his  recovery  should 
remove  to  a  milder  climate,  and  frequently  change  his  situation. 

Such  is  the  treatment  of  the  most  common  form  of  incipient 
consumption.  We  owe  the  principle  of  local  depletion  to 
Broussais,  and  among  the  many  boons  which  he  has  conferred 
on  practical  medicine,  there  is  none  greater  than  this.  On  this 
subject  I  shall  quote  two  of  his  propositions. 

"Les  sangsues  placees  a  la  partie  inferieure  clu  cou,  entrc 
les  insertions  dcs  muscles  sterno-masto'idiens,  enlevent  le  catarrlic 
bronchique  et  previennent  la  phthisie  pulmonaire. 

"  Les  sangsues  placees  autour  cles  clavicules  et  sous  les  aisselles 
arretent  les  progres  d'un  catarrhe  qui  vient  de  s'introduire  dans 

*  The  following  is  the  formula  which  I  employ  at  this  stage  :— R.  Mucilaginis  Arab, 
yel  Tragacanth.  Siii. ;  Syrup.  Limon.  5ss.  ;  Aq.  purse,  Siiss.  ;  Aq.  Lauro-Cerasi,. 
5ss. — 3i. ;  Acetatis  Morphias,  gr.  i.  This  can  be  permanently  used  without  deranging, 
the  stomach. 

f  The  formula  for  this  has  been  given  in  the  chapter  on  Bronchitis. 

H  H   2 


468  TUBERCLE    OF    THE    LUNG. 

le  lobe  stuperiew  et  qui  aurait  infailliblcment  produit  la  plitliisie 
jmlmonaire.  Un  son  mat  on  moins  clair,  tout  recent,  annonce 
que  le  catarrhc  a  penStre  dans  le  parenchyme,  et  indique  qu'ilfaut 
insister  sur  les  saignees  locales."  * 

Incipient  Tracheal  Irritation. — A  person  of  a  strumous 
habit,  some  of  the  members  of  whose  family  have  been  cut  off 
by  phthisis,  which  set  in  with  symptoms  precisely  similar  to  his, 
is  attacked,  after  exposure  to  cold,  with  a  loud  ringing  cough, 
occurring  in  distressing  and  uncontrollable  paroxysms.  He  has 
pain  and  soreness  of  the  windpipe,  loses  flesh,  and  is  feverish  at 
night.  There  is  frequently  pain  of  the  chest  and  shoulder,  and 
some  acceleration  of  breathing.  The  pharynx  is  healthy,  or 
only  slightly  vascular.  On  percussion  both  lungs  sound  well 
and  equally,  and  the  respiratory  murmur  is  everywhere  audible. 

The  treatment  in  this  case  must  be  active  and  decided,  for  if 
neglected  the  disease  runs  into  the  miserable  complication  of 
pulmonary  tubercle  with  laryngeal  ulceration. 

The  patient  must  be  confined  to  bed,  or  to  a  warm  room, 
and  placed  on  a  milk  diet ;  all  exertions  of  the  voice  are  to  be 
prohibited.  Leeches  are  to  be  applied  daily  to  the  windpipe, 
beginning  with  from  eight  to  ten,  and  diminishing  the  number 
for  four  or  five  clays ;  blisters  may  then  be  applied  to  the  nape 
of  the  neck  and  sternum. 

But  these  remedies,  though  successful  in  a  few  cases,  may  fail 
unless  we  adopt  the  mercurial  treatment  first  recommended  by 
Mr.  Porter  in  sub-acute  laryngitis.  By  the  use  of  mild  but 
frequently  repeated  doses  of  the  ordinary  mercurials,  in  combina- 
tion with  opium,  we  are  to  affect  the  gums  gently,  but  decidedly  ; 
when  it  will  commonly  happen  that  all  tracheal  and  pulmonary 
irritation  shall  subside. 

Thus  by  the  use  of  mercury  we  prevent  the  development  of 
tubercle.  This  brings  us  to  the  important  subject  of  the  mer- 
curial treatment  of  incipient  phthisis.  Before  entering  on  it, 
however,  we  shall  notice  the  two  remaining  cases  for  treatment. 

H^moptysical  Variety. — An  individual  in  perfect  health,  or 
labouring  perhaps  under  a  slight  cold,  is  attacked  with  copious 
haemoptysis,  accompanied  with  great  excitement  of  the  heart. 
The  haemorrhage  having  nearly  subsided,  we  find  the  breathing 

*  Examen  des  Doctrines  Medicales,  vol.  i. ;  Propositions  de  Medecine,  prop,  cclxxii. 
— -cclxxiii.    See  also  his  Commentaires  sur  les  Propositions  de  Pathologic 


TUBERCLE    OF    THE    LUNG.  460 

and  circulation  quick ;  cough  continues,  and  there  may  he 
local  pain.  The  upper  portion  of  one  side  sounds  dull,  and  here 
the  respiration  is  decidedly  feeble,  although  generally  with  little 
rale.* 

In  these  cases  the  tubercular  development  is  often  astonish- 
ingly rapid,  no  interval  occurring  from  the  first  invasion.  In  a 
few,  however,  there  is  an  interval  of  calm  between  the  cessation 
of  the  haemorrhage  and  the  phthisical  symptoms. 

For  controlling  the  haemoptysis  the  best  treatment  is  general, 
followed  at  once  by  local  or  revulsive  bleeding.  Guided  by  the 
stethoscope,  we  apply  a  great  number  of  leeches  over  the  affected 
part,  and  repeat  this  treatment  frequently.  In  a  few  cases  I 
have  seen  leeching  the  feet,  followed  by  the  pediluvium,  to  have 
an  excellent  effect ;  but  it  is  decidedly  inferior  to  local  bleeding. 
It  is  always  better  to  control  the  bleeding  in  this  way  than  by 
direct  astringents ;  if,  however,  we  must  have  recourse  to  these 
remedies,  we  may  employ  the  acetate  of  lead  in  full  doses,  com- 
bined with  opium,  and  a  little  excess  of  acetic  acid,  or  we  may 
use  the  sulphuric  acid  and  alum.  I  have  never  applied  cold  to 
the  chest.  The  patient  is  to  be  kept  perfectly  at  rest,  and  all 
unnecessary  examinations  avoided. 

Dr.  Cheyne  has  given  the  weight  of  his  testimony  strongly  in 
favour  of  bleeding  in  the  haemoptysical  variety  of  phthisis,  and 
in  cases  of  bronchial  haemorrhage  threatening  consumption,  he 
recommends  small  bleedings  at  intervals  of  a  week.  He  con- 
siders bleeding  to  be  justified  during  haemoptysis,  or  any 
symptom  or  sign  of  inflammation.  In  such  cases  he  exhibits 
tartar  emetic  in  nauseating  doses,  or  the  combination  of  one- 
fourth  of  a  grain  of  tartar  emetic  with  ten  or  fifteen  grains  of 
nitre,  a  combination  in  which  he  places  great  confidence. t  In 
such  cases  I  have  not  used  emetics,  from  a  dread  of  their 
increasing  haemorrhage.  I  have  seen  death  to  occur  in  a  case  of 
haemoptysis,  in  consequence  of  an  enormous  eruption  of  blood 
after  vomiting,  induced  by  a  very  small  portion  of  tartar  emetic. 

*  This  interesting  fact  has  been  already  alluded  to.  The  absence  of  rale  probably 
proceeds  from  the  obstruction  of  the  minute  tubes  by  coagula.  In  a  case  of  pul- 
monary apoplexy,  I  found  every  tube  that  could  be  traced  plugged  up  by  a  bloody 
coagulum.  But  in  certain  cases  of  the  strongly  marked  strumous  diathesis  we  see  a 
rapid  advance  of  tubercle  without  the  stethoscopic  signs  of  mucous  irritation,  particu- 
larly when  repeated  bleedings  have  been  performed. 

f  A  letter  on  Hremoptysis,  &c  ,  Dublin  Hospital  Reports,  vol.  v. 


470  TUBERCLE    OF    THE    LUNG. 

The  haemorrhage  being  controlled,  the  indication  is  to  restore 
the  lung  to  health  as  speedily  as  possible.  All  the  means 
pointed  out  in  the  treatment  of  the  first  variety  are  to  be  used, 
but  with  greater  activity.  I  shall  presently  notice  a  case  in 
which  mercury  was  employed.* 

Pneumonic  Variety. — This  has  been  already  alluded  to  when 
describing  the  succession  of  tubercle  to  an  unresolved  pneumonia. 
But  the  case  of  pneumonia  occurring  in  a  strumous  habit,  and 
particularly  when  engaging  the  upper  lobe,  may  be  arranged 
under  the  same  head.  In  this  case  the  disease  may  be  primary, 
or  occur  in  the  secondary  form.  The  treatment  is  to  consist 
in  repeated  local  bleeding  with  the  cupping-glass,  continued 
counter-irritation,  the  use  of  the  seton,  and  the  employment  of 
mercury  and  sarsaparilla,  as  in  the  case  of  chronic  pneumonia. 

Mercurial  Treatment  of  Incipient  Phthisis. — The  idea  of 
arresting  the  progress  of  scrofulous  inflammation  of  the  lung  by 
mercury  occurred  about  the  same  time,  and  without  any  mutual 
communication,  to  my  friends  Drs.  Graves  and  Marsh,  and  to 
myself,  and  for  the  last  few  years  these  gentlemen  and  I  have 
treated  with  mercury  several  cases  of  incipient  pulmonary  disease, 
which  would  in  all  probability  have  ended  in  phthisis. f  But  a 
great  number  of  observations  must  still  be  made  in  order  to 
establish  the  actual  value  of  this  practice,  and  it  must  be  recol- 
lected that  in  the  case  thus  treated  other  and  active  means  were 
employed  to  remove  the  local  disease. 

Independent  of  the  case  of  tracheal  irritation,  I  have  observed 

*  "  The  treatment,-'  says  Dr.  Cheyne,  "  which  I  would  recommend  in  incipient 
phthisis  may  be  stated  in  a  few  lines.  Journeying,  if  practicable,  or  what  is  better 
still,  in  fine  weather  going  from  shore  to  shore  in  the  steamers ;  short  residences  at 
Mallow,  or  the  Cove  of  Cork,  or  some  favourite  spot  in  England,  or  during  the 
summer,  in  Scotland.  Diet  as  generous  as  the  state  of  the  lungs  will  permit ;  in  some 
cases  a  glass  or  two  of  claret,  and  small  bleedings.  Sponging  the  chest  and  arms 
with  very  dilute  nitro-muriatic  acid,  or  with  five  parts  of  Mindererus's  spirit,  and  one 
of  spirit  of  rosemary ;  an  issue  over  the  most  suspected  portion  of  the  lungs,  or  a 
succession  of  blisters,  after  each  bleeding,  each  not  much  larger  than  a  dollar;  a  light 
bitter  two  or  three  times  a  day,  with  twenty  or  thirty  drops  of  laurel  water,  or  the 
nitro-muriatic  acid  internally,  or  perhaps  some  preparation  of  iron.  If  I  had  time 
I  would  explain  my  reasons  for  rarely  sending  patients  in  any  stage  of  consumption 
to  the  continent  of  Europe." — Op.  cit.,  p.  3G4. 

f  This  subject  is  alluded  to  in  Dr.  Graves's  Clinical  Lectures,  published  in  the 
Medical  Gazette  of  this  year.  The  facts  stated  in  Dr.  O'Beirne's  valuable  paper  on 
the  use  of  mercury  in  diseases  of  the  cartilages  (Dublin  Medical  Journal,  vol.  v.) 
first  led  to  the  hope,  that  by  similar  treatment  a  strumous  inflammation  of  the  lun<* 
might  be  arrested. 


TUBERCLE    OF    THE    LUNG.  471 

the  action  of  mercury  in  some  instances  where  the  lung  was 
decidedly  engaged ;  in  two,  permanent  recovery  followed ;  in  one 
the  disease  was  arrested  for  some  months,  after  which  it  re- 
turned with  its  former  symptoms,  and  the  patient  died  tuber- 
culous ;  and  in  one,  although  mercury  was  thrice  employed, 
no  good  effect  whatever  followed;  and  on  its  last  exhibition 
the  remedy  manifestly  disagreed.  I  shall  briefly  notice  these 
cases. 

A  gentleman,  aged  twenty-four,  was  attacked  with  violent 
haemoptysis;  in  a  week  afterwards  he  presented  the  following 
symptoms  :  the  respiration  was  hurried,  the  cough  troublesome, 
with  a  scanty,  mucous,  and  bloody  expectoration ;  the  pulse 
quick,  and  the  action  of  the  heart  strong ;  fever  of  a  remittent 
character,  with  a  tendency  to  perspiration,  existed  ;  the  patient 
lost  flesh,  looked  pale  and  haggard,  and  complained  of  pain  in 
the  upper  portion  of  the  left  side. 

The  antero-superior  portion  of  the  left  side  sounded  com- 
paratively dull ;  the  respiration  was  here  very  feeble,  with  an 
obscure  rale  evident  on  deep  inspiration ;  clearness  of  sound  and 
puerile  respiration  existed  over  the  remaining  portion  of  the 
chest. 

No  doubt  could  be  entertained  that  if  the  symptoms  and 
signs  were  not  removed,  a  rapid  consumption  would  ensue.  The 
patient  was  confined  to  bed  ;  bleeding,  both  general  and  local, 
was  repeatedly  performed,  and  mild  mercurials  exhibited  at  short 
intervals  of  time.  The  constitutional  symptoms  were  much  re- 
lieved, but  the  local  signs  continued  unchanged,  and  the  system 
resisted  the  mercurial  action ;  calomel  was  now  exhibited,  and 
ptyalism  at  last  produced,  when  a  marked  amendment  took 
place,  the  sound  became  much  less  dull,  and  the  respiration 
louder.  The  remedy  was  now  omitted,  and  a  large  open  blister 
established,  and  the  patient  was  removed  to  the  country.  His 
convalescence  was  slow,  but  satisfactory ;  the  pulse  was  kept  in 
check  by  prussic  acid ;  and  in  the  course  of  a  year  his  health 
Avas  restored.  During  this  time  several  slight  relapses  took 
place,  but  they  yielded  to  local  depletion  and  counter-irritation 
over  the  affected  part.  A  slight  degree  of  atrophy  of  the  sub- 
clavicular region  occurred. 

A  gentleman,  aged  thirty,  was  affected  for  several  months 
with   severe   dry  cough,    which   was   frequently  aggravated   by 


472  TUBERCLE    OF    THE    LUNG. 

exposure  to  cold  and  fatigue ;  be  became  pale,  bis  pulse  was 
quickened,  and  be  presented  all  tbe  appearances  of  approaching 
consumption.  Tbe  rigbt  clavicle  and  scapular  ridge  sounded, 
slightly  but  decidedly  dull ;  the  respiration  in  the  upper  portion 
of  this  lung  was  feeble,  and  mixed  with  an  obscure  mucous  rale ; 
no  signs  of  bronchitis  existed  in  any  other  portion  of  the  lung. 
These  circumstances,  and  the  fact  of  the  patient  having  lost  two 
brothers  in  consumption,  excited  the  greatest  alarm. 

The  trachea  was  repeatedly  leeched,  and  mercury,  first  in  the 
form  of  blue  pill,  and  afterwards  in  that  of  calomel,  exhibited : 
after  a  considerable  time,  full  ptyalism  was  produced,  when  all 
the  symptoms  subsided,  the  chest  regained  its  sonoriety,  and  the 
rales  altogether  disappeared ;  the  patient  regained  his  flesh  and 
strength.  Several  months  are  now  elapsed,  and  he  remains  in 
the  enjoyment  of  perfect  health. 

A  middle-aged  female  was  admitted  into  the  Meath  Hospital 
with  acute  phthisis,  under  which  she  speedily  sank;  the  lungs 
were  found  tuberculated.  It  appeared  that  about  three  months 
before  her  final  attack  she  had  been  seized  with  symptoms  pre- 
cisely similar  to  those  which  ushered  in  her  last  illness ;  these 
were  subdued  by  mercury,  and  during  the  interval  of  the  two 
attacks  she  had  remained  free  from  all  pectoral  symptoms. 

A  woman  was  admitted  into  the  Meath  Hospital,  labouring 
under  violent  symptoms  of  pneumonia,  principally  affecting  the 
upper  portion  of  the  left  lung,  which  resisted  repeated  bleedings, 
both  general  and  local,  and  the  use  of  tartar  emetic  ;  the  disease 
extended  to  the  left  lung,  without,  however,  passing  into  hepa- 
tization in  the  right ;  mercury  was  now  exhibited,  and  the  mouth 
made  sore,  but  without  any  alleviation  of  symptoms,  copious 
expectoration  came  on,  and  the  patient  died  in  about  three  weeks 
in  great  agony.  Both  lungs  contained  numerous  small  trans- 
parent tubercles,  the  intervening  tissue  was  of  a  greyish  white 
colour,  and  the  lung  infiltrated  with  an  enormous  quantity  of  a 
white  serous  fluid. 

A  gentleman  was  attacked  with  haemoptysis,  followed  by  violent 
and  distressing  cough.  Under  the  supposition  that  the  liver  was 
diseased,  mercury  was  exhibited,  but  without  improvement ;  he 
then  came  to  town  ;  he  had  cough,  hoarseness,  emaciation,  and 
a  quickened  pulse,  and  the  right  clavicle  presented  a  slight 
degree  of  dulness.     It  was  determined  to  again  employ  mercury, 


TUBERCLE    OF    THE    LUNG.  473 

but  the  medicine  distinctly  disagreed,  no  ptyalism  was  induced, 
the  tubercular  symptoms  rapidly  advanced,  and  the  remedy  was 
of  course  omitted. 

A  gentleman  residing  in  France  was  attacked  with  severe 
cough,  with  a  pain  in  the  chest,  and  tendency  to  hectic.  A 
syphilitic  affection  had  previously  existed,  but  in  its  primary 
form  at  least  had  been  removed.  The  symptoms  continuing,  he 
came  to  Dublin.  He  was  emaciated,  had  incessant  tracheal 
cough,  with  great  irritability  of  the  nervous  system.  The  fits  of 
coughing  were  most  distressing.  In  addition  to  these,  he  had 
severe  pain  in  the  upper  sternal  and  right  subclavicular  regions, 
which  seemed  to  proceed  from  periostitis,  a  diagnosis  rendered 
more  probable  from  the  fact  of  his  having  distinct  periostitis  of 
the  scalp,  accompanied  by  maddening  headaches.  From  the 
violence  of  the  cough  an  accurate  stethoscopic  examination  could 
be  scarcely  made. 

A  mild  mercurial  course  completely  removed  all  these 
symptoms.  The  patient  felt  for  several  weeks  restored  to  a 
state  of  health  to  which  he  had  been  long  a  stranger.  He  re- 
gained his  flesh,  strength,  and  appearance,  his  pulse  became 
perfectly  quiet,  and  he  returned  to  the  continent.  In  little  more 
than  two  months  he  died  of  pulmonary  tubercle. 

I  have  now  stated  my  experience  of  this  matter.  As  to 
the  general  employment  of  mercury  in  incipient  phthisis,  I  am 
anything  but  sanguine ;  yet  that  by  its  assistance  in  removing 
irritation  from  the  mucous  membrane  and  parenchyma,  we  may 
occasionally  arrest  the  development  or  progress  of  tubercle, 
seems  more  than  probable ;  for  there  can  be  little  doubt  that  in 
the  scrofulous  habit  there  is  more  danger  of  tubercle  from  the 
persistence  of  irritation  of  the  lung,  than  from  the  action  of 
mercury  on  the  system ;  but  the  remedy  is  a  two-edged  sword, 
and  its  exhibition  must  not  be  lightly  attempted.  Extensive 
numerical  investigations  must  be  made  before  the  treatment  can 
be  considered  as  in  any  way  established.* 

After  the  early  stages  of  treatment,  if  an  arrest  of  symptoms 

*  The  subject  is  one  of  the  greatest  importance.  In  all  cases  it  must  be  remembered, 
that  under  treatment  physical  signs  will  disappear,  or  become  less  evident ;  and  that 
this  proceeds  from  the  removal,  not  of  tubercle,  but  of  intercurrent  irritation  of  the 
lung.  We  must,  therefore,  use  the  greatest  caution  in  prognosis;  and  in  all  investi- 
gations bearing  on  the  point,  the  subsequent  history  of  the  patient  for  months  or  years, 
must  be  if  possible  ascertained. 


474  TUBERCLE    OF    THE    LUNG. 

be  happily  produced,  an  issue  or  seton  should  be  established ; 
and  the  patient  should  travel,  and  choose  for  the  next  season  a 
temperate  winter  residence. 

Treatment  after  Excavation  has  formed. — In  a  few  cases, 
even  after  excavation  has  formed,  I  have  seen  a  recover}'.  In 
these  cases  there  was  no  evidence  of  the  advance  of  tubercle, 
and  the  larynx  and  digestive  system  escaped  disease.  In 
other  instances  treatment  has  distinctly  prolonged  life  for  many 
years.  The  principal  remedy  employed  was  the  seton,  with 
frequent  changes  of  air,  or  sea  voyaging.  In  some  cases  the 
patients  confined  themselves  to  a  milk  and  farinaceous  diet, 
while  in  others  they  lived  freely,  indulged  in  wine,  and  entered 
into  all  the  enjoyments  of  society.  In  one  case  where  a  large 
cavity  existed,  the  symptoms  subsided  on  the  occurrence  of 
fistula  in  ano.  The  individual  is  now  in  robust  health.  Two 
of  his  brothers  died  of  phthisis. 

In  a  case  with  cavity,  yet  in  which  the  symptoms  and  signs 
are  not  progressive,  the  patient's  best  chance  I  believe  to  be 
the  use  of  the  seton,  and  travelling.  If  he  does  not  recover,  his 
life  will  be  probably  prolonged.  He  should  take  as  little 
medicine  as  possible  ;  he  should  adopt  all  strengthening  means, 
and  use  such  a  regimen  as  experience  points  out  as  the  best. 
Heated  rooms,  cough  mixtures,  acid  draughts,  inhalations, 
narcotics,  "repeated  counter-irritation,"  and  all  the  varied  and 
harassing  treatment  which  ignorance  supposes  to  be  curative, 
these  are  not,  the  means  of  recovery.  So  long  as  a  drain  from 
the  chest  does  not  weaken,  it  is  clearly  useful,  and  all  the  other 
means  should  be  calculated  to  give  enjoyment  to  the  mind  and 
to  strengthen  the  body.*  The  patient's  winter  residence  should 
be,  if  possible,  in  a  temperate  climate ;  but  his  occupation  in 
summer  and  autumn  months  should  be  travelling.  The  tem- 
perate and  even  colder  countries  may  be  visited  with  advantage. 

In  the  essential  point  of  equability  of  temperature  the  Cove 
of  Cork  is  surpassed  by  few  places.     Recent  observations  have 

*  See  Dr.  Forbes's  notes  to  the  translation  of  Laennec's  work,  article  Phthisis 
Pulmonalis.  It  is  no  little  gratification  to  me  to  find  my  views  of  treatment  of  con- 
firmed phthisis  coinciding  so  closely  with  those  of  this  distinguished  physician,  to 
whose  exertions  British  medicine  owes  so  deep  and  lasting  a  debt.  Our  experience  of 
the  use  of  issues  is  different ;  but  only  so  far,  that  in  a  certain  number  of  cases,  very 
limited  indeed,  1  have  known  recovery,  or  great  prolongation  of  life,  to  occur  after 
their  employment.  In  the  vast  majority  of  cases,  however,  they  seem  worse  than 
useless. 


TUBERCLE    OF    THE    LUNG.  475 

shewn  that  the  niean  difference  of  temperature  of  the  days  and 
nights  rarely  exceed  four  or  five  degrees,  and  often  in  the 
Avinter  months  does  not  exceed  one  degree.  The  town  is  com- 
pletely sheltered  from  the  north  wind,  and  from  its  southern 
exposure,  receives  the  full  influence  of  the  sun  and  the  southern 
breeze. 

It  is  only  within  the  last  few  years  that  Cove  has  attained  its 
celebrity.  It  is  now  the  resort  of  many  invalids.  Of  course, 
as  in  all  places  of  the  kind,  the  good  effects  of  the  climate  are 
seen  more  in  the  temporary  improvement  in  the  health  of 
patients  than  in  their  final  or  permanent  cure.  Such,  however, 
is  the  penalty  which  all  places  of  the  sort  must  pay  for  their 
celebrity.  Patients  in  the  advanced  stages  of  disease  are  con- 
tinually arriving,  and  the  favoured  climate  is  expected  to  effect 
impossibilities. 

I  shall  not  enter  further  into  the  subject  of  climate,  but  refer 
with  pleasure  to  the  works  of  Sir  James  Clark  ;  works  which 
must  ever  be  the  guides  of  the  consumptive,  and  the  text  books 
of  the  student  of  consumption. 

Palliative  Treatment. — I  shall  here  shortly  allude  to  some  of 
the  more  distressing  symptoms,  such  as  hectic,  pain,  cough, 
expectoration,  haemoptysis,  and  diarrhoea. 

The  hectic  is  more  a  measure  of  the  irritation  than  the  sup- 
puration of  the  lung.  It  will  be  often  relieved  or  suspended 
by  local  depletion,  by  an  haemoptysis,  or  by  the  adoption  of 
a  less  stimulating  regimen.  When  the  hectic  is  severe  in  the 
early  and  middle  stages,  the  patient  should  stay  as  little  as 
possible  in  bed.  He  should  not  sit  during  the  day  in  his 
sleeping-room,  which  should  be  a  large  airy  apartment.  The 
chest  should  be  sponged  with  tepid  vinegar  and  water ;  frequent 
changes  of  linen  are  to  be  provided,  a  fresh  garment  being  put 
on  when  the  sweating  commences  ;  his  diet  must  be  of  the  least 
stimulating  kind,  and  the  digestive  system  carefully  regulated. 
In  a  few  cases  some  of  the  preparations  of  bark  answer  well, 
particularly  where  the  fever  assumes  an  intermittent  character  ; 
but  we  cannot  persist  long  in  their  use.  We  cannot  too  strongly 
denounce  the  attempt  to  moderate  the  hectic  sweating  by  medi- 
cines merely,  without  attention  to  other  circumstances.  If  the 
season  be  mild,  the  patient  should  go  out  every  day. 

The  pains  are  best  relieved  by  a  few  leeches,  or  what  is  as 


470  TUBERCLE    OF    THE    LUNG. 

good,  a  small  blister  over  the  affected  part,  which  may  after- 
wards be  dressed  with  the  ointment  of  morphia.  The  applica- 
tion of  turpentine  sprinkled  on  a  hot  cloth  will  often  succeed ; 
and  in  many  cases,  the  belladonna  or  other  anodyne  liniments 
will  remove  the  pain.  When,  however,  the  pain  is  accompanied 
with  the  friction  signs,  the  best  treatment  will  be  a  few  leeches 
or  a  blister.* 

In  the  course  of  a  single  case  we  must  have  recourse  to 
various  remedies  to  allay  the  cough.  All  the  different  forms  of 
demulcents  and  opiates  may  be  employed  ;  of  the  latter,  the  most 
preferable  are  the  different  preparations  of  opium,  hyosciamus, 
cicuta,  and  belladonna.  Inhalations  of  the  vapour  of  water, 
containing  a  narcotic  extract,  are  often  useful. 

Where  the  cough  resists  these  means,  a  few  leeches  applied 
to  the  trachea  on  the  principle  advocated  by  Broussais,  and 
more  lately  adopted  by  Dr.  Osborne,  will  often  give  relief ;  and 
in  some  chronic  cases,  where  even  all  these  means  fail,  I  have 
often  found  that  the  common  anti-spasmodic  mixture  of  camphor, 
valerian,  opium,  ammonia,  and  sether,  gave  the  greatest  relief. 

But  the  greatest  caution  must  be  used  in  adopting  measures 
to  check  expectoration,  for  it  is  the  natural  relief  of  the  lung, 
and  unless  its  quantity  is  so  great  as  to  run  down  the  patient's 
strength  it  should  not  be  interfered  with.     Its  arrest  too  often 
lights  up  new  irritation  in   the  lung,  or  produces  the  enteric 
complication.      I  have    seen    the    most    dreadful    consequences 
from  the  use  of  stimulating  inhalations,  carelessly  or  too  long 
employed.     Those  of  which  I  have  had  much  personal  experience, 
are  the  inhalations  of  iodine,  chlorine,   and  tar.     They  all  act 
in  arresting  the   secretion  of  the  lung,  and    are    consequently 
hazardous.     They  have   no  specific  action  on   tubercle,  but  by 
arresting  purulent  secretion  they  cause  a  more  rapid  development 
of  the  disease.     I  have  seen  the  chlorine  inhalations  used  in  a 
number  of  cases,  and  always  with  bad  effects ;  fresh  irritations 
of  the  lung,  pains  of  the  side,  tightness  of  the  chest,  sudden 
anorexia,  diarrhoea,  and  sopor,  have  followed  its  use. 

*  There  is  a  curious  neuralgic  affection  of  young  females  which  simulates  the  pain 
of  phthisis.  The  patient  complains  of  severe  pain  of  one  clavicle,  generally  the  right ; 
the  pain  is  remittent  or  intermittent,  and  accompanied  with  exquisite  tenderness ;  the 
diagnosis  is  drawn  from  the  absence  of  the  stethoscopic  signs  of  pulmonary  or  pleural 
irritation,  the  clearness  on  percussion,  and  the  absence  of  constitutional  symptoms. 
The  value  of  these  diagnostics  is  of  course  directly  as  the  chronicity  of  the  case. 


TUBERCLE    OF    THE    LUNG.  477 

If  there  be  any  means  likely  to  diminish  the  chance  of  injury 
from  inhalation,  it  is  the  combining  it  with  decided  and  extensive 
counter-irritation . 

When  haemoptysis  occurs,  its  treatment  must  vary  according 
to  the  accompanying  circumstances.  In  the  active  variety,  or  that 
accompanied  with  much  fever  or  excitement  of  the  heart,  our  best 
treatment  will  be  small  general  and  local  bleedings,  the  applica- 
tion of  leeches  to  the  feet,  the  internal  use  of  ice,  and  the  different 
astringents,  particularly  sulphuric  acid,  alum,  and  the  acetate  of 
lead  in  free  doses. 

The  diarrhoea,  proceeding  as  it  almost  always  does  from  an 
enteritis,  is  best  treated  by  attending  carefully  to  regimen ;  in 
the  early  stages  it  can  be  generally  commanded  by  the  ordinary 
cretaceous  and  opiate  medicines,  but  these  soon  lose  their  effect. 
We  must  then  use  the  metallic  astringents  combined  with  opium, 
and  have  recourse  to  small  anodyne  enemata  ;  when  even  these 
fail,  I  have  often  seen  the  most  marked  advantage  from  the 
application  of  a  blister  to  the  abdomen.  In  many  cases  the 
diarrhoea  was  permanently  arrested,  and  the  comfort  of  the  patient 
materially  improved.* 

In  the  preceding  pages  I  have  not  dwelt  on  the  characters  of 
expectoration  in  phthisis,  for  two  reasons,  first,  that  these  have 
been  so  fully  described  by  Andral,  Laennec,  Forbes,  and  others, 
and  next,  that  I  have  not  made  any  original  observation  upon 
them.  The  student  of  consumption  must,  however,  recollect 
that  there  is  no  constant  relation  between  the  appearances  of 

*  It  is  scarcely  necessary  to  observe  that  the  above  section  on  treatment  is  imperfect 
and  behind  the  time,  it  having  been  written  long  before  the  introduction  of  cod  liver 
oil  and  other  analeptic  remedies.  No  more  decided  testimony  to  the  value  of  this 
newer  treatment  could  be  adduced  than  that  of  Dr.  Williams.  In  his  work  on  con- 
sumption he  states  the  results  as  to  the  prolongation  of  life  during  40  years.  («.)  "  la 
the  first  decennial  period"  (from  1830  to  1840)  "the  beneficial  effects  of  treatment 
were  very  limited,  being  chiefly  confined  to  incipient  cases,  &c,  and  life  was  rarely 
prolonged  beyond  the  duration  of  two  years,  assigned  by  Laennec  and  Louis  as  the 
ordinary  limit  of  the  life  of  the  consumptive." 

(b.)  "  In  the  next  period  of  ten  years  a  marked  improvement  took  place  in  the  results 
of  treatment,  apparently  in  connexion  with  the  allowance  of  a  more  liberal  diet,  and 
the  liberal  use  of  mild  alterative  tonics,  as  they  might  be  termed,  particularly  iodide 
of  potassium,  with  sarsaparilla  or  other  vegetable  tonic." 

(c.)  Of  the  influence  of  the  gradual  introduction  of  cod  liver  oil  during  the  latter 
half  of  this  period,  Dr.  Williams  says,  "When  I  state  that  the  average  duration  of 
life  in  phthisis  has,  during  my  experience  of  40  years,  been  at  least  quadrupled,  or 
raised  from  two  to  eight  years,  I  say  what  is  below  the  actual  results  as  calculated 
by  my  son ;  for  of  the  1,000  cases  802  were  still  living  at  the  last  report,  and  many  of 
these  are  likely  to  live  for  years  to  come."     (Ed.) 


478  TUBERCLE    OF    THE    LUNG. 

the  expectorated  matter  and  the  state  of  the  lung  ;  that  in  many 
cases  the  expectoration  is  not  characteristic ;  that  it  may  he 
mucous,  while  great  cavities  exist  in  the  lung,  or  purulent  from 
bronchial  irritation  merely.  It  may  be  scanty,  or  copious,  or 
even  absent,  although  the  lung  be  full  of  excavations.  If  we 
inquire  whether  there  be  any  kind  of  expectoration  more  pecu- 
liarly allied  to  phthisis,  I  would  say,  it  is  that  described  by  Dr. 
Forbes,  in  which  globular  ragged  masses  are  expelled.*  I  do  not 
recollect  a  single  case  in  which  I  observed  this  character,  that  did 
not  turn  out  to  be  phthisis. 

I  have  observed  several  cases  of  calculous  expectoration,  in 
which  a  great  quantity  of  tubercle  seemed  to  have  undergone 
the  cretaceous  transformation.  The  patients  after  having  under- 
gone an  attack  of  severe  bronchitis  affecting  the  small  tubes, 
became  hectic,  and  expectorated  purulent  matter  in  quantity. 
No  signs  of  excavation  existed,  but  one  side  presented  a  cer- 
tain degree  of  dulness,  with  a  muco-crepitating  rale.  These 
symptoms  continuing  for  several  weeks,  small  calculi  began  to 
appear  in  the  expectoration.  These  gradually  increased  in 
number  until  a  vast  quantity  were  expelled.  Their  size  was 
generally  about  that  of  a  large  pin's  head,  and  often  two  were 
connected  by  a  stalk  so  as  to  have  an  hour-glass  form.  The 
discharge  of  these  calculi  continuing  for  a  month  or  six  weeks, 
the  patients  began  to  recover,  and  ultimately  regained  their  flesh 
and  strength,  until  a  new  attack.  The  attack  may  recur  several 
times,  between  which  a  chronic  bronchitis  continues.  The  disease 
is  more  likely  to  affect  middle-aged  than  old  persons. 

*  Translation  of  Laennec,  p.  322.     The  entire  note  is  of  great  importance. 


479 


SECTION  IX. 


DISEASES    OF    THE    PLEURA. 


[This  chapter  is  compounded  of  that  in  the  first  edition,  with  some  trivial 
omissions,  and  of  new  matter  gathered  from  Dr.  Stokes'  notes,  embodying  his 
subsequent  experience,  up  to  the  year  1856.] 

We  shall  arrange  this  subject  as  follows : 

1st.  Simple  adhesions  by  inflammation. 

2nd.  Pleuritis  with  effusion. 

3rd.  Ulcerations  of  the  Pleura. 

4th.  Passive  or  mechanical  effusions. 
Before,  however,  we  enter  on  these  subjects  it  will  be  necessary 
to  premise  some  observations  on  the  structure  of  the  pleura,  and 
to    develope    my  views  as  to  the    influence   of  disease    on  the 
muscular  expansions  of  the  chest. 

It  has  been  long  taught,  that  while  the  pericardium  could  be 
demonstrated  to  be  a  fibro-serous  membrane,  at  least  in  that 
portion  not  reflected  over  the  heart,  the  pleura  was  a  serous 
membrane,  between  which  and  the  pulmonary  tissue  nothing- 
intervened,  except  the  sub-serous  cellular  tissue. 

That  this  opinion  is  grounded  on  an  imperfect  examination  of 
the  parts,  I  have  for  several  years  satisfied  myself;  and  I  have 
repeatedly  demonstrated  the  existence  of  a  strong  capsule  be- 
tween the  serous  membrane  and  the  lung,  and  which  completely 
envelopes  this  latter  organ.  In  the  healthy  state,  this  capsule, 
though  possessing  great  strength,  is  transparent,  a  circumstance 
in  which  it  differs  from  the  fibrous  capsule  of  the  pericardium, 
and  which  has  probably  led  to  the  fact  of  its  being  heretofore 
overlooked. 

The  first  instance  in  which  I  discovered  this  membrane,  was 
in  dissecting  the  lung  of  a  patient  who  had  died  of  chronic  pneu- 
monia. On  dividing  the  organ  with  a  sharp  knife,  through  the 
pleura,  I  observed  three  distinct  layers.  One,  the  pleura ;  another, 
apparently  the  sub-serous  cellular  tissue,  much  thickened  and 
hardened  ;  and  a  third  of  great  density,  and  nearly  opaque.  This 
was  the  tunic  in  question.      Since  then  I  have    several   times 


480  DISEASES    OF    THE    PLEURA. 

observed  it  in  the  diseased,  and  also  have  succeeded  in  demon- 
strating it  in  the  healthy  lung.  But  it  is  always  more  perceptible 
in  the  case  of  disease,  when  the  tissues  are  more  or  less  hyper- 
trophied  and  rendered  opaque. 

In  the  healthy  lung,  however,  it  is  not  difficult  to  exhibit  it. 
The  mode  which  I  adopt  is  the  following :  A  portion  of  the  lung 
being  made,  to  a  certain  degree  tense,  by  grasping  the  subjacent 
parts,  so  as  to  innate  the  more  superficial  layer  of  cells,  I  make 
with  a  sharp  scalpel  the  lightest  possible  scarification  of  the 
figure  of  an  U.  This  divides  the  serous  membrane,  but  leaves 
the  fibrous  untouched.  The  lower  edge  of  the  serous  membrane 
is  then  to  be  seized  with  a  delicate  forceps,  and  by  gentle  traction, 
and  an  occasional  division  of  the  true  sub- serous  cellular  tissue, 
a  flap  of  the  pleura  can  be  turned  up,  leaving  the  air  cells  still 
protected  by  the  strong  though  transparent  fibrous  coat.  The  sur- 
face of  this  latter  investment,  even  after  the  removal  of  the  serous 
membrane,  is  still  smooth  and  shining.  The  knife  is  now  to  be 
carried  through  the  fibrous  coat,  and  it  is  to  be  turned  back  in 
the  same  mode.  Its  great  strength  is  at  once  apparent,  on  its 
being  grasped  with  the  forceps,  or  raised  upon  the  point  of  the 
knife,  and  the  surface  of  the  lung  then  displayed  is  irregular  and 
fleshy. 

This  tunic  invests  the  whole  of  both  lungs,  covers  a  portion 
of  the  great  vessels,  and  the  pericardium  seems  to  be  but  its 
continuation,  endowed  in  that  particular  situation  with  a  still 
greater  degree  of  strength,  for  purposes  sufficiently  obvious.  It 
covers  the  diaphragm,  where  it  is  more  opaque,  and  in  connexion 
with  the  pleura  lines  the  ribs,  and  turning,  forms  the  mediastina, 
which  thus  are  shewn  to  consist  of  four  layers,  two  serous  and 
two  fibrous. 

This  description  of  the  investments  of  the  lung  is  interesting 
in  a  physiological  and  pathological,  as  well  as  an  anatomical 
point  of  view.  It  establishes  an  additional  analogy  between  the 
lung  and  the  parenchymatous  and  glandular  organs  of  the 
abdomen,  which  have  their  fibrous  capsules,  and  illustrates  the 
general  law,  of  the  constant  association  of  serous  and  fibrous 
membrane,  as  we  see  to  occur  with  respect  to  the  arachnoid, 
pericardium,  peritoneum,  tunica  vaginalis  testis,  and  the  synovial 
capsules.  Considered  pathologically,  it  may  explain  the  pain  of 
pleurodyne  and  pleuritis,  and  the  rarity  of  perforations  of  the 


DISEASES    OF    THE    PLEUKA.  481 

pleura,  so  remarkable  when  considered  in  connexion  with  the 
frequency  of  ulcerations  of  the  lung,  which  constantly  approach 
so  close  to  the  surface  as  to  be  bounded  by  the  fibro-serous 
membrane  alone.  In  pleuritis  with  effusion,  its  existence  may 
assist  in  explaining  the  binding  down  of  the  lung  and  its 
corrugated  appearance  after  the  removal  of  the  effusion  ;  and  as 
has  been  suggested  to  me,  it  may  be  the  seat  of  ossifications  of 
the  pleura. 

But  notwithstanding  this  structure  of  the  pulmonary  tunics, 
we  find  that  the  pleural  cavities  are  capable  of  great  dilatation, 
and  that  the  mediastinum  is  not  that  resisting  septum  which  it 
has  been  supposed.  On  the  contrary,  we  find  it  to  yield  rapidly 
to  the  pressure  of  intra-thoracic  accumulations,  and  I  have 
repeatedly  observed  this  to  occur  long  before  any  yielding  of  the 
muscular  parietes.  Hence  it  is  that  in  empyema  of  the  left  side, 
displacement  of  the  heart  occurs  long  before  the  intercostal 
spaces  are  obliterated,  or  the  diaphragm  depressed  ;  and  that  in  a 
case  of  dilatation  of  the  cells,  as  I  have  already  shewn,  an  attack 
of  bronchitis  causes  the  morbid  clearness  to  extend  beyond  the 
mesian  line.  It  is  not  improbable,  however,  that  the  strength  of 
the  fibrous  tissues  varies  in  different  individuals ;  indeed,  with 
respect  to  the  pericardium,  the  greatest  difference  of  strength 
exists,  for  in  some  subjects  we  find  it  dense  and  opaque, 
while  in  others  it  is  nearly  transparent.* 

We  may  now  proceed  to  consider  the  effects  of  internal  accu- 
mulation on  the  muscular  parietes  of  the  chest. 

The  diseases  of  accumulation  may  be  divided  into  two  classes. 
In  the  first  the  quantity  of  air  within  the  thorax  is  increased  ;  in 
the  second,  it  is  diminished.  Of  the  first,  we  have  examples  in 
Laennec's  emphysema,  and  in  pneumothorax,  and  of  the  next 
in  empyema,  hydrothorax,  effusions  into  the  pericardium,  and 
occasionally  intra-thoracic  tumours  ;  hence  the  diagnosis  of  these 
affections  depends,  on  the  one  hand,  on  the  evidences  of  accu- 
mulation, and,  on  the  other,  on  the  physical  properties  of  the 
accumulated  matter.  In  empyema,  there  is  accumulation,  and 
pressure  from  a  non-elastic  fluid ;  while  in  Laennec's  emphysema 

*  The  greater  or  less  extensibility  of  the  pericardium  may  influence  the  phe- 
nomena which  result  from  sudden  effusions  into  the  sac,  as  in  cases  of  rupture  of  the 
heart  or  aorta.  In  a  case  of  the  latter  description,  with  sudden  death,  I  found  the 
pericardium,  which  had  not  been  previously  distended,  containing  upwards  of  a 
pound  of  blood. 

I  I 


482  DISEASES   OF    THE    PLEUKA. 

and  in  pneumothorax  there  is  also  accumulation,  but  from  an 
elastic  medium  ;  hence  we  arrive  at  the  first  step  in  the  diagnosis 
of  these  lesions.  In  empyema  we  have,  in  addition  to  all  the 
evidences  of  displacement  of  the  lung,  the  side,  the  mediastinum, 
and  diaphragm,  proofs  of  a  diminution  of  the  quantity  of  air, 
which  may  amount  almost  to  its  total  absence  from  the  affected 
side,  the  sound  on  percussion  being  dull.  In  the  other  affections 
we  have  also  displacement  which,  as  far  as  the  non-muscular 
portions  of  the  chest  are  concerned,  is  similar  to  that  in  empyema, 
but  there  is  evidence  that  the  air  has  not  only  not  been  dimi- 
nished, but  that  it  is  increased,  the  sound  on  percussion  being 
clear,  or  morbidly  clear. 

When  we  compare  the  chests  of  two  individuals,  the  one 
affected  with  empyema,  and  the  other  with  this  dilatation  of  the 
cells,  we  observe  that  in  both  there  is  evidence  of  accumulation, 
the  side  being  distended,  and  the  mediastinum  displaced.  But 
when  we  investigate  this  point  more  closely,  we  find  some 
interesting  points  of  difference  between  the  results  of  these 
diseases  on  the  thoracic  parietes,  particularly  with  reference  to 
their  muscular  portions. 

I  have  already  published  my  views  as  to  the  mechanism  of  the 
muscular  displacement  in  empyema,  and  endeavoured  to  shew 
that  the  phenomena  are  inexplicable  by  the  formerly  received 
doctrine  of  simple  pressure  from  within  ;  but  that  a  loss  of  tone, 
a  paralysis  of  the  fibres,  was  necessary  before  they  yielded  to 
pressure.*  Subsequent  observations  have  only  confirmed  me  in 
these  opinions. 

The  peculiar  smoothness  of  the  side  in  empyema  has  been 
long  described  as  a  pathognomonic  sign  of  the  disease.  It  proceeds, 
as  every  one  knows,  from  a  yielding  of  the  intercostal  muscles, 
so  that  the  spaces  become  obliterated,  and  thus  the  smoothness 
is  produced.  Further  we  find,  as  I  have  shewn  in  a  former  paper, 
that  in  like  manner  the  diaphragm  yields  until  it  may  even  become 
concave  towards  the  chest,  and  convex  towards  the  abdomen  ; 
pushing  before  it  the  viscera  which  lie  in  the  upper  portion  of  that 
cavity. 

But  these  phenomena  are  by  no  means  so  marked  in  the  dila- 

*  See  Transactions  of  the  British  Association,  vol.  v.,  also  my  Observations  on 
Paralysis  of  the  Intercostal  Muscles  and  Diaphragm  considered  as  a  new  source  of 
Diagnosis,  Dublin  Journal  of  Medical  Science,  vol.  is. 


DISEASES    OF    THE    PLEURA.  483 

tation  of  the  air  cells,  in  which,  as  I  have  already  shewn,  the 
disease  may  exist  to  a  great  amount,  and  the  chest  be  extremely 
dilated,  without  any  one  of  the  appearances  above  mentioned. 
The  intercostal  spaces  continue,  in  all  cases,  well  and  deeply 
marked ;  and  in  one  class  of  cases  the  diaphragm  remains 
unaffected,  even  though  the  pressure  be  so  great  as  to  change  the 
form  of  the  chest. 

Let  us  now  inquire  why  it  is  that  this  remarkable  difference 
exists.  By  examining  the  circumstances  of  either  case  we  may 
arrive  at  the  explanation. 

In  empyema,  there  is  a  combination  of  vital  and  mechanical 
causes.  We  have  inflammation  followed  by  pressure,  and  pressure 
from  a  liquid. 

In  the  dilatation  of  the  cells  we  have  only  pressure,  and  this 
from  an  elastic  fluid. 

Now  in  this  circumstance  of  inflammation  of  the  pleura,  which 
causes  the  effusion  in  empyema,  and  which  continues  to  act  long 
after  the  effusion  has  set  in,  it  appears  to  me  that  we  have  the 
explanation  of  the  dilated  state  of  the  intercostals,  and  the  yield- 
ing of  the  diaphragm. 

When  a  tissue  such  as  a  mucous  or  serous  membrane  is 
inflamed,  we  find  that  certain  effects  are  produced  on  the  mus- 
cular expansions  or  masses  with  which  it  is  closely  connected ; 
their  functions  suffer,  and  we  observe,  first,  an  increase  of  inner- 
vation, as  shewn  by  pain  and  spasms  ;  and  next,  a  paralysis 
more  or  less  complete.  The  same  circumstances  occur  when  the 
inflammation  is  seated  in  the  muscular  structure  themselves,  or 
in  the  cerebro-spinal  centre  from  which  they  derive  their  inner- 
vation. In  all  these  cases,  whether  of  contiguous  inflammation, 
of  actual  disease  of  the  muscular  fibre  itself,  or  of  inflammation 
of  the  brain  or  spinal  marrow,  we  have  produced,  first,  a  plus, 
and  afterwards  a  minus  state  of  innervation.  When  the  latter 
condition  supervenes,  the  muscular  fibres  lose  their  contractility; 
and  if  the  organ  be  a  tube  surrounded  by  fibres,  it  dilates  ;  or  if 
an  expansion  similar  to  the  intercostals  or  diaphragm,  it  yields 
easily  to  pressure.* 

Now  the  true  explanation  of  the  protrusion  of  the  intercostals 

*  Abercrombie  has  shewn  that  in  Ileus,  the  contracted  portions  of  the  tube  are 
healthy,  and  that  the  morbid  appearances  are  confined  to  the  dilated  parts  ;  the  loss 
of  power  being  the  true  cause  of  the  constipation. 

n2 


484  DISEASES    OF    THE    PLEURA. 

and  diaphragm  will  be  found  to  be,  that  they  are  affected  with 
this  paralysis  following  inflammation  of  a  contiguous  structure, 
that  their  contractile  powers  are  lost,  and  that  hence  they  yield 
easily  to  a  pressure,  which,  in  their  healthy  state,  (as  we  see  in 
the  vesicular  emphysema,  in  hydrothorax,  and  the  first  stage  of 
pleurisy),  they  effectually  resist. 

But  we  must  examine  into  the  evidence  of  this  theory  of  dis- 
placement of  the  thoracic  muscles  in  empyema. 

The  first  point  of  evidence  is  obvious  when  we  reflect  on  the 
general  effect  of  irritation  on  muscular  fibre.  Now  in  the  case 
before  us  we  may  observe,  that  the  phenomena  are  in  accordance 
with  this  admitted  effect.  In  the  first  stage  of  pleuritis  we  have 
great  pain  ;  difficulty  of  respiration  ;  hurried  breathing ;  pain 
increased  on  a  deep  inspiration  ;  and  all  this  without  protrusion 
of  the  intercostal  spaces  or  diaphragm,  but  rather  with  a 
spasmodic  state  of  these  expansions,  conditions  which  accurately 
correspond  to  the  plus  state  of  innervation  observable  in  the  first 
stage  of  muscular  irritation. 

But  in  the  more  advanced  periods,  the  reverse  of  all  this  occurs. 
The  pain  ceases,  the  dyspnoea  greatly  diminishes,  the  breathing 
becomes  slower,  the  diseased  side  is  comparatively  motionless, 
ivhile  the  healthy  one  is  acting  with  great  power,  and  the  inter- 
costal spaces  and  diaphragm  yield ;  the  first  causing  the  charac- 
teristic smoothness  of  the  side,  and  the  next,  the  depression  of 
the  abdominal  viscera.  I  need  hardly  remark,  that  these  circum- 
stances correspond  with  the  minus  condition  of  innervation, 
or  paralysis  of  the  muscular  fibres. 

The  next  and  most  important  evidence  is  the  fact,  that  mere 
pressure  seems  insufficient  for  the  phenomenon  in  question.  If 
the  theory  which  I  have  given  be  true,  it  should  follow,  that  in 
other  diseases  of  accumulation,  where  inflammation  of  the  pleura 
was  not  present,  but  where  there  was  merely  pressure,  this  mus- 
cular protrusion  should  either  not  occur,  or  be  much  less  marked. 
Now  such  may  be  observed  to  be  the  fact.  'Let  us  take  Laennec's 
emphysema,  hydrothorax,  and  enlargement  of  the  liver  as 
examples ;  in  all  of  which  there  is  pressure  from  within.  Thus, 
in  Laennec's  emphysema,  we  have  already  studied  the  great 
enlargement  of  the  chest,  and  the  displacement  of  the  medias- 
tinum and  heart,  and  have  seen  that  even  when  the  diaphragm  is 
flattened,  (as  occurs  in  a  certain  class  of  cases),  its  innervation  is 


DISEASES    OF    THE    PLEURA.  485 

not  destroyed.  In  hepatic  enlargement  we  may  see,  also,  evi- 
dences of  pressure  from  the  great  tilting  out  of  the  side,  and  the 
state  of  the  lung ;  while  in  hydrothorax,  the  pressure  is  demon- 
strated hy  the  diminished  volume  of  the  lung,  which,  though 
a  muscular  organ,  cannot  avail  itself  of  its  powers  in  resisting 
pressure  from  without. 

But  notwithstanding  this  pressure,  it  will  he  found  that  in  all 
cases  of  emphysema  and  enlargement  of  the  liver,  and  in  many, 
at  least,  of  hydrothorax,  the  intercostal  spaces  do  not  yield ;  a 
fact  which  may  he  constantly  verified.  I  have  lately  observed 
three  cases  of  symptomatic  hydrothorax,  in  which,  although  the 
effusion  amounted  to  several  pints,  and  the  corresponding  lung 
was  reduced  in  volume,  neither  the  intercostals  nor  diaphragm 
were  affected.  The  same  occurs  in  the  earlier  stages  of  pleuritis, 
and  the  sub-acute  effusions.  In  all  these  cases  we  may  have 
groat  displacement  of  the  side  or  thoracic  viscera  ;  yet  there  is 
merely  pressure,  and  though  the  ribs  are  dilated,  the  intercostal 
spaces  preserve  their  relative  positions. 

The  last  point  of  evidence  is  the  fact,  that  in  some  cases  of 
empyema  there  occurs  a  sudden  yielding  of  the  diaphragm,  which, 
up  to  a  certain  period,  had  preserved  its  natural  position.  This 
yielding  may  be  as  extensive  as  sudden,  and  is  not  necessarily 
accompanied  by  increase  of  effusion.  How  much  more  easily 
can  we  explain  this  interesting  fact,  on  the  supposition  adopted, 
than  on  that  of  gradual  pressure  on  a  vitally  resisting  medium. 

From  these  observations  we  may  safely  conclude,  that  in 
empyema  the  protrusion  of  the  intercostal  spaces  and  diaphragm 
results  from  a  paralysed  state  of  these  expansions,  and  that 
pressure  is  secondary  to  inflammatory  action  causing  paralysis, 
in  inducing  the  yielding  of  the  muscles. 

In  my  original  paper  on  this  subject,  I  suggested  that  the 
amount  of  intercostal  paralysis  might  furnish  a  measure  of  the 
intensity  of  the  disease,  and  bo  thus  made  available  in  prognosis; 
since  then  two  instances  have  occurred,  in  which,  from  the 
absence  of  intercostal  paralysis,  I  prognosticated  the  rapid 
recovery  of  the  patients.  In  both,  acute  pleuritis  had  been 
followed  by  an  effusion  sufficiently  great  to  cause  extensive  dul- 
ness  of  the  left  side,  and  to  push  the  heart  to  the  right  of  the 
mesian  line ;  in  one  the  disease  was  of  ten  days,  in  the  other  of 
nearly  there  weeks'   standing ;    in  neither  were  the  intercostal  ■ 


486  DISEASES    OF    THE    PLEURA. 

spaces  or  diaphragm  protruded,  but,  on  the  contrary,  these 
muscles  were  acting  with  vigour.  In  the  first  case,  little  was 
done,  except  confining  the  patient  to  bed,  the  heart  returned  to 
its  position  on  the  third  day,  and  in  a  week  all  effusion  was 
removed ;  in  the  second,  on  the  seventh  day  of  treatment,  the 
posterior  portion  of  the  chest  was  clear,  and  presenting  the 
friction  sound.  The  recovery  in  both  instances  was  rapid  and 
permanent. 

In  the  diagnosis  of  pleural  disease,  we  may  divide  the  cases 
into  those  without  effusion  sufficient  to  cause  displacement  of 
surrounding  parts,  and  those  with  signs  of  accumulation. 

Dry  Pleuritis. — This  term  has  been  given  to  that  form  in 
which  nothing  is  effused  but  lymph.  The  characters  of  the  case 
may  in  general  be  stated  to  be,  that  the  constitutional  and  local 
distress  is  comparatively  slight,  that  organization  rapidly  ad- 
vances, that  the  sound  is  clear  on  percussion, — the  phenomena 
of  accumulation  or  displacement  wanting,  and  the  friction  signs 
evident. 

We  meet  with  dry  pleurisy  under  various  circumstances.  It 
may  occur  as  an  uncomplicated  and  original  disease,  or  as 
secondary  to  a  general  morbid  state,  such  as  fever,  erysipelas,  or 
the  diffuse  inflammation  ;  it  may  be  combined  with  or  succeed  to 
any  of  the  affections  of  the  lung,  or  occur  as  a  complication  of 
cardiac  or  hepatic  disease. 

The  physical  conditions  of  dry  pleurisy,  however,  may  be  met 
with  in  two  stages  of  the  ordinary  disease;  namely,  in  the  earliest 
periods,  before  effusion  takes  place,  and  in  the  latter  stages,  when 
the  liquid  effusion  is  absorbed.  In  the  first  case  the  duration  of 
the  friction  phenomena  depends  on  the  rapidity  of  effusion ;  in 
the  second,  on  the  vigour  of  the  constitution*  which  influences 
the  process  of  organization. 

*  It  must  be  admitted  that  the  opinions  of  Laennee,  with  respect  to  the  rarity 
of  dry  pleurisy,  and  the  influence  of  mechanical  pressure  in  preventing  it,  were 
erroneous ;  for  the  friction  phenomena  occur  repeatedly  in  cases  where  no  solidi 
fication  exists.  In  the  case  of  tubercle  of  the  upper  lobe,  the  friction  signs  are 
found  much  more  often  over  the  clear  than  the  dull  portion  of  the  lung.  The  fol- 
lowing are  Laennec's  observations  on  this  point :  "  I  am  even  doubtful  whether 
dry  j:>leurisies  exist  in  which  there  is  simple  secretion  of  a  false  membrane,  without 
any  tendency  to  serous  exhalation  at  the  same  time.  All  the  cases  mentioned  may 
be  reduced  to  two  kinds, — that  iu  which  the  effused  serum  has  been  absorbed 
before  death,  and  that  in  which  its  exhalation  has  been  mechanically  prevented  by 
an  indurated  lung."— Forbes's  Translation,  1831,  p.  397. 


DISEASES    OF    THE    PLEUBA.  487 

The  characters  of  this  friction  sound  are  various,  but  in  all 
instances  it  conveys  the  idea  of  two  rough  and  dry  surfaces, 
moving  with  an  interrupted  motion  upon  another.  It  accom- 
panies the  inspiration  and  expiration,  and  may  he  absent  during 
ordinary  breathing,  but  become  manifest  on  a  forced  expansion  of 
the  lung.  In  the  early  periods  of  the  disease,  pain  is  often  felt 
in  the  situation  corresponding  to  the  phenomenon  ;  but  this  soon 
disappears.  Tn  many  instances  the  rubbing  sensation  is  perceptible 
to  the  patient  for  a  length  of  time,  but  we  may  repeatedly  observe 
the  sound  to  continue  long  after  the  patient  ceases  to  perceive  the 
obstruction. 

The  sound  in  the  early  stages  of  the  simple  disease,  or  imme- 
diately after  the  absorption  of  an  empyema,  is  frequently  accom- 
panied by  the  rubbing  sensation,  perceptible  to  the  hand.  Like 
the  former  sign,  this  may  be  absent  during  ordinary  breathing, 
but  become  manifest  when  the  patient  inspires  deeply.  In  the 
progress  towards  cure  of  simple  dry  pleurisy  this  is  the  first 
of  the  physical  signs  to  subside  ;  it  is  obviously  connected  with 
the  most  unorganized  condition  of  the  effused  lymph. 

Although  these  phenomena  are  precisely  analogous  with  those 
of  the  dry  pericarditis,  their  characters  are  not  so  variable  as  in 
that  affection,  nor  are  they  so  speedily  and  curiously  modified  by 
treatment.  The  organization  of  lymph  seems  to  advance  much 
more  rapidly  in  the  pericardium  than  the  pleura.  The  sound, 
however,  is  susceptible  of  certain  modifications  :  thus,  in  a  case 
of  absorbed  empyema  in  a  very  emaciated  subject,  the  friction 
sound,  which  existed  extensively  over  the  side,  was  similar  to 
that  produced  by  the  rubbing  of  a  wet  finger  on  a  tambourine  ; 
it  was  so  loud  as  to  be  audible  for  more  than  a  foot  from  the 
patient's  chest,  particularly  when  he  sneezed,  coughed,  or  laughed. 
A  case  has  been  already  mentioned  in  which  the  friction  pheno- 
mena existed  both  in  the  pleura  and  pericardium  with  a  distinctly 
metallic  character,  in  conseomence  of  the  distention  of  the  stomach 
and  colon  with  air-*  The  creaking  sound,  bruit  de  cuir  ncuf,  is 
rare  in  pleurisy :  I  have  only  observed  it  in  two  instances ;  in 
both  an  effusion  had  been  absorbed,  but  the  phenomenon  was  by 
no  means  so  characteristic  as  that  in  inflammation  of  the  heart 
or  peritoneum. 

Until  very  lately,  I  had  believed  and  taught  that  the  friction 

*  Researches  on  the  Diagnosis  of  Pericarditis,  Dublin  Medical  Journal,  vol.  iv. 


488  DISEASES    OF    THE    PLEURA. 

sounds  were  always  accompanied  by  clearness  on  percussion,  or 
with  a  slightly  diminished  resonance — pulmonary  expansion, 
pure,  or  mixed  with  rales,  being  always  audible.  But  I  have 
lately  witnessed  a  case  of  empyema,  in  which,  although  great 
and  universal  dulness  of  the  side  existed,-  the  phenomena  were 
audible,  and  even  perceptible  to  the  patient  in  the  postero-inferior 
and  lateral  portions  of  the  chest.  They  may,  then,  co-exist 
with  extensive  liquid  effusion.  This,  however,  must  be  con- 
sidered as  an  exception  to  the  general  rule,  that  after  the  absorp- 
tion of  an  empyema,  the  friction  sound  coincides  with  clearness 
on  percussion. 

The  duration  of  the  friction  phenomena,  depending  on  the 
absorption  of  the  liquid,  and  the  rapidity  of  organization,  varies 
remarkably  in  different  individuals  :  it  is  comparatively  short  in 
the  young  and  robust;  while  in  the  feeble  and  cachectic,  the 
phenomena  may  continue  without  changing  for  upwards  of  a 
month :  thus,  in  a  case  of  phthisis  senilis,  the  friction  sound 
continued  for  upwards  of  five  weeks  audible  from  the  third  to 
the  seventh  rib.  When,  however,  it  succeeds  to  the  absorption 
of  an  effusion,  it  may  continue  for  a  period  varying  from  three 
days  to  as  many  weeks.  In  one  case  the  phenomenon  continued 
unabated  for  this  space  of  time,  but  on  the  patient  being  sent  to 
the  country,  it  at  once  subsided.  The  organization  went  on 
rapidly  on  the  improvement  of  the  vital  force. 

As  might  be  expected,  the  friction  sound  is  generally  more 
audible  over  the  central  than  either  the  upper  or  lower  portions 
of  the  chest.  I  have  never  found  it  in  the  acromial  or  supra- 
spinous regions,  but  have  observed  it  immediately  below  the 
clavicle.  The  case  was  one  of  aneurism  of  the  innominata,  with 
pleuritis  of  the  upper  portion  :  dissection  verified  the  diagnosis. 
In  a  case  of  empyema,  in  progress  of  absorption,  the  friction 
phenomena  existed  posteriorly  down  to  the  very  lowest  boundary 
of  the  thorax. 

The  rarity  of  these  signs  in  the  upper  portion  is  explicable 
by  the-  less  degree  of  motion  of  the  pulmonary  on  the  costal 
pleura." 

*  In  discussing  the  subject  of  organization  of  the  false  membranes,  Andral 
observes,  that  this  process  may  occur  with  an  incredible  rapidity  in  some  instances, 
while  in  others  months  may  elapse  without  the  change  occurring:  "  L 'organisation 
<hs  fansses  numbranes  lie  depend  done  pas  seulement  du  temps  plus  on  moins  long  qui 
s'est  ecoule  depuis  lew  formation,  et  aucune  regie  generate  ne  saurait  etre  posee  sur 


DISEASES    OF    THE    PLEURA.  489 

When  describing  the  phenomena  of  dilatation  of  the  air  cells, 
I  alluded  to  Laennec's  opinion,  that  the  murmur  of  ascent  and 
descent  proceeded  from  the  friction  of  sub-pleural  vesicles,  and 
stated  my  reasons  for  agreeing  with  Meriadec  Laennec  in  his 
dissent  from  this  opinion,  and  without  denying  the  possibility  of 
its  occurrence,  I  must  observe  that  I  never  met  it  in  any  case  of 
Laennec's  emphysema,  and  that  in  the  instance  recorded  by 
Reynaud,  in  which  the  friction  signs  coincided  with  an  emphy- 
sematous state  of  the  lower  lobe  in  a  phthisical  patient,  the  facts 
are  far  from  conclusive/" 

The  rarity  of  the  friction  phenomena  in  pneumonia  has  been 
already  noticed.  In  no  case  have  I  found  them  after  hepatization 
had  formed ;  and  their  co-existence  with  the  crepitating  rale  in 
the  early  stages  is  extremely  rare. 

A  case  of  acute  hepatitis  shall  be  presently  noticed,  in  which  the 
friction  signs  existed  extensively  over  the  right  side  and  region 
of  the  liver :  the  pleura  and  peritoneum  were  both  engaged. 

But  one  of  the  most  interesting  combinations  is  that  of  dry 
pericarditis  and  pleuritis  of  the  left  lung.  On  this  subject  we 
want  some  more  accurate  information.  In  a  case  of  dry  peri- 
carditis, with  acute  pneumonia  of  the  lower  portion  of  the  left 
lung,  a  singular  phenomenon  occurred,  which  could  only  be 
explained  by  the  combination  of  the  cardiac  and  pulmonary  fric- 
tion sounds.  During  inspiration,  the  rubbing  sounds  over  the 
heart  became  intense  and  rasping,  while  at  the  end  of  expiration, 
they  approached  to  the  bruit  de  soufjlct ;  in  this  way  a  rhythm  was 
produced,  and  that  it  was  connected  with  the  respiration  was 
evident,  as  it  ceased  whenever  the  latter  was  suspended.  In  this 
instance  there  was  probably  a  double  frottement  proceeding  from 


le  moment  oh  cette  organisation  commence.  11  semble  qu'il  y  a  sous  ce  rapport  des 
dispositions  indiciduelles  inexplicables,  qui,  chez  les  tins,  accelerent  I'epoque  du  travail 
d' organisation,  et  qui,  chez  les  aatres,  le  retardent.  Rtmorquerons-nous  ici  en  passant 
que  la  plus  grande  analogie  existe  entre  le  mode  de  developpement  des  vaisseaux  dans 
les  j'ausses  membranes,  et  leur  mode  de  production  dans  la  membrane  du  jaune  chez 
le  pou/et.  Notons  toute/ois  une  remarquable  difference,  savoir,  I'inconstance,  I'irre- 
gularite  du  travail  a" organisation  dans  les  pseudo-membranes,  et,  au  contraire,  la 
Constance  et  la  regularize  de  ce  travail  dans  lamembrane  du  jaune." — Cliniquc  Medicale, 
vol.  ii.,  Maladies  de  Poitrine. 

*  We  owe  the  discovery  of  the  friction  phenomena  of  dry  pleurisy  to  M.  Rpynaud. 
See  his  original  memoir,  Sur  1' Auscultation  de  la  Poitrine,  Journal  Hebdomadaire  de 
Medicine,  torn,  v.,  IS'20.  The  science  of  auscultation  has  been  much  enriched  by  the 
labours  of  M.  Reynaud  on  this  subject. 


490  DISEASES    OF    THE    PLEURA. 

the  pericardium  and  pleura ;  and  when  we  recollect  the  relative 
frequency  of  the  lung  and  heart,  we  can  understand  the  produc- 
tion of  a  rhythm  in  the  sounds. 

When  the  lower  portion  of  the  left  pleura  is  inflamed  while  the 
pericardium  remains  healthy,  the  action  of  the  heart  may  produce 
a  rubbing  sound,  the  result  of  its  impulses  on  the  mediastinum. 
This  sound  is  synchronous  with  the  heart,  and  is  not  interrupted 
by  the  stoppage  of  respiration ;  it  is  heard  not  over  the  region  of 
the  heart,  but  a  little  beyond  the  situation  of  the  pericardium  ; 
and  in  one  case  in  which  it  occurred,  the  lower  portion  of  the 
pleura  was  covered  with  recently  effused  lymph,  and  the  pericar- 
dium perfectly  healthy.  In  another  case,  however,  of  double 
pleuritis  and  pericarditis,  this  curious  phenomenon  did  not  occcur, 
although  the  friction  signs  were  evident. 

Causes  of  the  Friction  Sounds.— On  this  subject  there  has 
been  some  difference  of  opinion  among  pathologists ;  but  when 
we  consider  that  there  is  a  perfect  analogy  between  the  pheno- 
mena of  inflammation  of  the  pleura,  pericardium,  and  peritoneum, 
we  can  have  little  hesitation  in  adopting  the  opinion  of  Reynaud, 
that  in  these  diseases  the  friction  signs  are  caused  by  the 
existence  of  unorganized  lymph  on  the  surface  of  the  serous 
membrane.* 

In  my  memoir  on  the  diagnosis  of  pericarditis, 1 1  have  demon- 
strated, I  trust,  satisfactorily,  the  dependence  of  the  friction 
phenomena  on  the  effusion  of  lymph,  and  the  state  of  its  orga- 
nization. In  the  occurrence  of  the  rubbing  sounds,  and  of 
vibrations  communicable  to  the  hand  ;  in  their  re-appearance 
after  the  absorption  of  fluid  from  the  pericardium ;  in  the  con- 
tinuance of  sounds,  after  the  sensation  of  rubbing  is  no  longer 
perceptible  to  the  hand,  and  in  their  modification  by  antiphlo- 
gistic treatment,  there  is  the  most  complete  similarity  between 
the  signs  of  the  dry  form  of  inflammation  of  the  pericardium  and 
of  the  pleura. 

PLEURITIS    WITH    LIQUID    EFFUSION. 

This  disease  may  be  met  with  under  various  circumstances. 
It  may  occur  primarily,  in  a  healthy  constitution,  and  accom- 
panied  by  high  inflammatory  symptoms,    which    demand,    and 

*  Journal  Hebdomadaire  de  Medicine,  tome  v. 

t  Dublin  Journal  of  Medical  Science,  vol.  iv.,  1st  series. 


DISEASES    OF    THE    PLEUKA.  491 

bear,  a  vigorous  antiphlogistic  treatment.  It  may  supervene  in 
the  more  delicate  or  lymphatic  subject,  without  great  severity  of 
symptoms,  and  with  but  little  fever.  It  may  complicate  acute 
or  chronic  diseases  of  the  lung  or  liver,  or  succeed  to  the  metas- 
tasis of  an  inflammatory  rheumatism. 

But  there  are  other  forms  in  which  we  find  it  accompanied 
with  much  greater  danger.  In  most  of  these  a  typhoid  state 
has  preceded,  and  accompanies  the  disease.  The  liquid  effusion 
is  rapid  and  copious,  and  nature  makes  little  if  any  effort  to 
absorb  the  fluid,  or  organize  the  lymph. 

This  secondary  or  typhoid  pleuritis,  is  met  with  in  the  follow- 
ing cases — 

1st.  Typhus  or  maculated  fever. 

2nd.  Occurring  in  the  course  of  the  exanthemata. 

3rd.  Complicating  diffuse  inflammation,  or  bad  erysipelas. 

4th.  Consequent  on  phlebitis,  or  purulent  absorption. 

Lastty,  we  have  a  pleuritic  inflammation  from  perforation  of  the 
serous  membrane,  analogous  to  peritonitis  from  a  similar  cause. 
This  wo  shall  examine  when  describing  ulcerations  of  the  pleura. 

Acute  Sthenic  Inflammation. — Fever,  acute  pain  of  the 
side,  hurried  and  interrupted  breathing,  and  dry  cough,  with  a 
hard  resisting  pulse,  are  the  prominent  symptoms  of  this  disease 
in  its  early  stages.  The  pain  is  often  intense,  all  motions  of  the 
thorax  increase  it,  and  the  affected  side  is  fixed  and  motionless. 
The  patient  complains  of  intense  heat  within  the  chest,  and  there 
is  not  unfrequently  an  extreme  tenderness  of  the  integuments. 
The  pain  occurs  in  various  situations.  The  infra-mammary,  and 
inferior  lateral  regions  are  the  most  common,  but  it  may  be 
most  severely  felt  in  the  shoulder,  the  axilla,  the  lumber  region, 
or  lower  portion  of  the  right  hypochondrium  or  hypogastrium. 
In  many  cases  it  is  accompanied  by  a  puffy  tumefaction  of  the 
integuments,  threatening  superficial  abscess.  In  a  case  of  this 
kind,  where  the  shoulder  was  the  seat  of  pain,  I  have  seen  the 
sterno-clavicular  articulation  loosened,  and  the  clavicle  extensively 
dislocated. 

The  pain,  after  continuing  for  forty-eight  or  sixty  hours,  in 
general  diminishes  or  ceases  altogether,  and  this  coincides  with 
an  effusion.  But  in  some  severe  cases  the  pain  continues  with 
slight  remissions,  long  after  copious  effusion  has  occurred,  or 
even  remains  unabated  up  to  the  period  of  death. 


492  DISEASES    OF    THE    PLEURA. 

During  this  first  stage  the  patient  seldom  lies  on  the  affected 
side,  in  consequence  of  the  position  causing  increase  of  pain.    The 
rule  generally  is,  that  in  the  first  stage  the  decubitus  is  on  the 
healthy,  in  the  second  on  the  diseased  side.     But  to  both  these 
observations  many  exceptions  occur.     Thus,  in  the  second  stage, 
when  pain  ceases,  and  copious  effusion  occurs,  we  may  often  see 
the  decubitus   on  the    healthy  side.*     As    might   be    expected, 
the  respiration  is  more  hurried  and  difficult  during  the  persist- 
ence of  the  pain.    I  have  long  been  satisfied,  that  in  this  disease, 
as  well  as  in  pneumonia,  the  acceleration  of  breathing  was  to  be 
explained  more  by  the  excitement  of  the  lung  attending  acute 
inflammation,    than    by  pain  on  the  one  hand,   or  mechanical 
obstruction,  as  from  hepatization  or  effusion,  on  the  other.  There 
are  of  course  cases  of  sudden  extensive  solidity,  or    enormous 
and  rapid  effusions,  where  a  mechanical  cause  must  be  admitted, 
but  these  are  not  the  ordinary  cases,  in  which  (with  respect  to 
dyspnoea  and  acceleration  of  breathing)  we  see  a  great  similarity 
between  pneumonia  and  pleurisy.     In  one  an   improvement  in 
breathing  may  coincide  with  an  extensive  hepatization,  the  patient 
being  apyrexial,  and  in  the  other,  even  with  a  copious  effusion., 
there  may  be  great  ease  of  respiration. 

Indeed,  nothing  can  be  more  singular  than  the  slight  degree  of 
suffering,  which  may  coexist  with  an  extensive  recent  effusion. 
I  have  often  been  consulted  by  patients,  in  consequence  of  their 
finding  the  heart  pulsating  at  the  right  side.  They  had  never  been 
confined  to  bed,  nor  supposed  themselves  unwell,  further  than 
that  they  found  a  little  shortness  of  breath  on  exercise.  They 
confessed  having  had  a  slight  cold  some  time  back,  but  nothing 
sufficient  to  make  them  change  their  ordinary  habits.  I  have 
seen  a  copious  recent  effusion,  of  which  no  symptom  existed  but 
a  collapsed  countenance ;  fever,  pain,  and  cough  were  absent ; 
yet  in  a  week  the  heart  had  been  displaced ;  nay,  further,  it  may 
coexist  with  a  good  appetite,  and  perfectly  healthy  appearance. 
The  disease,  when  established,  runs  one  of  two  courses,     The 

*  On  this  subject  Andral  remarks,  that  the  decubitus  is  most  commonly  on  the 
back,  with  a  slight  tendency  to  one  side,  (decubitus  diagonal.)  I  cannot  agree  with 
him  in  his  statement,  that  during  the  existence  of  fever  and  dyspi  cea,  the  decubitus  on 
the  healthy  side  is  impossible.     But  every  practical  man  must  coincide  in  his  opinion 

that  the  decubitus  gives  us  no  sign  by  which  we  can  recognize  the  disease. Clinique 

Medicate,  Maladies  de  Poitrine,  tome  ii.     When  speaking  of  chronic  pleurisy,  I  shall 
return  to  this  subject. 


DISEASES    OF    THE    PLEURA..  493 

effusion  may  increase  rapidly ;  and  between  the  first  attack  and 
fatal  termination,  no  interval  of  ease  is  afforded  to  the  patient ; 
or,  more  frequently,  as  in  other  visceral  irritations,  a  change  of 
symptoms  occurs,  characterized  by  diminished  suffering,  and  a 
transition  from  the  inflammatory  to  a  hectic,  or  nearly  apyrexial 
condition.  The  symptoms  vary  according  as  the  effusion  is  on 
the  increase,  or  stationary.  In  the  first  case  we  observe  the 
cough  continuing  with  increase  of  dyspnoea  on  motion ;  the 
patient  emaciates ;  the  countenance  becomes  pale,  or  sallow,  and 
contracted  ;  palpitations  are  complained  of ;  and  the  feet  or  ankles 
become  slightly  swollen.  In  this  condition  the  side  will  be  found 
extensively  dull ;  the  mediastinum  displaced ;  and  in  all  proba- 
bility, protrusion  of  the  intercostals  or  diaphragm  will  be  found 
to  exist. 

But  when  the  effusion  is  not  very  extensive,  nor  on  the 
increase,  it  may  coincide  with  a  constitutional  state,  but  little 
removed  from  health.  The  patient  may  gain  flesh  and  strength 
up  to  a  certain  point ;  his  countenance  shall  not  be  expressive  of 
visceral  disease ;  he  shall  have  little  or  no  hectic ;  and  be  enabled 
to  take  exercise.  In  this  way  the  patient  may  go  on  for  months. 
The  disease  is  almost  always  mistaken,  and  treated  as  debility, 
consumption,  remittent  fever,  liver  disease,  or  morbus  cordis  ; 
and  too  often  it  happens  that  the  neglect  and  exasperation  of  the 
disease  produces  the  affection  for  which  it  was  first  mistaken. 

I  have  known  a  case  to  pass  through  all  its  stages,  from 
effusion  to  absorption  and  cure,  where  the  lesion  was  never 
suspected.  The  real  nature  of  the  disease  was  learned  acci- 
dentally long  after  recovery  had  taken  place.  While  the  child 
was  in  the  act  of  dressing,  its  mother,  in  slipping  off  the  shirt, 
perceived  the  deformnVy  of  the  left  side.  I  saw  this  case,  and 
never  before  witnessed  such  great  contraction,  otherwise  the 
recovery  was  perfect.  In  the  young  female  there  is  no  error 
more  common  than  treating  this  disease  for  phthisis,  proceeding 
from  suppressed  uterine  action.  In  several  instances  I  have  been 
able  to  correct  this  important  error  in  time.  In  all,  the  effusion 
was  confined  to  the  lower  lobe  ;  and  the  uterine  action  returned  on 
the  removal  of  the  effusion. 

There  is  nothing  characteristic  in  the  expectoration.  In  the 
early  periods  the  cough  is  dry,  or  there  is  nothing  expelled  but  a 
little  transparent  mucus  ;  in  the  advanced  stages,  the  discharge 


494  DISEASES    OF    THE    PLEURA. 

is  more  copious  ;  and  under  these  circumstances,  the  case  is  often 
supposed  to  be  one  of  confirmed  phthisis. 

The  disease  ma}'  terminate  by  asphyxia,  in  consequence  of  an 
enormous  accumulation.  The  fluid  may  be  evacuated  by  an 
ulcerative  opening  in  the  thoracic  integuments,  or  into  the  lung 
itself,  or  pass  through  the  diaphragm  into  the  abdomen.  The 
effusion  may  be  absorbed  rapidly  or  with  extreme  slowness,  and 
the  patient  be  restored  at  once  to  health,  or  pass  through  the 
doubtful  convalescence  of  Laennec,  under  which  circumstances, 
he  runs  the  greatest  risk  of  pulmonary  consumption. 

Such  is  the  history  of  the  simplest  form  of  this  disease  ;  but  it 
presents  numerous  modifications,  according  to  its  violence,  situa- 
tion, and  extent,  and  also  the  susceptibility  of  the  patient :  to  one 
of  the  most  remarkable  of  these  cases  the  name  of  diaphragmatic 
pleurisy  has  been  given. 

Diaphragmatic  Pleurisy. — When  the  diaphragmatic  pleura  is 
engaged  there  is  generally  orthopncea,  and  it  was  taught  in  the 
older  books  that  delirium  and  the  risus  sardonicus  occurred  as 
symptoms  of  inflammation  of  the  diaphragm.  Modern  observa- 
tions have  shewn  that  these  symptoms  are  by  no  means  constant, 
and  not  more  indicative  of  diaphragmitis  than  of  other  diseases. 
Andral  has  given  the  following  symptoms,  as  indicative  of  this 
disease.  A  severe  pain,  increased  by  pressure,  inspiration,  and 
by  every  effort,  is  felt  along  the  edge  of  the  false  ribs  ;  it  extends 
into  the  hypochondria,  and  is  accompanied  by  complete  immo- 
bility of  the  diaphragm.  There  is  extreme  anxiety,  alteration 
of  the  countenance,  and  the  patient  sits  bent  forward  :  any 
attempt  to  change  his  position  producing  intolerable  pain  ;  in 
some  cases  hiccup,  nausea,  and  vomiting,  have  been  observed. 

The  same  author  has  given  four  cases  of  this  affection.  In 
the  first,  inflammation  of  the  right  diaphragmatic  pleura,  in 
addition  to  the  other  symptoms,  was  accompanied  with  bilious 
vomiting  and  jaundice  :  the  liver  was  displaced.  In  the 
second,  a  chronic  phthisis  had  existed,  on  which  pleuritis  of  the 
left  side  supervened.  From  this  time  till  the  period  of  death 
the  respiration  was  purely  costal.  A  vast  collection  of  pus  was 
found  in  the  left  pleura  :  the  diaphragm  was  perforated,  and  the 
purulent  matter  effused  behind  the  peritoneum.  In  the  last 
two  cases,  the  symptoms  supervened  in  the  progress  of  disease, 
in  the  one  instance,  of  the  pleura  ;  in  the  other,  of  the  lung  itself. 


DISEASES    OF    THE    PLEURA.  495 

In  the  case  of  pleuritis,  the  disease  was  nearly  latent  until 
the  diaphragm  became  engaged. 

It  is  obvious  that  symptoms  such  as  the  above  do  not  neces- 
sarily belong  to  inflammation  of  the  diaphragmatic  pleura,  as 
they  are  seldom  or  never  met  with  in  ordinary  empyema,  when 
the  whole  pleura  is  equally  engaged.  On  this  subject  additional 
facts  are  required. 

Other  forms  of  partial  pleurisy  have  been  observed,*  viz.  :  — 

Inter-lobular  pleuritis,  forming  a  collection  of  pus,  simulating 
pneumonic  abscess. 

Circumscribed  inflammation  of  the  costo-pulmonary  pleura, — 
This  affection  is  much  more  common  than  the  preceding.  It  may 
occur  in  the  upper,  lateral,  or  inferior  portions  of  the  chest.  I 
have  seen  it,  when  existing  in  the  antero-superior  portion,  mis- 
taken for  pulmonary  tubercle. 

In  such  cases,  perforation  of  the  pulmonary  or  costal  pleura 
may  occur,  and  the  matter  be  expectorated,  or  evacuated  through 
the  integuments.  I  have  seen  three  cases  in  which  a  fluctuating 
tumour  existed  externally  for  a  great  length  of  time,  the  tume- 
faction of  which  varied  with  the  respiration,  being  greatest  during 
expiration,  while  the  tumour  fell  in  on  inspiration  ;  and  it  seems 
probable  that  this  would  occur  in  all  cases  where  the  matter  had 
perforated  the  thoracic  walls,  and  was  confined  only  by  the 
external  muscles  and  integuments.  I  have  seen  a  case  in  which 
matter  in  great  quantity  had  already  existed  in  the  right  pleura, 
displacing  the  liver.  A  fluctuating  tumour  appeared  over  the 
lower  sternal  region,  which  was  considered  to  be  connected  with 
the  internal  empyema.  On  examination,  a  distinct  circular  per- 
foration could  be  felt  over  the  last  bone  of  the  sternum.  The 
abscess  was  opened,  a  small  quantity  only  of  scrofulous  matter 
was  evacuated,  and  the  apparent  orifice  turned  out  to  be  the 
raised  edges  of  the  base  of  the  abscess,  which  had  resulted  from 
sternal  periostitis,  and  had  no  connexion  whatever  with  the 
pleural  collection. 

Here  the  tumour,  though  fluctuating,  had  nothing  of  the 
alternating  collapse  and  puffing  out,  corresponding  to  the  acts  of 
respiration. 

Acute  pleuritis  may  be  complicated  with  pneumonia,  bronchitis, 

*  Clinique  Medicale,  Maladies  de  Poitr'ne.     See  also  J.  P.  Frank,  Bs  Curandis 
Hominum  Morbis,  who  has  accurately  described  the  disease. 


49G  DISEASES    OF    THE    PLEURA. 

inflammation  of  the  pericardium,  or  peritoneum.  M.  Tarral  has 
taught  that  the  complication  of  pneumonia  is  more  frequent  than 
has  heen  supposed  ;  and  that  in  many  cases,  hy  changing  the 
position  of  the  patient,  we  can  discover  a  crepitating  rale,  before 
inaudible.  He  believes  that  pleurisy  with  effusion  never  exists 
without  pneumonia.*  My  experience  is  altogether  different :  it 
is  true  I  have  seen  this  complication,  but  never  in  the  simple 
original  pleuritis.  In  my  cases,  a  chronic  inflammation  of  the 
parenchyma  preceded  the  pleurisy,  or  the  disease  was  of  the 
typhoid  or  secondary  form,  which  has  been  already  noticed. 

Laennec  has  described  three  varieties  of  this  complication.  The 
first,  is  the  ordinary  one  of  pneumonia,  with  slight  dry  pleuritis. 
In  the  second,  inflammation  of  the  compressed  lung  may  occur, 
producing  that  variety  of  hepatization,  wbich  he  has  denominated 
carnification ;  while  in  the  third,  severe  inflammatory  action 
affects  both  the  pleura  and  lung.  This  is  by  far  the  rarest 
case.t 

My  experience  of  the  complication  with  pericarditis  is  but 
limited,  but,  as  far  as  it  goes,  is  different  from  that  of  Broussais. 
In  my  cases,  however,  the  pericarditis  was  of  the  dry  form,  in 
which  the  symptoms  are  never  so  violent  as  in  that  with  effusion. 
I  have  observed  this  complication  in  cases  of  acute  pleuritis,  and 
in  two  instances  of  very  chronic  empyema :  in  the  latter  cases, 
the  usual  symptoms  of  pericarditis  were  completely  wanting, 
and  no  new  suffering  marked  the  invasion  of  the  disease,  which 
was  only  to  be  discovered  by  auscultation.  J 

The  observations  of  Broussais  apply  rather  to  cases  with  copious 
effusion  :  he  dwells  particularly  on  the  precordial  pains,  the  great, 
anxiety,  and  want  of  sleep.  The  patient  sits  bending  forward, 
with  his  head  resting  on  his  knees  ;  and  yet,  notwithstanding 
great  concentration  of  the  pulse,  there  is  a  tendency  to  fainting, 
and  almost  complete  absence  of  fever.  §  I  have  no  doubt  that, 
under  such  circumstances,  the  complication  in  question  might  be 
safely  diagnosticated. 

Chronic  Uncircumscribed   Pleurisy,   with   Effusion. — To 

*  Recherches  sur  la  Diagnostique  des  Maladies,  Journal  Hebdomadaire  de  Medicine, 
vol.  vii.,  1830. 

f  Laermec,  Forbes's  Translation. 

%  See  my  Researches  on  the  Diagnosis  of  Pericarditis,  Dublin  Medical  Journal,  vol. 
vi.    Also  Dr.  Law's  Pathological  Obervations,  ibid.,  vol.  vii. 

§  Traite'  des  Phlegmasie3  Chroniques,  torn.  i. 


DISEASES    OF    THE    PLEUKA.  497 

this  condition,  whether  supervening  on  an  acute  and  violent 
attack,  or  from  the  first  with  sub-acute  symptoms,  the  name  of 
empyema  has  been  long  given.  And  although  the  composition  of 
the  fluid  effused  is  often  different  from  that  of  pus,  it  being 
sometimes  bloody  or  serous,  yet  the  term  is  applied  conven- 
tionally to  these  as  Avell  as  to  the  purulent  effusions. 

Chronic  effusion,  compressing  the  lung,  and  displacing  the 
mediastinum,  may  exist  with  or  without  distressing  constitu- 
tional symptoms.  In  the  first  case,  if  we  separate  the  physical 
signs,  we  find  nothing  characteristic  in  the  symptoms  alone  ; 
hectic  may  or  may  not  be  present ;  and  no  characters  of  the  cough ; 
expectoration,  respiration,  decubitus,  or,  with  a  single  exception, 
the  appearance  of  the  patient,  are  sufficient  to  distinguish  this 
from  other  diseases  of  the  lung.  The  exception  alluded  to,  is  the 
dilatation  of  the  side  and  intercostal  spaces — a  subject  which 
we  shall  just  now  handle. 

But  if,  in  addition  to  the  symptoms  of  pulmonary  irritation 
and  obstruction,  as  shewn  by  cough ;  dyspnoea,  increased  by 
exertion,  and  by  lying  on  the  healthy  side  ;  and  a  sense  of  fulness 
and  oppression  referred  to  one  side,  which  is  often  cedematous, 
we  find  the  physical  signs  of  accumulation,  compression,  dis- 
placement, and  paralysis  of  the  thoracic  muscles,  we  may  safely 
diagnosticate  the  disease  in  question. 

In  certain  instances,  however,  the  symptoms  are  all  but  want- 
ing. I  have  repeatedly  known  persons  with  copious  effusions, 
to  look  well,  to  be  free  from  fever,  pain,  or  any  local  distress  ;  to 
lie  equally  well  on  both  sides ;  to  have  a  good  appetite,  which 
they  could  indulge  without  apparent  injury ;  and  all  this  when 
the  heart  was  pulsating  to  the  right  of  the  sternum. 

Thus  it  appears,  that  in  both  classes  of  cases,  the  physical 
signs  are  of  the  last  importance.  Indeed,  in  pleuritic  effusion, 
physical  signs  have  greater  value  than  in  any  other  thoracic 
disease.  Most  cases  of  bronchitis,  of  pneumonia,  and  of  phthisis, 
can  be  at  least  recognized  without  these  aids ;  but  such  is  not 
the  case  in  pleurisy ;  and  it  is  fortunate  that  its  physical  signs 
are  more  simple,  numerous,  and  striking  than  those  of  any 
other  of  the  uncomplicated  diseases  of  the  lung. 

In  the  failure  of  the  attempt  to  found  any  differential  diagnosis 
on  the  s}7mptoms  of  chronic  pleurisy,  considered  apart  from 
physical  signs,  we  must  study  the  latter  with  care,  and  the  more 

K  K 


498  DISEASES    OF   THE    PLEURA. 

so  as  the  statements  on  empyema  contained  in  surgical  books, 
are  exceedingly  loose  and  insufficient. 

As  a  symptom  of  copious  effusion,  we  meet  with  it  more 
frequently  in  the  chronic  cases :  yet  even  here  it  is  often  absent. 
As  a  si<m  it  is  anything  but  pathognomonic :  as  a  constant 
symptom  I  have  only  observed  it  in  extreme  cases,  and  where 
the  mediastinum  and  diaphragm  were  extensively  displaced. 
Facts  are  still  wanting  to  clear  up  the  cause  of  this  symptom. 
Eicherand,  believing  that  the  mediastinum  was  a  strongly 
resisting  septum,  denied  the  doctrine  of  Le  Dran,  that  the 
difficulty  of  tying  on  the  healthy  side,  arose  from  the  pressure 
of  the  superincumbent  fluid,  and  attributed  it  solely  to  the 
obstruction  to  dilatation  of  the  healthy  side,  in  consequence  of 
its  being  placed  undermost. 

But  the  extensibility  of  the  mediastinum  cannot  be  denied. 
The  fact,  which  I  have  often  observed,  of  displacement  of  the 
heart  before  that  of  the  intercostals,  or  diaphragm,  is  sufficient. 
On  this  point  Dr.  Townsend  observes,  that  in  cases  of  pneumo- 
thorax, with  empyema,  we  have  direct  proof  of  the  influence  of 
the  weight  of  the  fluid. 

"  The  patient  can  generally  lie  on  the  sound  side  so  long  as 
the  effusion  is  principally  gaseous ;  but  as  the  proportion  of 
ponderable  fluid  increases,  decumbiture  on  the  sound  side 
becomes  impossible.  In  like  manner  in  cases  of  empyema, 
the  dyspnoea  is  in  general  greatly  aggravated  by  lying  on  the 
sound  side  ;  but  when  the  fluid  is  evacuated,  the  patient  is  imme- 
diately enabled  to  turn  on  the  sound  side,  although  the  necessity 
for  its  free  dilatation  continues  as  great  as  before,  the  disease 
being  still  in  a  state  of  perfect  inaction.  In  the  case  of  pneumo- 
thorax with  empyema,  related  in  the  fifth  volume  of  the  Dublin 
Transactions,  in  which  the  operation  of  paracentesis  was  performed, 
the  patient  was  enabled  to  lie  on  the  sound  side  the  night  after 
the  fluid  was  drawn  off,  though  it  was  ascertained  by  auscultation 
that  the  side  was  then  filled  with  air,  and  the  necessity  for  the 
free  dilatation  of  the  sound  side  consequently  as  great  as  before 
the  operation. 

"  These  observations  render  it  probable  that  the  difficulty  of 
lying  on  the  sound  side  arises  from  the  load  which  is  thereby 
thrown  on  the  mediastinum,  as  well  as  from  the  obstruction 
which  the  muscles  of  inspiration  experience  when  the  side  which 


DISEASES    OF    THE    PLEUKA.  499 

they  have  to  dilate  is  placed  under  the  weight  of  the  hody.     To 
avoid  this  inconvenience,  patients  labouring  under  effusion  into 
the  chest  generally  lie  on  the  diseased  side,  or  else  on  the  back, 
with  a  slight*inclination  of  the  body  towards  that  side.    This  latter 
position  is  the  more  general  of  the  two,  and  is  so  very  charac- 
teristic, as  to  lead  in  some  cases  to  a  suspicion  of  the  disease, 
even  before  any  farther  examination  has  been  made.     This  posi- 
tion, however,  is  not  so  constantly  observed,  but  that  we  meet 
with  frequent  deviations  from  it.    When  the  fever  has  completely 
subsided,    and   the  thoracic  viscera  have  become  habituated  to 
the   pressure  of   the    effusion,  the   patient    can    sometimes    lie 
indifferently  on  his  back,  or  on  either  side ;  and  there  are  even 
some  cases  on  record,  where  the  patient  lay  constantly  on  the 
sound  side.     J.  F.  Isenflamm  relates  a  remarkable  case  of  this 
kind,  in  which  a  patient,  presenting  all  the  usual  symptoms  of 
empyema,  lay  generally  on  the  right  side,  which,  for  this  reason, 
was  supposed  to  be  the   seat   of  the   disease :  accordingly,  the 
operation  of  paracentesis  was  performed,  but  no  pus  was  found.* 
The  patient  died ;  and  on  dissection,  it  was  discovered  that  the 
left  side  was  the  seat  of  the  empyema.     Morgagni  relates  a  case 
of  this  kind  on  the  authority  of  Valsalva ;  and  M.  Baffos  records 
another  instance.^    These,  however,  may  be  considered  as  excep- 
tions to  a  general  rule,  and  probably  depend  on  some  adhesions 
which  confine  the  effusion,  and  prevent  its    gravitating  to   the 
most  dependent  part  of  the  chest. "J 

There  seems  reason  for  admitting  both  the  explanations 
if  Eicherand  and  Le  Dran,  as  adopted  by  Dr.  Townsend ;  for 
although  the  decubitus  on  one  side  interferes  less  with  respiration 
of  the  corresponding  lung  than  we  would  a  priori  suppose,  yet 
it  has  some  effect ;  and,  on  the  other  hand,  it  is  easy  to  conceive 
a  case  in  which  the  fluid,  by  lying  on  the  mediastinum,  would, 
by  its  weight,  oppress  the  heart  and  affected  lung.  In  an  extreme 
case,  however,  where  the  pleural  sac  was  at  its  maximum  of 
distention,  it  seems  possible,  if  the  patient  had  become  habituated 
to  the  new  condition  of  the  mediastinum,  that  decubitus  on  the 
healthy  side  would  not  cause  so  much  distress  as  in  cases  with 
less  effusion. 

*  Versuche  einer  praktischen  Abhandlung  ueber  die  Knochen.  Erlangen,  1782. 

f  Dissertation  Inaugurate  sur  l'Empyeme.     Paris,  1814. 

%  See  Dr.  Townsend's  Essay  on  Empyema,  Cyclopaedia  of  Practical  Medicine. 

kk2 


500  DISEASES    OF    THE    PLEURA. 

But   there  is  another  cause  as  yet   unnoticed,    namely,  the 

effect  of  change  of  position  on  the  abdominal  viscera.     In  a  case 

with   protrusion    of  either  ala    of  the  diaphragm,  the  turning 

on  the  healthy  side  would,  by  increasing  the  pressure  on  the 

abdominal  viscera,  impede  the  descent  of  the  opposite  portion  of 

the  muscle,  and  consequently  produce  distress  of  breathing.     It 

would  have  the  same  effect  as  we  see  from  accumulations  in  the 

bowels,  or  from  external  pressure,  as  accurately  observed  by  Dr. 

Townsend,  who,  in  testing  the  statements  of  Bichat  and  Boux, 

that  pressure  on  the  side  of  the  abdomen  corresponding  to  the 

effusion  caused  extreme  distress,  by  forcing  up  the  fluid,  and 

increasing  its  pressure  on  the  lung,  found  that  the  very  reverse 

was    the    fact ;    for,    while    no    uneasiness    was   produced    by 

pressing  up  the  diaphragm  on  the  side  where  the  effusion  existed, 

any  attempt  to  stop  the  motion  of  the  opposite  ala  of  the  muscle 

caused  extreme  and  immediate  distress.* 

Considering  the  great  weight  and  mobility  of  the  liver, 
we  should  expect  that  in  empyema  of  the  right  side,  there  would 
be  greater  distress  from  the  cause  now  pointed  out  than  in  the 
opposite  case. 

As  the  physical  signs  of  the  primary  sthenic,  and  secondary  or 
typhoid  varieties  of  pleurisy  are  the  same,  it  will  be  right  to 
discuss  them  before  we  examine  the  latter  forms  of  the  disease. 
Indeed  so  latent,  quoad  symptoms,  are  many  cases  of  the  typhoid 
pleurisy,  that  it  is  only  by  physical  signs  that  the  disease  can  be 
recognized. 


THYSICAL    SIGNS    OF   EFFUSION    INTO    THE    PLEURA. 

The  physical  signs  of  pleurisy,  in  its  different  stages,  will 
be  easily  intelligible,  if  we  arrange  them  in  the  following 
manner  : 

1st.  Passive  auscultatory  signs.  Loss  of  sonoriety  of  the 
chest. 

2nd.  Active  auscultatory  signs. 

a.  Phenomena  of  respiration. 

b.  Phenomena  of  voice. 

*  Cyclopaedia  of  Practical  Medicine,  article  Empyema:  also  Professor  Chomel, 
Dictionnaire  de  Medicine,  art.  Pleurisie.  This  eminent  and  accurate  observer's 
experience  coincides  with  that  of  Dr.  Townsend. 


DISEASES    OF    THE    PLEURA.  501 

3rd.  Signs  of  liquid  accumulation,  causing  compression  and 
displacement. 

a.  Of  the  ribs. 

b.  Mediastinum  and  heart. 

c.  Intercostal  muscles. 

d.  Diaphragm  and  abdominal  viscera. 

The  earliest  sign  is  loss  of  sonoriety  of  the  portion  of  the 
chest,  corresponding  to  the  effusion.  This  dulness,  supervening 
much  more  rapidly  than  in  ordinary  pneumonia,  and  unaccom- 
panied or  unpreceded  by  the  crepitating  rale,  generally  points 
out  pleuritic  effusion. 

When  describing  pneumonia,  I  shewed  that  the  occurrence  of 
dulness,  without  preceding  crepitus,  was  not,  as  Laennec  has 
taught,  necessarily  indicative  of  pleurisy,  as  it  was  met  with  in 
the  typhoid  solidity.  The  constitutional  state  of  the  patient,  the 
expectoration,  and  the  absence  of  the  signs  of  displacement,  will, 
in  general,  suffice  to  distinguish  this  typhoid  solidity  from 
pleuritic  effusion.* 

The  dulness  is  first  perceived  in  the  postero-inferior  portion, 
and  in  the  earlier  periods  is  more  valuable  when  occurring  in  the 
left  than  in  the  right  side ;  it  extends  upwards,  engages  the 
lower  portion  of  the  side  and  infra-mammary  region ;  and 
as  the  effusion  advances,  may  extend  to  the  scapular  ridge ; 
or  anteriorly  to  the  third  rib.  I  have  even  seen  universal  dulness 
produced  by  a  comparatively  recent  effusion. 

In  the  early  periods  of  the  case,  and  before  adhesions  occur, 
the  lung,  as  it  were,  floats  on  the  fluid,  which  is  permitted  to  pass 
freely  around  it.     Hence  is  derived  the  interesting  sign  of  varia- 

*  The  following  is  the  statement  of  Laennec  on  this  subject : — "  This  complete 
■disappearance  of  respiration,  after  the  existence  of  disease  for  a  few  hour?,  is  quite 
pathognomonic  of  pleurisy  with  copious  effusion,  whether  there  exists  pain  in  the 
side  or  not.  In  pneumonia,  the  disappearance  of  the  respiration  is  gradual,  and 
is  perceived  to  be  unequal  in  different  parts  of  the  chest ;  it  is  scarcely  ever 
•quite  wanting  below  the  clavicle  ;  and  when  this  takes  place,  it  is  not  till  after 
some  days,  or  even  ■weeks.  It  is  further  preceded  for  twenty-four  or  thirty-six 
hours  by  the  crepitous  rhonchus,  which  is  quite  characteristic.  In  pleurisy  with 
copious  effusion,  on  the  contrary,  the  loss  of  the  respiratory  murmur  is  sudden, 
equable,  uniform,  and  so  complete,  that  no  effort  of  inspiration  can  render  it  percep- 
tible."— Forbes's  Translation,  1834,  p.  465.  In  his  excellent  article  on  pleurisy,  Dr. 
Law  makes  the  same  statement  : — "  We  may  state  that  the  sudden,  equable,  and 
uniform  absence  of  respiration,  and  dulness  of  sound,  are  peculiar  to  pleuritic 
effusion." — Cyclopaedia  of  Practical  Medicine.  In  Dr.  Hudson's  paper  on  Typhoid 
Pneumonia  there  are  some  interesting  examples  illustrative  of  this  point.— See  Dublin 
Medical  Journal,  vol.  vii. 


502  DISEASES    OF    THE    PLEURA. 

tions  in  the  sound  on  percussion,  corresponding  to  the  position 
of  the  patient.  Under  these  circumstances,  we  may  find  that 
when  the  patient  turns  on  his  face,  the  postero-inferior  portion, 
which  had  been  dull,  becomes  clearer  ;  and  in  a  few  instances  I 
have  observed  a  return  of  clearness  to  the  lateral  portions  when 
the  patient  turned  on  the  opposite  side,  so  as  to  allow  the  fluid 
to  accumulate  along  the  mediastinum.  But  these  signs,  although 
so  satisfactory  and  unequivocal,  are  by  no  means  so  often  met 
with  as  might  be  expected :  and  I  have  long  believed  that  the 
change  of  situation  of  the  fluid  is  prevented  by  an  agglutination 
of  the  pleurae,  sufficient  for  this  purpose,  though  yielding  to  the 
gradual  accumulation  of  fluid.  The  sign,  however,  is  a  favour- 
able one  ;  and  the  more  so  in  proportion  to  the  chronicity  of  the 
case,  as  shewing  but  a  small  amount  of  effusion,  and  a  sub-acute 
inflammation.  We  must  then  admit,  with  Piorry,*  Reynaud, 
and  Forbes,  that  the  opinion  of  Laennec,  with  respect  to  the 
immobility  of  the  fluid  in  pleurisy,  was  incorrect ;  but  it  is 
certain,  as  I  have  before  stated,  that  the  sign  is  not  so  frequent 
as  we  might  a  priori  expect. 

The  dulness  is  generally  complete ;  and  when  the  effusion 
is  partial,  terminates  by  a  well-defined  (transverse)  line,  a  circum- 
stance which  is  never  observed  in  progressive  pneumonia.  At 
this  line,  particularly  in  cases  of  absorption,  I  have  sometimes 
observed  the  bruit  de  pot  fele ;  but  I  do  not  know  whether  this  is 
the  same  as  the  son  liumorique  observed  by  Piorry  in  hydro-pneu- 
mothorax.f  I  do  not  recollect  any  case  in  which  the  distention 
of  the  stomach  produced  the  peculiar  tympanitic  sound  which 
occurs  in  hepatization. 

I  have  already  stated  that  when  the  effusion  is  copious,  the 
entire  side  may  be  dull  from  the  clavicle  down.  I  have  seen 
this  to  coincide  with  but  little  distress,  and  mild  constitutional 
symptoms.  Under  these  circumstances,  the  respiration  may  be 
extensively  bronchial,  or  feebly  vesicular  in  the  upper  half  of  the 
thorax ;  and  in  consequence  of  the  displacement  of  the  medias- 
tinum, the  dulness  extends  beyond  the  mesian  line. 

This  extensive  dulness  is  often,  as  Piorry  has  remarked,  a 
precious  sign  of  pleuritic  effusion.  J 

*  De  la  Percussion  Mediate,  etc.,  etc.,  Paris,  1828,  page  80.  The  author  well 
remarks,  that  Laennec,  -when  speaking  of  egophonia,  admits  the  change  of  position  of 
the  fluid.    But,  even  in  recent  pleurisies,  the  sign  is  rarer  than  M.  Piorry  teaches. 

t  Op.  cit.,  p.  93.  J  Op.  cit. 


DISEASES    OF    THE    PLEURA.  503 

Active  Auscultatory  Signs. — We  shall  first  examine  the 
phenomena  of  respiration,  and  afterwards  those  of  voice. 

With  reference  to  respiration,  the  cases  may  be  divided  into 
four  classes.  In  the  first,  all  respiratory  phenomena  disappear 
over  the  dull  portion  of  the  chest;  while  in  the  remaining 
portions,  the  respiration  may  or  may  not  be  puerile. 

In  the  second,  a  feeble  respiratory  murmur  may  be  extensively 
heard,  gradually  diminishing  as  we  approach  the  lowest  portion 
of  the  thorax. 

In  the  third,  a  feeble  murmur  is  heard  only  along  the  spinal 
column,  as  observed  by  Laennec. 

In  the  fourth,  an  extensive  and  well-marked  bronchial  respira- 
tion, most  audible  in  the  posterior  and  lateral  portions,  is  heard 
from  an  early  period. 

Of  these  cases,  the  two  last  always  coincide  with  extensive 
dulness  on  percussion. 

The  sign  of  bronchial  respiration  has  been  considered  too  much 
as  peculiar  to  solidity  of  the  lung.  It  is  by  no  means  uncommon 
in  pleuritic  effusion,  and  may  be  observed  in  the  most  recent  as 
well  as  in  chronic  cases.  Its  mechanism  is  not  yet  understood. 
In  two  cases  observed  by  Dr.  Graves,  the  usual  phenomena  of 
pleurisy  were  so  well  marked,  and  the  cases  of  so  urgent  a 
nature,  that  paracentesis  would  have  been  performed  but  for 
the  occurrence  of  this  bronchial  respiration,  which  was  to  be 
heard  distinctly  over  the  anterior  portion  of  the  chest,  particularly 
in  a  line  drawn  vertically  through  the  mammary  region ;  the 
same  was  observed  posteriorly  above  and  below  the  scapular 
ridge,  and  nowhere  was  the  sound  of  respiration  absolutely  null. 

These  phenomena  occurred  in  two  cases,  and  on  dissection 
the  appearances  were  almost  precisely  similar  in  both. 

A  very  strong  and  uninterrupted  adhesion  extended  from 
about  two  inches  below  the  clavicle  of  the  affected  side,  in  a  line 
passing  through  the  middle  of  the  mammary  region,  nearly  to 
the  bottom  of  the  anterior  part  of  the  lung. 

This  adhesion,  about  two  inches  in  breadth,  was  very  firm 
and  close,  so  as  to  form  an  intimate  union  between  the  pulmo- 
nary substance  and  the  anterior  parietes  of  the  chest,  and 
extended  nearly  from  the  apex  of  the  lung  to  its  base.  Along 
this  line,  the  pulmonary  tissue  formed  a  plate  of  compressed 
lung,  about  two  inches  in  thickness,  which,  like  a  vertical  par- 


504  DISEASES    OF    THE    PLEURA. 

tition,  divided  the  pleural  cavity  into  two  chambers,  each  filled 
with  sero- purulent  matter,  and  separated  by  the  lung  extending 
from  its  root  to  its  anterior  adhesions. 

It  is  to  be  observed,  that  these  two  cavities  communicated 
towards  the  clavicle,  where  the  adhesion  was  wanting,  and  were 
still  further  divided  by  other  adhesions  posteriorly,  extending 
upwards  from  the  root  of  the  lung  to  the  superior  lobe. 

The  lung  forming  these  different  partitions  was  red,  com- 
pressed, and  totally  destitute  of  crepitus.  The  air  cells  were 
rendered  impermeable  by  the  pressure  of  the  pleuritic  effusion ; 
but  the  bronchial  tubes  were  not  obliterated,  and  could  easily 
be  traced  to  within  a  line  or  two  of  the  parietes  of  the  chest.* 

In  a  remarkable  case  of  empyema  which  I  have  seen,  a  some- 
what similar  state  of  parts  occurred.  A  musket-ball  had  pene- 
trated the  lung  from  above,  downwards  and  forwards,  entering 
at  the  supra-spinous  region,  and  lodging  at  the  anterior  attach- 
ments of  the  diaphragm.  A  violent  pleuritis,  followed  by  copious 
effusion,  was  the  result ;  and  after  a  few  days  the  heart  was  dis- 
placed. In  this  case,  as  in  the  two  former,  the  occurrence  of 
intense  bronchial  respiration  posteriorly  created  doubt  as  to  the 
nature  of  the  disease,  which  was  supposed  by  some  to  be  hepa- 
tization of  the  lung.  The  knowledge  of  the  two  preceding  cases, 
however,  and  the  fact  of  the  dislocation  of  the  heart,  made  me 
conclude  that  the  case  was  one  of  empyema,  notwithstanding  the 
singular  circumstance  of  the  side  being  much  contracted.  On 
dissection,  a  vast  quantity  of  pus  was  found  in  the  pleura; 
the  trajet  of  the  ball  formed  a  long  funnel-shaped  cavity,  dis- 
tended by  purulent  matter,  and  inferiorly  communicating  with 
the  pleural  sac  by  a  wide  opening.  The  lung  adhered  along  the 
mediastinum  ;  and  in  the  upper  and  lateral  portions,  its  tissue 
was  much  condensed. 

Thus,  we  have  three  cases  in  which  the  sign  of  bronchial 
respiration  coincided  with  a  bilocular  empyema,  with  consoli- 
dation and  adhesion  of  the  lung ;  but  that  it  may  occur  without 
any  such  physical  conditions,  I  have  no  doubt,  as  I  have 
frequently  found  it  at  a  very  early  period  in  persons  before 
healthy,  and  in  whom  the  inflammation  was  of  an  acute  character.f 

*  Dublin  Hospital  Reports,  vol.  v. 

t  Andral  has  noticed  the  occurrence  of  bronchial  respiration  in  pleurisy,  and 
attributes  it  to  the  condensation  of  the  air  vesicles  by  the  pressure  of  the  fluid  ;  but 
we  have  still  to  learn  why  the  phenomenon  is  not  constant. 


DISEASES    OF    THE    PLEUKA.  505 

p 

In  these  cases  a  speedy  recovery  followed ;  and  it  seems  pro- 
bable that  we  must  consider  bronchial  respiration  as  a  favourable 
sign  in  pleurisy,  as  shewing  that  the  lung  is  not  wholly  con- 
densed, but  admitting  some  passage  of  air  into  the  cells. 

The  bronchial  respiration  of  pleurisy  is  to  be  distinguished 
from  that  of  pneumonia  by  its  concomitant  signs.  The  absence 
of  rale,  and  the  concurring  signs  of  displacement,  are  those  on 
which  we  are  most  to  rely.  Its  disappearance  in  pneumonia  is 
generally  accompanied  by  the  crepitus  of  resolution ;  but  this  is, 
of  course,  absent  in  pleurisy. 

Phenomena  of  Voice. — I  have  little  to  add  to  the  observations 
of  Laennec  on  this  subject ;  but  I  quite  agree  with  Andral,  that 
the  word  egophonia  is  but  a  generic  term,  under  which  must  be 
comprehended  numerous  modifications  of  sound,  in  which  the 
voice  has  a  peculiar  vibratory  character.  In  some,  the  peculiar 
vibration  accompanies  every  word  of  the  sentence ;  in  others, 
only  certain  words  have  the  peculiar  thrill;  while  in  a  third 
class,  it  is  only  heard  as  a  sort  of  echo,  at  the  end  of  particular 
words.  These  phenomena  are  always  best  heard  about  the 
scapular  regions.  I  have  never  heard  them  in  the  lateral  or 
anterior  portions.  They  may  be  heard  in  the  earlier  periods  of 
the  case,  or  persist  throughout  to  the  fatal  termination,  as  in 
the  case  recorded  by  Andral.*  In  many  instances  we  never  find 
them,  and  even  when  present  they  are  extremely  inconstant,  and, 
taken  alone,  have  but  little  value  in  diagnosis.  It  must  always 
be  recollected,  that  between  the  egophonic  sounds  and  those  from 
hepatization,  there  is  often  the  closest  resemblance  ;  indeed, 
in  a  few  cases  of  pneumonia,  in  the  stage  of  resolution,  I  have 
found  an  almost  perfect  egophonia :  these  signs,  too,  are  fre- 
quently absent,  and  may  even  mislead  from  the  circumstance 
that  some  persons  have  a  voice  naturally  egophonic.  In  such 
cases,  before  determining  as  to  the  morbid  sign,  the  sound  of 
the  voice,  heard  without  the  stethoscope,  and  its  characters  over 
the  healthy  portions  of  the  lung,  must  always  be  observed. 

The  pectoriloquism  of  phthisis,  and  the  egophonia  of  pleurisy, 
are  the  least  valuable  of  the  physical  signs  of  these  diseases. 

There  is  another  phenomenon  of  voice,  however,  of  far  greater 
value.     It  is  a  negative  rather  than  a  positive  sign.     We  find, 

*  Clinique  Medicale,  Maladies  de  Poitrine,  torn.  ii.  obs.  xxi. 


")0G  DISEASES    OF    THE    PLEURA. 

where  a  quantity  of  fluid  lias  been  effused  sufficient  to  give  dul- 
ness,  that  when  the  hand  is  placed  over  the  affected  side  while 
the  patient  is  speaking,  no  vibration  is  observed ;  or,  if  it  be 
present,  that  it  is  singularly  diminished.  In  this  way,  by  placing 
a  hand  under  each  scapula,  we  can  detect  a  pleuritic  effusion  by 
the  absence  of  vibration  over  the  dull  portion."  *  It  is  an 
exceedingly  useful  sign,  and  assists  much  in  the  diagnosis  of 
pleural  effusion,  hepatization,  and  enlargement  of  the  liver.  In 
the  second  case,  however,  I  have  found,  although  bronchophony 
existed  over  the  dull  portion,  yet  that  the  vibration  perceived  by 
the  hand  was  less  distinct  than  on  the  healthy  side.  Hepatization 
of  the  lung  seems  in  some  cases  to  diminish,  but  not  remove  this 
vibration. 

In  the  case  of  enlarged  liver,  we  may  have  considerable 
dulness,  the  vibration  continuing;  yet,  in  extreme  cases  of 
enlargement  upwards,  it  is  probable  that  the  sign  would  not 
apply. 

Lastly,  we  find  that  this  test  is  inapplicable  in  many  cases  of 
females,  and  boys,  previous  to  the  change  of  voice.  In  these 
subjects  the  vocal  vibrations,  although  audible,  are  not  sufficiently 
powerful  to  be  felt  by  the  hand. 

Signs  of  Accumulation  of  Fluid  causing  Compression  and 
Excentric  Displacement. 

Dilatation  of  the  Side.— This  sign,  which  is  to  be  ascer- 
tained by  measurement  and  inspection,  may  be  observed  at  a 
very  early  period  of  disease.  Laennec  has  found  it  distinct  after 
two  days'  illness ;  Andral  on  the  fourth  or  fifth  day.  I  have 
never  observed  it  at  so  early  a  period  ;  but  often  within  the  first 
fortnight.  Its  greatest  amount  seems  to  be  within  two  inches. 
It  may  exist  without  protrusion  of  the  intercostal  spaces;  a  fact 
which  I  have  recently  ascertained,  and  which  is  opposed  to  the 

*  This  observation  was  first  made  in  this  country  by  Dr.  Hudson,  and  published  by 
me  in  1833,  in  my  Researches  on  the  Diagnosis  of  Empyema,  Dublin  Medical  Journal, 
vol.  iii.  The  discovery  of  the  sign,  however,  is  due  to  M.  Reynaud,  of  whose 
researches  neither  my  friend  Dr.  Hudson  nor  myself  were  aware  at  the  time  above 
mentioned.  The  observation  in  question,  with  others  of  importance,  will  be  found  in 
M.  Reynaud's  Inaugural  Thesis,  Paris,  1819.  In  most  cases  where  the  lungs  are  free 
from  disease,  the  vibrations  of  the  right  lung  will  be  found  stronger  than  those  of  the 
left,  and  corresponding  with  the  greater  resonance  of  voice.  In  a  few,  however,  the 
vibrations  are  equal ;  and  I  have  observed  some  cases  in  which  there  was  the  greatest 
resonance  on  the  side  where  there  occurred  least  vibration,  as  perceived  by  the  hand. 


DISEASES    OF    THE    PLEURA.  507 

statements  of  Andral,  who  describes  the  dilatation  as  always 
existing  with  this  condition.  I  shall  recur  to  this  point  when  on 
the  differential  diagnosis,  particularly  with  reference  to  the  case  of 
enlarged  liver;  But  dilatation  of  the  side  is  by  no  means  a 
constant  sign,  even  where  copious  effusion  exists.  The  lung 
may  be  compressed,  and  the  heart  displaced,  without  any  notable 
amount  of  dilatation. 

I  have  ascertained  from  a  number  of  observations,  that  the 
right  is  often  larger  than  the  left  side.  The  average  result  of  the 
most  accurate  measurements  of  twenty  chests  of  persons  not 
labouring  under  lung  disease  gave  for  the  right  side  17.86 
inches ;  and  for  the  left  17.23,  or  more  than  half  an  inch  in 
favour  of  the  right  king.  Of  these,  the  most  capacious  chest, 
measured  22  inches  for  the  right,  and  21.50  for  the  left.  In 
one  case  only  was  the  left  side  larger  than  the  right ;  and  in 
three  the  sides  were  symmetrical. 

In  the  case  of  greater  development  of  the  left  side,  the  man 
was  left-handed ;  and  the  left  biceps  measured  half  an  inch  in 
circumference  more  than  the  right. 

This  greater  development  then  of  the  right  side  must  be 
always  borne  in  mind ;  and  we  deduce  two  practical  rules  from 
these  observations  : 

First,  that  the  sign  of  dilatation  is  more  valuable,  as  indicative 
of  empyema;  of  the  left  than  the  right  side. 

Second,  that  in  empyema  of  the  right  side,  we  are  not  to 
place  confidence  in  the  occurrence  of  dilatation  unless  it  is  more 
than  half  an  inch. 

Displacement  op  the  HeaPvT. — This  important  sign  occurs 
from  the  earliest  periods,  and  exists  long  before  any  protrusion  of 
the  intercostals  or  diaphragm.  In  effusions  of  the  left  side,  the 
heart  crossing  the  mesian  line  is  a  phenomenon  so  singular  as 
commonly  to  awaken  the  attention  of  the  patient ;  and  is  one  of 
the  circumstances  which  render  the  discovery  of  empyema  of  the 
left  side  more  easy  than  that  of  the  right,  in  which  the  heart  may 
be  scarcely  altered  from  its  position,  or  if  it  be,  its  movement 
for  an  inch  or  so  more  to  the  left  often  escapes  observation. 

There  is  nothinsr  more  interesting  than  to  follow  the  dis- 
placement  of  the  heart  in  effusions  of  the  left  pleura :  we 
observe,  first,  that  the  apex  strikes  in  a  situation  about  mid- 
way between    its    natural    position    and    the    upper    portion    of 


508  DISEASES    OF    THE    PLEURA. 

the   xiphoid   cartilage.      As  the  distention   goes  on,  the   heart 

buries  itself  under  the  sternum,  and  its  impulses  for  a  time  are 

greatly   diminished,    and   have   wholly  disappeared   from  their 

natural  position ;  presently  the  heart  reappears  from  the  right 

side  of  the  sternum,  and  then  pulsates  between  the  fifth  and 

seventh  ribs,  at  about  an  inch  from  the  sterno-costal  articulations ; 

the  pulsations  are  often  visible,  and  the  patient  conscious  that  the 

heart  is  displaced.     The  hand,  applied  under  the  left  mamma, 

perceives  no  impulse  whatever,  but   the    sounds    are    generally 

feebly  audible,  increasing  in  loudness  as  we  carry  the  stethoscope 

upwards  and   across  the  chest,  till  we  arrive  at  the  situation  of 

the  heart,  where  they  are  at  their  maximum. 

The  experience  of  upwards  of  twenty  cases  has  convinced  me, 
that  this  dislocation  of  the  heart,  even  when  at  its  greatest  degree, 
does  not  cause  any  alteration  in  the  natural  sounds  of  the 
organ  ;*  indeed,  it  is  singular  how  little  its  action  is  excited  in 
many  of  these  cases.  In  two  instances  I  have  observed  the  dry 
pericarditis  to  supervene  in  the  last  stages  of  empyema.  The 
friction  signs  were  evident,  but  the  action  of  the  heart  was  scarcely 
excited. 

Displacement  of  the  heart  to  the  right  side  by  no  means  implies 
complete  obliteration  of  the  left  lung,  on  the  contrary,  the 
upper  lobe  may  present  distinct  vesicular  murmur,  while  the 
heart  pulsates  to  the  right  of  the  sternum.  I  have  also  observed 
extensive  bronchial  respiration  in  these  cases. 

It  appears  to  me  that  Laennec,  and  most  subsequent  writers 
on  auscultation,  have  paid  too  little  attention  to  this  sign,  which, 
from  its  frequency  of  occurrence,  and  facility  of  recognition,  forms 
the  most  important  of  the  signs  of  excentric  displacement. f 

*  That  they  are  sometimes  changed  is  proved  by  the  observations  of  Drs.  Hope  and 
Walshe.  The  former  states,  that  in  a  case  of  effusion  into  the  left  pleura  the  aorta 
was  felt  to  pulsate  between  the  second  and  third  ribs  on  the  right  sida  an  inch  from 
the  sternum,  and  here  a  murmur  was  heard  with  the  first  sound,  which  disappeared 
with  the  restoration  of  the  heart  to  its  natural  situation  by  the  absorption  of  the  fluid. 
"  In  a  most  interesting  case,"  says  Dr.  Walshe,  "  for  many  successive  days  during  the 
height  of  left  pleural  effusion,  both  sounds  of  the  heart  (pushed  to  the  right  of  the 
sternum)  were  more  or  less  masked  by  blowing  murmurs.  These  murmurs  when  the 
heart  was  restored,  or  very  nearly  restored,  to  its  natural  position,  almost  completely 
disappeared."     (See  Dr.  Walshe  on  Diseases  of  the  Lungs,  p.  259,  4th  ed.)     (Ed.) 

f  It  is  not  alluded  to  by  Laennec  in  his  account  of  the  signs  of  pleurisy;  he 
mentions  it  incidentally  under  displacement  of  the  heart :  Andral  has  observed  a 
single  case  of  it.  Dr.  Townsend,  in  the  Cyclopaedia  of  Practical  Medicine,  in  his 
articles  on  Empyema  and  Displacement  of  the  Heart,  dwells  strongly  on  its  im- 
portance. 


DISEASES    OF    THE    PLEUKA.  509 

I  have  observed  that  during  recovery  the  heart  returns  to  its 
natural  situation  with  great  rapidity,  and  long  before  the 
posterior  and  lateral  portions  of  the  side  have  become  clear  on 
percussion. 

To  Dr.  Townsend  is  due  the  merit  of  first  observing  that,  in 
copious  effusions  of  the  right  pleura,  the  heart  may  be  pushed 
towards  the  left  axilla.  In  a  case  of  pleuro-pneumothorax  of 
the  right  side,  he  saw  and  felt  the  heart  pulsating  between  the 
fourth  and  fifth  ribs,  near  the  left  axilla,  from  which  it  gradually 
returned  to  its  natural  position  as  the  pressure  was  removed  by 
drawing  off  the  fluid  from  the  opposite  side.* 

"When  describing  the  phenomena  of  absorption,  I  shall  notice 
the  interesting  fact,  which  I  have  lately  observed,  of  displacement 
of  the  heart  to  the  right  side,  in  consequence  of  the  absorption  of 
an  effusion  into  the  right  pleura. 

From  our  knowledge  of  displacements  of  the  heart,  we  might 
anticipate  that  the  mediastinal  protrusion  could  be  ascertained 
by  percussion,  and  thus  a  diagnosis  be  drawn  between  the 
accumulation  of  fluid  and  solidification,  without  change  of 
volume  :  this  is  what  really  occurs ;  and  the  dulness  in  the  first 
affection  extends  beyond  the  mesian  line,  and  this  even  in  the 
upper  sternal  region.  As  in  the  dilatation  of  the  air  cells  we 
may  have  morbid  clearness  beyond  the  mesian  line,  so  in 
empyema,  the  mediastinum  being  displaced  by  liquid,  dulness 
extends  as  far  as  the  mediastinal  displacement. 

Displacement  of  the  Intekcostals. — After  a  certain  period, 
shorter  in  proportion  to  the  violence  of  the  disease,  we  find  the 
intercostal  spaces  becoming  obliterated  ;  the  side  becomes  smooth, 
and  this,  when  the  patient  is  emaciated,  contrasts  remarkably 
with  the  appearance  of  the  opposite  ribs.  I  have  never  found  the 
intercostal  spaces  to  rise  beyond  the  ribs,  as  described  by  some 
authors,  unless  when  an  empyema  opened  externally. 

This  smoothness  of  the  side  seems  peculiar  to  pleurisy  in  its 
advanced  stages  ;  it  is  not  met  with  in  the  earlier  periods  of  the 
disease :  and  an  effusion  sufficient  to  dilate  the  side  and  dis- 
place the  heart,  may  exist  for  iveeks  without  producing  it.  It  is 
not  met  with  in  Laennec's  emphysema,  in  pneumonia,  simple 
hydrothorax,  or  enlargement  of  the  liver,  and  hence  becomes 
one  of  the  most  valuable  of  the  physical  signs  of  advanced  pleurisy. 
*  Cyclopseiia  of  Practical  Medicine,  Art.  Displacement  of  the  Heart. 


510  DISEASES    OF    THE    PLEURA. 

It  must  always,  however,  be  borne  in  mind,  that  it  is  not 
invariably  present  in  cases  with  even  a  copious  effusion. 

On  the  absorption  of  the  fluid,  the  intercostal  depressions 
again  appear  ;  but  for  a  length  of  time  the  action  of  the  muscles 
continues  feeble.  I  have  often  thought  that  at  this  period  we 
might,  by  electricity,  more  rapidly  remove  the  paralysis  produced 
by  inflammation. 

This  phenomenon  of  muscular  displacement  in  empyema  ap- 
pears to  me  to  be  inexplicable  by  the  formerly  received  doctrine 
of  simple  pressure  from  within ;  but  a  loss  of  tone,  a  paralysis  of 
the  fibres  seems  to  be  necessary  before  they  can  yield  to  the 
pressure.  In  evidence  of  this  theory,  let  us  reflect  on  the 
general  effect  of  irritation  on  muscular  fibre.  When  a  tissue 
such  as  a  mucous  or  serous  membrane  is  inflamed,  we  find  that 
certain  effects  are  produced  on  the  muscular  expansions  or 
masses  with  which  it  is  closely  connected ;  their  functions 
suffer,  and  we  observe,  first,  an  increase  of  innervation  as  shewn 
by  pain  and  spasms  ;  and  next  a  paralysis  more  or  less  complete. 
The  same  circumstances  occur  when  the  inflammation  is  seated 
in  the  muscular  structure  themselves,  or  in  the  cerebro-spinal 
centre  from  which  they  derive  their  innervation.  In  all  these 
cases,  whether  of  contiguous  inflammation,  of  actual  disease  of 
the  muscular  fibre  itself,  or  of  inflammation  of  the  brain  or 
spinal  marrow,  we  have  produced  first  a  plus,  and  afterwards  a 
minus  state  of  innervation.  When  the  latter  condition  super- 
venes, the  muscular  fibres  lose  their  contractility  :  and  if  the 
organ  be  a  tube  surrounded  by  fibres,  it  dilates ;  or  if  an 
expansion  similar  to  the  intercostals,  or  diaphragm,  it  yields 
easily  to  pressure. 

Now  in  the  case  before  us  we  may  observe,  that  the  phenomena 
are  in  accordance  with  this  admitted  effect.  In  the  first  stage 
of  pleuritis  we  have  great  pain-;  difficulty  of  respiration  ;  hurried 
breathing ;  pain  increased  on  a  deep  inspiration ;  and  all  this 
without  protrusion  of  the  intercostal  spaces  or  diaphragm,  but 
rather  with  a  spasmodic  state  of  these  expansions  ;  conditions 
which  accurately  correspond  to  the  plus  state  of  innervation 
observable  in  the  first  stage  of  muscular  irritation. 

But  in  the  more  advanced  periods,  the  reverse  of  all  this 
occurs.  The  pain  ceases,  the  dyspnoea  greatly  diminishes,  the 
breathing  becomes  slower,  the  diseased  side    is    comparatively 


DISEASES   OF    THE    PLEURA.  511 

motionless,  while  the  healthy  one  is  acting  with  great  power, 
and  the  intercostal  spaces  and  diaphragm  yield ;  the  first 
causing  the  characteristic  smoothness  of  the  side,  and  the  next, 
the  depression  of  the  abdominal  viscera.  I  need  hardly  remark 
that  these  circumstances  correspond  with  the  minus  condition  of 
innervation,  or  paralysis  of  the  muscular  fibres. 

The  next  and  most  important  evidence  is  the  fact,  that  mere 
pressure  seems  insufficient  for  the  phenomenon  in  question.  If 
the  theory  which  I  have  given  be  true,  it  should  follow,  that  in 
other  diseases  of  accumulation,  where  inflammation  of  the  pleura 
was  not  present,  but  where  there  was  merely  pressure,  this 
muscular  protrusion  should  either  not  occur,  or  be  much  less 
marked.  Now  such  may  be  observed  to  be  the  fact.  Let  us 
take  Laennec's  emphysema,  hydrothorax,  and  enlargement  of 
the  liver  as  examples  ;  in  all  of  which  there  is  pressure  from 
within.  Thus,  in  Laennec's  emphysema,  we  have  studied  the 
great  enlargement  of  the  chest,  and  the  displacement  of  the 
mediastinum  and  heart,  and  have  seen  that  even  when  the 
diaphragm  is  flattened  (as  occurs  in  a  certain  class  of  cases), 
its  innervation  is  not  destroyed.  In  hepatic  enlargement  we  may 
see,  also,  evidences  of  pressure  from  the  great  tilting  out  of  the 
side,  and  the  state  of  the  lung ;  while  in  hydrothorax,  the 
pressure  is  demonstrated  by  the  diminished  volume  of  the  lung, 
which,  though  a  muscular  organ,  cannot  avail  itself  of  its  powers 
in  resisting  pressure  from  without. 

But  notwithstanding  this  pressure  it  will  be  found  that  in  all 
cases  of  emphysema,  and  enlargement  of  the  liver,  and  in  many, 
at  least,  of  hydrothorax  the  intercostal  spaces  do  not  yield  ;  a 
fact  which  may  be  constantly  verified.  I  have  observed  cases  of 
symptomatic  hydrothorax,  in  which  although  the  effusion 
amounted  to  several  pints,  and  the  corresponding  lung  was 
reduced  in  volume,  neither  the  intercostals,  nor  diaphragm  wero 
affected.  The  same  occurs  in  the  earlier  stages  of  pleuritis,  and 
the  sub-acute  effusions.  In  all  these  cases  we  may  have  great 
displacement  of  the  side  or  thoracic  viscera  ;  yet  there  is  merely 
pressure,  and  though  the  ribs  are  dilated,  the  intercostal  spaces 
preserve  their  relative  positions. 

The  last  point  of  evidence  is  the  fact  that  in  some  cases  of 
empyema  there  occurs  a  sudden  yielding  of  the  diaphragm, 
which  up  to  a  certain  period  had  preserved  its  natural  position. 


512  DISEASES    OF    THE    PLEUEA. 

This  yielding  may  be  as  extensive  as  sudden,  and  is  not  neces- 
sarily accompanied  by  increase  of  effusion.  How  much  more 
easily  can  we  explain  this  interesting  fact  on  the  supposition 
adopted  than  on  that  of  gradual  pressure  on  a  vitally  resisting 
medium. 

From  these  observations  we  may  safely  conclude  that  in 
empyema  the  protrusion  of  the  intercostal  spaces,  and  diaphragm, 
result  from  a  paralysed  condition  of  these  expansions,  and  that 
pressure  is  secondary  to  inflammatory  action  causing  paralysis, 
in  inducing  the  yielding  of  the  muscles. 

But  these  phenomena  are  by  no  means  so  marked  in  the  dilata- 
tion of  the  air  cells,  in  which  the  disease  may  exist  to  a  great 
amount,  and  the  chest  be  extremely  dilated,  without  any  one  of 
the  appearances  above  mentioned.  The  intercostal  spaces  con- 
tinue in  all  cases  well  and  deeply  marked ;  and  in  one  class  of 
cases  the  diaphragm  remains  unaffected,  even  though  the 
pressure  be  so  great  as  to  change  the  form  of  the  chest.*  And 
we  may  arrive  at  the  explanation,  why  this  remarkable  difference 
exists  ;  by  considering,  that  in  empyema  there  is  a  combination 
of  vital  and  mechanical  causes  ;  inasmuch  as  we  have  inflamma- 
tion followed  by  pressure,  and  pressure  from  a  liquid  ;  while  in 
the  dilatation  of  the  cells  we  have  only  pressure,  and  this  from 
an  elastic  fluid. 

On  the  absorption  of  the  fluid,  the  intercostal  depressions 
again  appear ;  but  for  a  length  of  time  the  action  of  the  muscles 
continues  feeble. 


DISPLACEMENTS    OF    THE    DIAPHRAGM. 

The  protrusion  of  this  muscle  follows  the  same  course  and  is 
influenced  by  the  same  laws,  as  that  of  the  intercostals.  "VVe 
recognize  it  by  examining  the  upper  portion  of  the  abdomen, 
which  is  often  found  full  and  resisting.  If  the  empyema  be  of 
the  right  side,  the  liver  is  pushed  downwards,  forwards,  and 
across  the  abdomen ;  if  of  the  left,  the  spleen  is  displaced.  Of 
the  first  I  have  seen  many  examples ;  but  of  the  second  I  have 
no  experience.     This  observation  I  first  made  in  1822. f 

*  See  "Walshe's  remarks  on  this  question,  p.  32G,  4th  edition. 

f  For  full  particulars  of  these  observation?,  I  beg  to  refer  to  my  papera  on  the 


DISEASES    OF    THE    PLEURA.  513 

When  the  liver  is  displaced  we  find  a  tumour  in  the  right 
hypochondriurn,  answering  to  the  volume  of  the  liver,  and  often 
accompanied  by  a  distinct  sulcus  immediately  below  the  ribs, 
and  above  the  upper  boundary  of  the  tumour.  This  results 
from  the  space  left  by  the  touching  of  the  two  convex  bodies, 
namely,  the  upper  portion  of  the  liver  and  the  protruded 
diaphragm.  On  the  absorption  of  the  fluid  the  liver  ascends 
and  the  sulcus  disappears. 

But  the  disappearance  of  this  sulcus  does  not  necessarily 
imply  the  ascent  of  the  liver  to  its  natural  position,  for  the 
organ  may  yield  to  the  pressure  of  the  diaphragm,  and  become 
deeply  concave  on  its  upper  surface.  This  interesting  circum- 
stance occurred  in  a  case  where  the  liver  was  softened  and 
engorged;  so  that  the  rule  is  that  the  disappearance  of  the 
sulcus  is  only  favourable  when  accompanied  by  the  ascent  of 
the  hepatic  tumour. 

PHENOMENA   OF   ABSORPTION. 

When  the  effusion  has  caused  dulness  so  high  as  the  scapular 
ridge,  or  clavicle,  its  removal  is  first  pointed  out  by  alterations 
in  the  respiration  which  may  occur  while  the  sound  continues 
dull.  If  perspiration  has  been  absent,  a  feeble  but  increasing 
murmur  in  the  upper  portions  of  the  side  both  anteriorly  and 
posteriorly ;  this  gradually  spreads  downwards  and  may  become 
universally,  though  feebly  audible,  even  though  the  side  con- 
tinues extensively  dull ;  should  bronchial  respiration  have 
existed,  the  character  of  the  sound  is  first  lost  in  the  portions 
of  the  lung  furthest  removed  from  the  root ;  here  it  passes  into 
the  vesicular  murmur,  and  every  day  its  situation  becomes  more 
and  more  circumscribed,  by  the  advance  of  vesicular  murmur 
towards  the  centre. 

In  recent  and  sub-acute  cases,  clearness  on  percussion 
generally  coincides   with    the   return    of  respiration ;    in    such 

Diagnosis  of  Empyema  and  Pericarditis,  Dublin  Journal  of  Medical  Science,  vols.  iii. 
and  iv. 

(Dr.  Walshe  justly  observes  that  "No  matter  how  copious  the  effusion,  whether 
acute  or  chronic,  nor  how  complete  the  evidences  of  centrifugal  or  dilating  pressure, 
signs  of  centripetal  pressure  are,  as  a  rule,  absolutely  wanting — the  trachea,  oesophagus, 
and  larger  veins  escape  serious  encroachment.  Hence  the  detection  of  the  latter  class 
of  signs  in  a  case  of  pleuritic  effusion  may  be  accepted  as  proof  of  some  additional 
disease,  such  as  tumour  or  aneurism  within  the  chest."— Loc.  cit.)  (Ed.) 

L  L 


514  DISEASES    OF    THE    PLEURA. 

cases  the  friction  sounds  are  generally  audible,  and  the  vibra- 
tions can  be  perceived  over  an  extensive  surface.  The  more 
rapid  the  absorption,  the  greater  the  probability  of  these 
phenomena  existing.  In  some  cases,  however,  where  the 
effusion  seemed  to  be  principally  serous,  I  have  observed  its 
rapid  absorption  without  consequent  friction  signs.* 

When  an  effusion  into  the  left  pleura,  sufficiently  copious 
to  displace  the  heart  to  the  right  of  the  sternum  begins  to  be 
absorbed,  the  organ  retraces  its  steps,  and  returns,  often  with 
rapidity,  to  its  normal  situation.  I  have  seen  this  to  occur  within 
four  days.  The  dulness  of  the  sternum  subsides  and  we  have 
no  longer  the  signs  of  mediastinal  displacement.  But  this 
return  of  the  heart  by  no  means  implies  the  complete  removal 
of  the  effusion,  for  it  will  be  commonly  observed,  wbile  dulness 
continues  up  to  the  third  rib. 

In  cases  of  complete  absorption,  we  may  observe  variations 
with  respect  to  the  position  of  the  heart.  In  some  its  apex 
strikes  in  the  original  situation,  while  in  others  the  organ 
remains  manifestly  closer  to  the  sternum ;  and  further,  I  have 
ascertained,  that  the  absorption  of  effusions  into  the  right  pleura 
may  so  modify  tbe  position  of  the  heart,  as  to  cause  its  extensive 
displacement,  and  thus  produce  the  singular  phenomenon  of  the 
displacement  of  the  heart  to  the  right  side,  consequent  on  the 
removal  of  an  effusion  of  the  right  side.  Of  this,  the  following 
case  is  a  most  interesting  illustration. 

A  man,  aged  40,  was  admitted  into  the  Meath  Hospital  in 
December,  1835,  labouring  under  pleuro-pneumony  of  the  right 
lung  of  five  days  standing.  On  the  seventh  day  the  signs  were 
those  of  a  copious  effusion  into  the  pleura,  he  complained  prin- 
cipally of  pain  in  the  shoulder ;  a  puffy  swelling  occupied  the 
right  sterno-clavicular  articulation,  the  clavicle  was  dislocated 
forwards,  and  for  several  days  its  sternal  extremity  could  be 
moved  upwards  and  downwards.     On  the  eighth  and  ninth  days 

*  Dr.  Graves  long  ago  directed  my  attention  to  a  peculiar  rustling  crepitation  heard 
over  the  site  of  a  lung  expanding  after  temporary  compression  by  fluid  in  the  pleura. 
I  have  since  frequently  heard,  and  pointed  out  to  others,  this  peculiar  phenomenon,  but 
only  in  cases  of  temporary  compression  by,  and  rapid  absorption  of,  the  effused  fluid. 
It  is  very  fugacious,  seldom  to  be  observed  after  the  second  day,  disappearing  from 
above  downwards  as  the  air  cells  expand,  to  be  replaced  by  pure  vesicular  respiration. 

Dr.  Walshe  says  that  in  absorption  without  retraction,  friction-sound,  mixed  or  not 
with  pleura]  pseudo-rhonchus,  or  pulmonary  pseudo-crepitation,  reappears  for  a  variable 
period.  (Ed.) 


DISEASES   OF   THE    PLEUEA.  615 

a  distinct  crepitus  existed  over  the  postero-superior  portion  of 
the  side.  The  patient  had  become  affected  with  mercury,  his 
fever  had  subsided,  and  on  the  thirteenth  day  of  his  illness  the 
following  observations  were  made.  The  left  side  was  everywhere 
clear,  even  over  the  left  mammary  region,  where  no  pulsation 
•could  be  felt. 

The  right  mammary,  lateral  and  postero-inferior  portions  of 
the  right  side  sounded  completely  dull,  respiration  being  absent, 
the  upper  portions  were  tolerably  clear  and  with  a  feeble  murmur 
mixed  with  rale  in  the  sub-clavicular,  axillary,  and  supra- 
scapular regions.  The  sounds  of  the  heart  were  distinctly 
perceptible  in  the  right  mammary  region.  On  the  eighteenth 
day  the  heart  could  be  seen  and  felt  pulsating  to  the  right  of  the 
sternum,  in  the  fourth  and  fifth  intercostal  spaces ;  here  the 
sound  was  completely  dull,  and  without  any  rale  or  vesicular 
murmur;  the  left  mammary  region  was  perfectly  clear  on  per- 
cussion, and  the  heart's  impulses  were  here  quite  imperceptible. 
In  the  course  of  the  next  week  the  respiration  had  returned  to 
the  upper  middle  and  lateral  portions  of  the  right  side ;  and 
although  the  heart's  action  was  less  excited,  its  situation 
obviously  remained  unchanged.  Up  to  the  period  of  death,  no 
bruit  de  soufflct  or  morbid  sound  accompanied  its  actions  ;  the 
right  side  recovered  its  sonoriety,  with  the  exception  of  the 
mammary  region,  which  over  a  space  exactly  corresponding  to 
the  size  of  the  heart,  remained  perfectly  and  permanently  dull. 

The  patient  became  affected  with  mercurial  eczema,  after 
which  he  fell  into  a  cachectic  state,  with  frequent  diarrhoea  ; 
under  careful  tonic  treatment  he  at  last  seemed  to  improve,  when 
the  head  became  suddenly  engaged,  and  he  died  in  two  days, 
with  all  the  symptoms  of  violent  arachnitis.  From  the  invasion 
of  the  first  disease  to  his  death,  about  eight  weeks  intervened. 

Not  having  seen  this  patient  during  the  first  periods  of  his 
illness,  I  experienced  some  difficulty  in  determining  the  nature 
of  the  displacement  of  the  heart.  Physical  signs  shewed  that  it 
was  not  owing  to  any  accumulative  disease  of  the  left  lung  or 
pleura.  Here  there  was  no  emphysema,  no  tumour,  pneumo- 
thorax or  liquid  effusion.  The  question  naturally  arose,  was  it  a 
case  of  congenital  displacement,  in  which  the  heart  had  remained 
■at  the  right  of  the  sternum,  unknown  to  the  patient,  and  only 
made  evident  by  the  excitement  of  disease  ?     This  question  was 

l  l2 


516  DISEASES    OP    THE    PLEURA. 

settled  by  reference  to  a  principle  never  before  employed  in  such 
a  case.  In  every  recorded  instance  of  congenital  displacement 
there  has  been  a  universal  transposition  of  viscera,  the  stomach 
occupies  the  right,  the  liver  the  left  hypochondrium.  The  case 
was  investigated  with  this  view  and  no  evidence  of  any  hepatic 
tumour  in  the  left  side  could  be  detected ;  and  although  it  was 
somewhat  difficult  to  ascertain  the  presence  of  the  liver  in  its 
natural  situation,  yet  I  was  satisfied  that  it  was  not  transposed. 

We  could  only  then  conclude,  that  in  consequence  of  the  rapid 
removal  of  the  effusion  (no  time  being  allowed  for  contraction  of 
the  chest,  while  the  lung,  probably  from  its  inflamed  state,  or 
being  bound  by  adhesions  could  not  again  fill  the  cavity  of  the 
chest),  the  heart  had  been  drawn  across  the  mesian  line,  and  the 
left  lung  enlarged,  so  as  to  assist  in  occupying  the  vacant  space. 
This  diagnosis  proved  to  be  correct ;  the  right  lung  was  found 
permeable  but  reduced  to  less  than  a  third  of  its  natural  volume. 
The  pleural  cavity  was  obliterated,  and  a  large  quantity  of 
coagulated  lymph  occupied  the  lower  and  posterior  portions  of 
the  side.  In  this  effusion  a  purulent  collection  of  about  an 
ounce,  apparently  the  last  remains  of  the  empyema,  existed. 
The  heart  lay  to  the  right  of  the  sternum  in  a  transverse  direc- 
tion, and  its  base  corresponded  to  the  fourth  and  fifth  ribs ;  it 
was  perfectly  healthy ;  the  left  lung  was  much  enlarged,  and 
stretched  far  across  the  mesian  line ;  no  lesion  of  its  structure 
could  be  detected. 

Thus  while  empyema  of  the  left  side  forces  the  heart  to  the 
right  of  the  mesian  line,  the  rapid  absorption  of  an  empyema  of 
the  right  side  draws  it  in  the  same  direction.  This  circumstance 
is  obviously  favoured  by  the  rapidity  of  the  absorption,  when 
there  is  not  time  for  the  side  to  contract.  It  will  be  probably 
found  to  occur  more  or  less  in  many  cases  but  particularly  in 
those  of  a  combination  of  an  acute  or  chronic  disease  of  the  lung, 
with  a  pleuritis,  the  effusion  being  rapidly  absorbed. 

Dexiocardia,  then,  when  not  congenital,  may  be  of  three 
kinds. 

I.  Where  the  heart  is  pressed  across  the  mesian  line,  but  not 
permanently  fixed  in  its  new  situation.  It  returns  to  its  original 
situation,  or  nearly  so,  on  the  absorption  of  the  fluid. 

II.  Where  the  heart  remains  permanently  fixed  at  the  right 
side,  notwithstanding  the  removal  of  the  fluid. 


DISEASES    OF   THE    PLEUEA.  517 

III.  Where  the  dexiocardia  is  induced  not  by  pressure  from 
accumulation  in  the  left  pleura,  but  from  the  diminished  volume 
of  the  right  lung,  induced  by  an  effusion  into  the  corresponding 
pleura. 

With  relation  to  the  modified  position  of  the  heart  after  the 
cure  of  empyema,  I  have  made  the  following  interesting  observa- 
tion. A  gentleman,  aged  20,  recovered  from  acute  empyema 
of  the  left  side.  The  heart  had  been  pushed  far  to  the  right, 
but  returned  to  its  former  position  early  in  the  progress  of  cure. 
It  is  now  three  months  since  he  recovered,  with  a  clear  sounding 
chest.  From  this  time  he  observed,  that  whenever  he  turned  on 
the  right  side,  the  heart  seemed  to  fall  over,  and  pulsate  at  the 
right  of  the  sternum.  This  curious  phenomenon  still  continues. 
In  the  erect  position,  the  heart  occupied  a  situation  midway 
between  the  usual  position  and  the  sternum  ;  but  when  he  turns 
on  the  right  side  immediately  the  pulsations  can  be  felt  to  the 
right  of  the  sternum,  whilst  they  cease  at  the  left  side.  The 
sound  on  percussion,  too,  varies  with  the  position  of  the  heart. 
In  this  case,  there  can  be  no  doubt  that  the  mediastinum 
stretched  by  the  empyema,  has  not  recovered  its  tone,  and 
permits  by  its  extension,  this  extraordinary  change  of  the  situa- 
tion of  the  heart. 

In  connexion  with  this  subject  the  following  case  is  inter- 
esting :  — A  young  man  was  treated  for  typhus  fever  in  the 
Meath  Hospital.  He  was  maculated,  but  presented  nothing 
unusual  in  his  symptoms.  The  second  sound  of  the  heart  pre- 
dominated, and  the  impulse  was  feeble.  On  the  tenth  day  of  his 
fever,  it  was  found  that  the  left  pulse  was  much  stronger  than 
the  right.  The  case  went  through  the  usual  course  of  typhoid 
affection  of  the  heart,  and  on  the  fifteenth  day,  the  cardiac 
sounds  had  nearly  returned  to  their  natural  state.  He  was 
convalescent  on  the  sixteenth  day.  Three  days  after  this  period, 
it  was  found  that  when  the  patient  lay  on  the  right  side,  the 
impulse  of  the  heart  could  be  heard  and  felt  to  the  right  of  the 
sternum  at  a  point  situated  one  inch  to  the  left  of  the  right 
nipple.  No  impulse  could  be  perceived  in  the  cardiac  region, 
and  the  sounds  were  much  louder  at  the  right  than  the  left  side 
of  the  sternum.  When  he  turned  to  the  left  side  the  heart  could 
be  seen  and  felt  in  its  ordinary  situation — the  impulse  entirely 
disappeared  from  the  right  side,  and  the  sounds  became  feeble 


518  DISEASES    OF    THE    PLEUEA. 

in  that  situation.     These  phenomena  continued  up  to  the  time- 
when  the  patient  left  hospital. 

Was  this  a  case  of  relaxed  mediastinum  ?  There  was  no 
evidence  of  any  former  attack  of  pleurisy  ;  but  the  patient's- 
chest  was  generally  narrow,  and  it  may  be  that  the  case  only 
exemplifies  in  a  remarkable  degree,  the  greater  distinctness  of 
the  heart's  impulse  when  a  patient,  labouring  under  typhoid 
softening,  turns  to  the  left  side.  It  may  be  that  in  such  a  case, 
the  pressure  of  the  ribs  against  the  heart,  by  bringing  them  into 
closer  opposition  to  the  heart,  enables  us  to  feel  an  impulse 
otherwise  indistinct,  and  in  a  man  with  a  very  narrow  chest  we 
might  suppose  the  same  to  occur  when  the  right  ribs  were 
compressed.  But  this  would  not  explain  the  want  of  impulse  at 
the  left  side  when  the  patient  lay  on  his  right. 

CONTK ACTION    OF    THE    SIDE. 

This  condition,  first  properly  investigated  by  Laennec,  is  met 
with  in  those  cases,  where  after  the  inflammatory  action  has 
ceased,  and  absorption  is  going  on  the  lung  does  not  re-expand 
so  as  to  regain  its  original  volume.  The  causes  of  this  deficient 
expansion  of  the  lungs  are  various.  Some  having  reference  to 
the  condition  of  the  lung  itself;  others  to  that  of  the  parietes  of 
the  chest.  Laennec  has  considered  the  question  solely  in  con- 
nexion with  the  state  of  the  lung.  Yet  though  this  is  obviously 
a  most  important  element,  in  the  explanation  of  the  result  in 
question,  it  must  be  taken  only,  as  one  of  the  conditions  which 
produce  contraction  of  the  side. 

I  have  known  many  cases  of  pleurisy  to  recover,  without  con- 
traction of  the  side,  or  depression  of  the  shoulder  :  these  were 
cases  of  sub-acute  inflammation,  or  where  the  effusion  had  been 
rapidly  removed.  In  other  instances,  the  contraction  has  been 
confined  solely  to  the  lower  portion  of  the  chest,  while  the 
shoulder  was  not  depressed  :  and  in  several,  where  the  disease 
occurred  in  young  persons,  the  deformity  was  either  removed  in 
process  of  time,  or  so  much  diminished,  as  to  be  scarcely 
perceptible. 

The  return  of  a  dilated  side  to  its  natural  circumference  is- 
sometimes  exceedingly  rapid.  I  have  known  a  dilated  side  to 
lose  as  much  as  an  inch  and  a  half  in  eight  days.     In  some,  the 


DISEASES   OF   THE    PLEURA.  519 

contraction  is  shewn  merely  by  the  flattening  of  the  anterior 
portion,  causing  visible  deformity,  yet  with  but  little  alteration 
of  size.  In  others,  the  affected  side  becomes  of  a  triangular 
form,  the  base  of  the  triangle  corresponding  to  the  mesian  line, 
and  the  apex  to  the  centre  of  the  ribs.  Even  this  condition, 
when  occurring  in  the  young  person,  may  be  much  improved  by 
time. 

But  contraction  of  the  chest,  in  connexion  with  empyema, 
may  occur  under  circumstances  very  different  from  those  described 
'by  Laennec  and  subsequent  authors.  It  may  coincide  with  an 
increasing  empyema,  and  occur  at  a  very  early  period  of  the  case. 
This  interesting  circumstance  I  have  known  to  occur  in  two 
cases.  In  both,  pleuritis  with  effusion  followed  on  injury,  and 
long  after  effusion  there  was  exquisite  pain  whenever  the  patient 
attempted  to  expand  the  side.  In  one  case  the  patient,  up 
to  the  period  of  death,  kept  himself  strongly  bent  on  the 
affected  side  ;  so  that  the  case  presented  the  singular  com- 
bination of  a  vast  empyema,  with  extreme  contraction  of  the 
affected  side. 

Before  going  further,  it  may  be  laid  down  that  the  liability  to 
contraction,  is  directly  as  the  violence  of  the  inflammation,  and 
the  length  of  time  that  the  disease  remains  uninfluenced  by 
treatment,  or  the  curative  efforts  of  nature.  Hence  it  is,  that  we 
find  the  greatest  liability  to  contraction  is  met  with  in  the  cases 
which  have  been  overlooked  or  treated  improperly.  The  occur- 
rence of  the  condition  then  is  in  many  cases  a  proof  of  some 
error  in  commission,  or  omission,  on  the  part  of  the  attendant. 
That  this  is  in  most  cases  true,  I  believe,  but  there  is  a  case  in 
which  apparently  from  the  very  violence  of  the  inflammation 
contraction  results,  although  no  fault  has  been  committed. 
These  cases  we  shall  presently  examine. 

There  are,  at  least,  three  conditions  of  the  lung  itself  which 
tend  to  the  result  of  contraction  of  the  chest. 

I.  Its  being  bound  down  by  organized  adhesions,  or  by  great 
masses  of  coagulable  lymph. 

II.  Its   atrophy,  or  real  loss  of  substance,   caused  by  long- 
continued  pressure  and  disease. 

III.  The  occurrence  of  a  fistula,  as  where  an  empyema  opens 
through  the  pulmonary  pleura. 

That  the  existence  of  the  two  first  conditions  should  act  in 


520  DISEASES    OF   THE    PLEURA. 

preventing  the  lung  assuming  its  former  bulk  is  sufficiently 
obvious,  and  we  derive  from  this  additional  proofs  of  the 
importance  of  early  treatment  in  the  case  of  pleurisy  with 
effusion ;  and  of  perseverance  in  the  effort  to  remove  the  effusion 
after  the  constitutional  symptoms  have  subsided. 

The  operation  of  the  third  cause  is  merely  mechanical,  so  long 
as  the  fistula  remains  open,  the  respiratory  efforts  cannot  act  in 
re-expanding  the  lung.  The  fluid  escapes  through  the  lung,  the 
side  falls  in  unless  permanent  empyema  and  pneumothorax 
be  established  (which  is  one  of  the  rarest  of  cases  under  the 
circumstances),  and  it  is  not  until  the  fistula  is  closed  that  any 
re-expansion  of  the  lung  can  take  place ;  but  as  this  generally 
takes  place  only  in  the  advanced  periods  of  the  case,  and  as  the 
contracting  process  has  been  going  on,  during  all  the  period 
previous  to  the  closure  of  the  fistula,  I  believe  that  these  are  the 
cases  in  which  we  shall  find  the  greatest  amount  of  permanent 
deformity  of  the  chest. 

I  have  said  "permanent  deformity,"  for  there  are  cases  of 
deformity  resulting  from  the  cure  of  pleurisy  in  which  the  con- 
traction either  wholly,  or  nearly  altogether  disappears. 

In  the  second  class  of  causes — which  are  independent  of  the 
mere  condition  of  the  lung — the  most  important  appears  to  be  the 
paralysed  condition  of  the  intercostals  and  the  diaphragm,  and 
thus,  the  same  inflammation,  which  tends  to  bind  down  the  lung 
and  produce  its  atrophy,  acts  also  in  destroying  the  only  influence 
by  which  it  can  be  restored  to  its  natural  size.  I  suggested  this 
explanation  in  my  former  memoir  on  empyema ;  a  more  full  con- 
sideration has  convinced  me  of  its  truth,  and  I  find  that  Hasse 
has  adopted  it ;  he  says,  speaking  of  the  contraction  of  the  chest 
in  pleurisy,  "  a  more  influential  cause  is,  however,  in  all  pro- 
bability the  paralysis  of  the  diaphragm  and  intercostal  muscles 
assigned  by  Stokes,  for  these  muscles  remaining  inert  during  the 
process  of  absorption  the  lung  cannot  inhale  sufficient  if  any  air, 
and  atmospheric  pressure  will  consequently  compel  the  wall  of 
the  thorax  to  fill  up  the  void  caused  by  the  removal  of  pleuritic 
effusion.  The  more  intensely  the  muscles  are  affected  the  longer 
will  their  paralysis  endure,  and  the  more  striking  during  that 
period  be  the  deformity  of  the  trunk,  confirming  Stromeyer's 
theory  as  to  the  origin  of  lateral  curvatures  of  the  spine." 

These  considerations  furnish  the  key  to  many  circumstances 


DISEASES   OF   THE    PLEUKA.  521 

connected  with  cases  of  pleurisy.  "We  can  understand  how,  even 
when  the  lung  is  not  bound  down  by  adhesions,  there  may  be 
contraction,  even  to  a  great  degree  ;  we  can  see  why  it  is  that  the 
contraction  is  not  always  permanent,  but  in  many  cases  becomes 
less,  or  may  finally  disappear.  If  the  disease  of  the  pleura  has 
been  violent,  and  that  the  inspiratory  muscles  remain  long 
inactive,  there  will  be  contraction  arising  from  all  the  causes  now 
specified  acting  in  combination,  and  again  if  the  force  of  the 
disease  has  been  principally  on  the  costal  and  diaphragmatic 
pleura,  there  may  be  contraction  although  the  inflammation  of 
the  lung  has  been  comparatively  slight,  and  the  period  of  com- 
pression short. 

The  circumstance  of  cases  of  contraction  in  sub-acute  pleurisy 
is  thus  explained,  and  finally  it  appears  probable  that  the  dilata- 
tion of  the  bronchial  tubes,  so  commonly  resulting  when  the 
original  disease  of  the  pleura  has  been  neglected,  is  to  be 
explained  by  the  return,  though  at  a  late  period,  of  the  force  of 
the  inspiratory  muscles  ;  the  lung  having  now  lost  much  of  its 
vesicular  structure  from  atrophy,  this  dilating  force  is  exerted 
upon  the  larger  air  tubes. 

A  remarkable  case  occurred  to  me  some  time  since  illustrative 
not  only  of  the  history  of  contraction  in  pleurisy,  but  of  the 
disease  generally. 

The  patient  was  a  young  lady  of  fair  complexion  and  full  habit, 
she  was  attacked  with  severe  pleuritis  of  the  left  side,  which 
soon  produced  a  copious  effusion,  with  dislocation  of  the  heart; 
from  this  she  recovered  in  about  the  course  of  a  month,  the 
lower  portion  of  the  side  being  contracted  to  a  slight  degree ; 
within  a. short  time  symptoms  of  an  acute  attack  of  peritonitis 
set  in,  and  in  a  few  days  the  abdomen  became  swelled  and 
fluctuating  ;  under  this  new  attack  she  remained  for  several  weeks, 
but  ultimately  the  disease  subsided,  and  the  copious  abdominal 
effusion  was  absorbed  ;  she  was  then  much  reduced  and  exhausted, 
but  free  from  any  indication  of  inflammatory  action,  when  she  was 
seized  with  acute  pleuritic  pain  in  the  right  side,  the  disease  ran 
the  same  course  as  in  the  left ;  she  laboured  for  weeks  under  an 
effusion  so  copious  as  to  cause  dulness  up  to  the  spine  of  the 
scapula,  but  from  this  third  attack  she  also  recovered,  and  from 
this  time  her  convalescence  was  steady  and  progressive.  Great 
contraction  of  the  right  side  and  depression  of  the  shoulder  made 


522  DISEASES    OF   THE    PLEUKA. 

its  appearance,  yet  even  this  ultimately  disappeared,  and  after  a 
few  months  this  lady's  figure  regained  its  symmetry.  I  never 
before  saw  a  case  at  which  contraction  occurred  at  so  early  a 
period,  and  in  which  it  so  greatly  disappeared,  and  it  may  be 
concluded  that  in  cases  of  contraction  the  earlier  the  deformity 
appears  the  greater  will  be  the  chance  of  its  subsiding.  In  those 
cases  in  which  it  is  slow  in  appearing  there  is  probably  not 
only  paralysis,  but  atrophy  of  the  inspiratory  muscles. 

I  believe  that  in  certain  cases  the  contraction  of  the  chest  may 
commence  at  an  extremely  early  period  of  the  case,  and  while 
accumulation  of  fluid  is  actually  going  on.  This  seems  to 
occur  under  the  double  influence  of  an  intense  inflammation,  and 
the  bending  down  of  the  chest  from  the  pain  of  inspiration.  The 
following  case,  illustrative  of  this,  is  worthy  of  study. 

A  boy,  aged  19,  accompanied  a  party  of  soldiers  to  their 
firing  ground,  where  they  practiced  at  a  mark,  and  was  occupied 
with  several  of  his  companions  in  picking  up  the  bullets  which 
fell  wide  of  the  target ;  while  stooping  he  received  a  ball  in  the 
right  acromial  region,  and  was  brought  into  the  Meath  Hospital 
in  a  state  of  great  agony  of  pain  referred  to  the  left  mammary 
region ;  in  the  course  of  ten  days  his  symptoms  were  so  urgent 
as  to  suggest  the  propriety  of  an  operation.  By  some  it  was 
considered  that  a  great  empyema  had  formed,  but  this  opinion  was 
by  others  doubted,  from  the  fact  that  the  affected  side  was  greatly 
contracted.  I  had  no  doubt  whatever  as  to  the  nature  of  the 
case,  as  the  heart  was  found  pulsating  under  the  right  mamma. 
The  operation  was  determined  on  ;  Mr.  Cusack  and  I,  taking 
into  consideration  the  extreme  contraction  of  the  side,  strongly 
urged  that  the  puncture  should  be  made  at  a  point  much  higher 
up  than  that  usually  selected  ;  we  were  apprehensive  that  the 
diaphragm  would  be  wounded.  Our  advice,  however,  was  not 
taken,  and  the  operation  was  performed  in  the  usual  place,  and  in 
the  old  manner — viz.,  by  making  a  free  division  of  the  integuments, 
and  then  puncturing  the  sac  with  the  bistoury.  In  this  case  no 
purulent  matter  followed,  and  it  was  then  determined  to  pass  a 
trocar  upwards  and  inwards  so  as  to  reach  the  sac  of  the  empyema. 
A  few  drachms  only  of  purulent  matter  followed  this  attempt,  and 
the  operation  was  evidently  a  failure.  The  patient  soon  after 
began  to  sink,  and  died  within  a  few  hours  in  collapse.  On  dis- 
section it  was  found  that  the  capsule  of  the  left  kidney  had  been 


DISEASES    OF    THE    PLEURA.  523 

deeply  wounded  by  the  knife,  and  a  profuse  haemorrhage  had 
taken  place  into  the  surrounding  cellular  tissue.  More  than  a 
pound  of  blood  was  thus  effused.  The  diaphragm  had  been 
punctured  from  below,  but  the  vast  empyema  remained.  The 
lung  had  been  perforated  by  the  ball  through  its  whole  extent, 
and  the  trajet  of  the  ball  distended  by  the  effusion  gave  a  bilocular 
appearance  to  the  sac. 

It  is  improbable  that,  even  under  more  favourable  circumstances, 
the  operation  of  paracentesis  would  have  succeeded  in  this  case, 
for  the  lung  was  so  much  compressed  and  altered  by  the  effect 
of  the  wound  that  it  would  hardly  have  ever  recovered  any  notable 
amount  of  permeability.  But  the  case  was  rendered  unfit  for 
operation,  from  the  fact  that  the  entire  system  had  suffered  so 
deeply  in  consequence  of  a  violent  disease  being  allowed  to  run 
on  so  long.  Had  the  affection  been  recognized  at  an  early 
period,  and  the  force  of  the  disease  reduced  by  treatment,  a 
different  result  might  have  occurred. 

I  owe  to  Mr.  Hamilton  another. case,  in  which  contraction  of 
the  side  appeared  at  the  commencement  of  the  disease.  A  man 
suffered  from  fracture  of  the  fourth,  fifth,  and  sixth  ribs;  in  this, 
as  in  the  preceding  case,  there  was  extreme  pain  of  the  side, 
and  total  inability  to  extend  it.  After  twenty-four  hours  of 
suffering  all  the  signs  of  copious  effusion  into  the  pleura  set  in. 
The  patient  was  ultimately  discharged,  but  the  side  remained 
contracted  all  through  the  case. 

From  a  consideration  of  these  cases  it  appears  probable  that  in 
certain  cases,  where  the  pain  is  extreme,  we  may  have  a  con- 
traction from  the  first  periods  of  the  case,  and  we  may,  therefore, 
recognize  two  forms  of  contraction  in  pleurisy  with  effusion,  one 
active,  the  other  passive,  one  occurring  at  the  commencement  of 
the  disease,  the  other  indicative  of  its  termination,  and  it  is 
very  probable  that  in  certain  cases,  where  contraction  exists 
all  through  the  case,  it  may  proceed  from  these  essentially 
opposite  causes  at  different  periods,  the  one  acting  in  the 
beginning,  the  other  towards  the  termination  of  the  case. 

In  1843  Sir  D.  Corrigan  exhibited  to  the  Pathological  Society 
two  casts  illustrative  of  the  occurrence  of  empyema  with  con- 
traction of  the  side,  one  on  the  right,  the  other  on  the  left  side  of 
the  chest,  and  he  has  re-expressed  my  observations  that  in  such 
cases  the  contraction  goes  on  from  below  upwards  as  well  as  from 


524  DISEASES    OF    THE    PLEURA. 

without  inwards,  and  that  the  safety  of  the  operation  for  empyema 
must  he  materially  influenced  by  this  circumstance.  In  one  of 
his  cases  had  the  puncture  of  the  side  been  made  in  the  usual 
place  of  election  the  great  curvature  of  the  stomach  must  have 
been  wounded,  and  he  adds  the  important  practical  remark  that 
if  the  constitutional  symptoms  indicating  recovery  do  not  proceed, 
pari  2>^ssu,  with  the  contraction  of  the  parietes  of  the  thorax, 
considerable  danger  is  to  be  apprehended. 

The  contraction  of  the  side  may  be  described  generally  as 
taking  one  of  two  forms,  the  one  that  is  so  well  described  by 
Laennec,  characterized  by  depression  of  the  shoulder,  and  general 
diminution  of  the  volume  of  the  side ;  in  the  second  there  is  little 
or  no  depression  of  the  shoulder,  but  we  observe  a  remarkable 
flattening  of  the  anteroinferior  portion  of  the  side.  In  some 
cases  indeed  a  distinct  hollowing,  or  depression,  engaging  two 
or  three  ribs  may  be  seen,  the  lateral  portion  has  lost  its  rounded 
form  and  has  become  sharply  angular,  constituting  a  condition  to 
which  I  have  given  the  name  of  the  "  knife-edge  "  contraction 
of  the  side.  Viewed  from  behind,  the  scapula  of  the  affected  side 
appears  much  more  marked  and  prominent,  and  when  both 
hands  are  passed  upwards,  under  the  inferior  angles  of  the  scapulae, 
the  hand  corresponding  to  the  affected  side  meets  with  little 
resistance  in  passing  under  the  bone.  I  have  seen  cases  where 
the  hand  would  be  passed  nearly  to  the  line  which  corresponds 
to  the  scapular  spine ;  the  lower  part  of  the  chest  is  comparatively 
dull,  with  a  feeble  and  confused  respiratory  sound,  and  the  heart 
beats  strongly  against  the  anterior  wall  of  the  chest,  often  with 
a  double  impulse,  and  the  peculiar  vermicular  motion  per- 
ceptible both  by  the  hand  and  eye.  The  second  impulse,  of 
course,  coinciding  with  the  second  sound,  and  perceptible  at 
the  base  rather  than  at  the  apex  of  the  heart. 

In  forming  our  opinion,  not  only  as  to  the  intensity  of  the 
original  inflammation,  but  also  as  to  the  remote  prognosis,  we 
may  derive  important  assistance  from  observing  the  state  of  the 
intercostal  muscles  and  diaphragm.  If  in  the  early  stages  of  the 
case  we  find  that  the  intercostal  spaces  continue  distinct,  while 
their  muscles  are  in  active  contraction,  we  may,  notwithstanding 
the  existence  of  a  copious  effusion  sufficient  to  dilate  the  side 
and  dislocate  the  heart,  diagnose  a  sub-acute  inflammation,  the 
effusion  from  which  is  in  all  probability  of  a  serous  nature.      It 


DISEASES    OF   THE    PLEURA.  525 

is  not  uncommon  to  find  within  a  week  from  the  first  attack  of 
pain  the  posterior  and  infero-lateral  portions  of  the  side  perfectly- 
dull  on  percussion,  yet  on  examining  the  front  of  the  chest  to 
discover  that  the  thorax  is  resonant  and  the  intercostal  muscles 
are  acting  with  force.  We  may  also  observe  that  the  epigastrium 
is  hollow,  and  that  there  is  no  sign  of  hepatic  displacement,  from 
which  we  are  justified  in  concluding  that  the  diaphragm  and  a 
large  portion  of  the  intercostal  muscles  are  unaffected,  and  it  will 
generally  happen  under  these  circumstances  that  the  disease  will 
yield  to  ordinary  treatment,  and  that  little,  if  any,  contraction  of 
the  side  will  attend  the  cure.  In  many  of  such  cases  the  effusion 
appears  to  be  limited  by  adhesions,  not  changing  its  place  with 
the  varying  position  of  the  patient,  and  if  there  be  no  friction 
phenomenon,  anteriorly  or  laterally,  we  may  safely  conclude  that 
a  large  portion  of  the  costal  pleura  and  the  intercostal  muscles 
has  not  participated  in  the  disease. 

If  we  exclude  those  cases  in  which,  from  the  great  accumula- 
tion of  fluid  or  the  severity  of  the  constitutional  symptoms, 
the  patient's  sufferings  are  considerable,  we  find  that  the  class  of 
cases  presented  for  consultation  are  those  in  which  the  process  of 
cure  has  already  gone  on  to  some  extent.  Of  such  cases,  there- 
fore, I  will  make  the  following  groups,  arranging  them,  with 
reference  to  their  variations  in  local  or  general  conditions,  and 
indicating  the  prominent  features  of  some  instances,  so  that  each 
individual  case  presented  to  us  may  meet  with  its  type  in  one  or 
other  of  these  groups. 

I.  The  fluid  has  been  absorbed  with  more  or  less  contraction 
of  the  affected  side  ;  the  ribs  are  approximated  ;  and  the  shoulder 
may  or  may  not  be  depressed.  There  is  nothing  remarkable  in 
the  condition  of  the  heart,  though  in  some  cases  its  apex  beats  a 
little  nearer  than  natural  to  the  mesian  line.  The  contraction 
may  not  amount  to  more  than  some  flattening  of  the  antero-in- 
ferior  portion  of  the  chest — or  it  may  be  in  that  greater  degree 
indicated  by  the  knife-edge  formation,  and  the  falling  away  of 
the  ribs  from  the  inferior  surface  of  the  scapula.  The  cure  in 
such  a  case  is  often  perfect  and  permanent,  and  it  frequently 
happens  that  the  physician  is  cod  suited,  not  on  account  of  any 
constitutional  suffering,  but  from  the  alarm  experienced  by  the 
patient  or  his  friends  at  the  appearance  of  the  contraction. 
Disease  of  the  heart  is  sometimes  apprehended  from  the  causes 


526  DISEASES    OF   THE    PLEUKA. 

already  indicated.  Or,  lastly,  the  cause  of  complaint  may  be  a 
frequently  recurring  pain  in  the  lower  portion  of  the  side.  This 
pain  is  excited  by  fatigue,  cold,  mental  emotion,  or  indigestion, 
and  appears  to  be  an  example  of  that  form  of  neuralgia  which 
affects  parts  that  have  previously  been  the  seat  of  inflammation. 

II.  In  more  extreme  cases  of  contraction,  the  shoulder  is 
depressed,  and  the  physician  is  consulted,  not  with  reference  to 
any  supposed  affection  of  the  chest,  but  under  the  idea  that  the 
patient  has  got  disease  of  the  spine.  Laennec  has  well  indicated 
the  diagnosis  of  this  affection. 

III.  There  is  a  case,  which  I  believe  to  be  extremely  rare,  but 
of  which  I  have  seen  a  few  examples.  The  process  of  absorption 
is  arrested,  and  a  circumscribed  and  perfectly  indolent  empyema 
remains  occupying  generally  the  postero-inferior  portion  of  the 
side.  I  have  reason  to  believe  that  patients  may  continue  with 
this  condition  for  a  very  great  length  of  time,  and  there  are  few 
cases  the  positive  diagnosis  of  which  is  so  extremely  difficult. 
From  the  apparently  complete  indolence  of  this  condition,  from 
the  absence  of  any  pathological  transformation  of  the  contents  of 
the  sac,  and  the  nearly  complete  absence  of  local  symptoms,  this 
lesion  might  be  compared  to  those  serous  cysts  which  sometimes 
follow  the  absorption  of  apoplectic  clots. 

IV.  There  is  a  class  of  cases  of  more  frequent  occurrence  than 
the  last,  in  which,  after  a  very  copious  effusion  has  taken  place, 
the  recovery  of  the  patient  proceeds  favourably  up  to  a  certain 
point.  The  upper  part  of  the  chest  regains  its  sonoriety,  and 
permeability,  and  the  general  health  is  to  all  appearance  re- 
stored. But  we  find  that  the  lower  half  of  the  affected  side,  or 
in  some  cases  the  postero-inferior  and  lateral  portion  remains 
absolutely  dull,  presenting  neither  contraction,  nor  dilatation  ; 
and  by  no  means  in  our  power  can  we  remove  this  condition  (I 
do  not  here  speak  of  paracentesis).  This  is  a  case  in  which 
notwithstanding  the  long-continued  absence  of  any  local  or 
general  symptom  of  disease,  we  should  make  an  unfavourable 
prognosis,  for  there  is  great  danger  of  its  turning  out  to  be  one 
in  which  the  transformation  of  an  empyema  into  cancer  may  be 
apprehended. 

If  we  have  had  an  opportunity  of  studying  such  a  case  from 
its  commencement,  there  will  be,  of  course,  less  difficulty  in 
the  general  view  which  is  to  be  taken  of  it.     But  when  the 


DISEASES    OF    THE    PLEURA.  527 

physician,  as  often  happens,  is  for  the  first  time  called  to  see  a 
patient  in  the  condition  now  described,  he  will  experience  the 
greatest  difficulty  in  coming  to  an  accurate  conclusion.  In  fact 
such  a  case  is  one  of  those  the  nature  of  which  can  only  be  deter- 
mined by  successive  observations.  But  as  this  opportunity  is 
seldom  given  to  the  consulting  physician  his  best  course  will  be 
to  abstain  from  any  positive  diagnosis — simply  pointing  out  that 
one  of  these  conditions  most  probably  exists,  viz.,  an  extraor- 
dinary deposit  of  coagulable  lymph  ;  the  circumscribed  empyema 
which  we  have  just  now  indicated ;  or  the  earlier  stages  of  the 
encephaloid  disease.  I  object  to  the  practice  of  making  an  ex- 
ploratory puncture,  either  by  Weiss's  needle,  or  a  capillary 
trocar,  in  such  cases,  and  on  these  grounds — that  if  the  case  be 
not  cancerous  there  is  no  need  for  interference,  for  the  respiration 
is  not  embarrassed,  and  the  general  health  is  good ;  while  on  the 
other  hand  if  the  malignant  transformation  has  been  set  up,  we 
run  the  double  risk  of  converting  the  indolent  disease  into  a 
more  active  condition,  and  of  producing  an  external  fungus  at 
the  point  of  the  orifice.  This  terrible  accident  I  have  known  to 
occur,  a  sad  example  of  officious  and  unnecessary  interference. 

V.  A  not  uncommon  case,  in  which  the  physician  is  called  by 
the  patient  after  the  pleuritic  disease  has  gone  through  its  stages 
of  invasion,  accumulation,  and  absorption,  all  of  which  have  been 
either  unsuspected  or  unrecognized,  is,  that  in  which  alarm  is 
first  created  by  the  accidental  discovery  of  concentric  dislocation 
of  the  heart.  The  transverse  dislocation  is  that  which  most 
commonly  excites  attention,  and  belongs  to  the  diminished 
volume  of  the  right  lung  ;  while  the  vertical  is  observed  where 
the  empyema  has  existed  in  the  left  side.  In  both  of  these 
cases  there  may  be  disease  of  the  lung  as  shewn  by  diffuse  gur- 
gling, comparative  dulness,  which  indicate  atrophy  of  the  lung 
with  dilated  tubes,  or  again  the  combination  of  this  state  with 
chronic  tubercle  ;  and  I  am  disposed  to  believe  that  in  the  con- 
centric dexiocardia,  there  is  a  greater  chance  of  the  lung  remaining 
healthy,  than  in  the  upper  vertical  displacement  which  follows 
the  unrecognized  disease  of  the  left  pleura. 

Our  knowledge  of  empyema  would  be  very  limited  if  we  con- 
fined ourselves  to  the  study  of  the  symptoms  and  physical  signs 
of  those  cases  in  which  we  observe  only  the  phenomena  of  accu- 
mulation and  absorption.     There  are  other  conditions  of  great 


528  DISEASES   OF    THE    PLEURA. 

importance  which  claim  our  attention,  especially  those  which  are 
connected  with  the  efforts  of  nature  to  evacuate  the  fluid,  by 
direct  means,  or  hy  the  establishment  of  a  vicarious  secretion 
from  the  mucous  membrane  of  the  lung. 

These  important  subjects  will  be  most  advantageously  studied 
by  the  patient  investigation  of  cases  which  illustrate  some  of  the 
above  conditions.  These  shall  be  given  in  as  succinct  a  manner 
as  may  be  consistent  with  the  objects  we  have  in  view. 

Case. — Obs. — Chronic  empyema — opening  externally — caries  of 
several  ribs — pneumothorax — aneurism  oj  the  aorta,  and  pul- 
monary tubercle. 

In  September,  1838,  a  woman  named  Egan,  aged  28,  was 
admitted  with  symptoms  of  hectic  fever  and  cough.  For  the  two 
previous  years  she  had  been  subject  to  a  dry  cough.  After 
exposure  to  cold  she  had  been  attacked  with  severe  pain  under 
the  left  mamma,  soon  after  which  the  symptoms  of  cough, 
dyspnoea,  and  hectic  fever  made  their  appearance.  She  pre- 
sented the  following  physical  signs,  the  whole  left  side  was  dull, 
but  this  was  best  marked  on  the  inferior  portions.  The  vesicular 
murmur  was  generally  feeble,  especially  in  the  inferior  portion, 
where  it  was  extremely  indistinct.  Two  peculiar  auscultatory 
sounds  could  be  heard,  the  one  resembling  friction,  during  in- 
spiration, while  during  expiration  its  character  changed  so  as  to 
resemble  a  series  of  short  metallic  crepitations.  The  other 
sound  was  like  the  ticking  of  a  watch,  it  continued  when  the 
patient  held  her  breath,  and  was  synchronous  with  the  action  of 
the  heart.  This  latter  was  very  distinct  and  audible  over  the 
whole  chest. 

The  heart's  sounds  were  more  distinctly  audible  under  the 
left  clavicle  than  in  the  cardiac  region,  and  so  distinct  over  the 
right  side  that  if  the  pulsations  had  not  been  seen  under  the 
edges  of  the  left  ribs,  it  might  have  been  supposed  that  the  heart 
was  at  the  right  of  the  sternum.  No  murmur  accompanied 
either  sound.  The  ticking  sound  was  not  constant,  nor  was 
each  tick  equally  loud.  There  was  no  cegophony,  and  change  of 
position  of  the  patient  made  no  alteration  in  the  percussion 
sound.  The  side  was  not  dilated,  there  was  puerile  respiration 
in  the  right  lung.     Decubitus  on  left  side. 

In  the  course  of  three  days,  well  marked  metallic  tinkling 


DISEASES   OF   THE   PLEURA.  529 

became  developed  in  the  cardiac  region.  It  was  observed  that 
the  vessels  about  the  right  sterno-clavicular  articulation  pulsated 
with  violence,  while  nothing  of  this  kind  was  observed  on  the 
left. 

Little  change  occurred  during  the  next  ten  days.  The  patient 
complained  principally  of  pain  in  the  shoulders,  cough,  and 
abundant  mucous  expectoration.  Her  breath  now  exhaled  a 
gangrenous  odour,  and  her  expectoration,  now  resembling  thin 
flummery,  also  became  foetid.  The  left  side  of  the  chest  was 
(Edematous,  and  there  was  slight  pain  beneath  the  left  breast, 
where  there  was  also  considerable  tenderness,  but  no  redness  of 
the  integuments  was  observed.  The  patient  was  aphonious. 
On  the  following  day  a  small  portion  of  integument  immediately 
below  the  left  nipple  was  observed  to  be  swollen  and  exceedingly 
tender.  In  the  course  of  three  days  this  part  (which  had  been 
poulticed)  exhibited  a  distinct  tumour  manifestly  containing 
fluid.  The  whole  side  was  extremely  tender,  and  when  the 
patient  coughed  the  tumour  was  protruded  against  the  fingers, 
conveying  the  sensation  given  by  a  hernia ;  in  its  centre  a 
diastolic  throb  could  be  felt  corresponding  to  the  action  of  the 
heart.  The  breath  continued  horribly  foetid — there  was  no 
sweating,  and  the  pulse  was  about  100  and  feeble.  Decubitus 
on  back. 

The  tumour  daily  increased,  feeling  elastic,  and  still  pulsating. 
The  whole  of  the  anterior  and  lateral  portion  of  the  side  was 
excessively  tender  and  completely  dull  on  percussion.  In  the 
upper  portion  of  the  left  lung  gurgling  could  be  heard.  She 
now  became  affected  with  diarrhoea.  The  tumour  continued  to 
enlarge  and  pulsated  with  much  force;  when  pressed  upon 
extreme  pain  darting  round  to  the  spine  and  shoulder  was  pro- 
duced, and  the  shoulder  itself  was  exquisitely  tender.  The 
tumour  soon  became  red  at  the  point,  and  surrounded  by  large 
veins,  it  became  exceedingly  prominent  when  she  sat  up  or 
coughed,  and  a  diastolic  pulsation  could  now  be  felt  over  its 
whole  surface. 

The  respiration  under  the  left  clavicle  was  bronchial,  and  the 
same  character  existed  posteriorly  where  loud  resonance  of  the 
voice  and  a  muco-crepitating  rale  were  perceived.  Her  pulse 
rose  to  130 — no  sweating  was  present.  The  cutaneous  veins 
formed  a  complete  network  over  the  affected  side. 

M  M 


530'  DISEASES   OF   THE    PLEURA. 


0 


On  the  20th  October  she  expectorated  a  large  quantity  of 
opaque  puriform  matter,  which  was  horribly  foetid;  it  was 
mixed  with  white  flakes  like  curd.  The  diarrhoea  continued. 
The  following  clay  the  tumour  burst,  and  discharged  not  less  than 
six  pounds  of  purulent  matter  of  most  extreme  fcetor.  The 
diarrhoea  now  ceased,  the  cough  became  less  troublesome,  and 
the  expectoration  was  diminished. 

Thus  within  forty-eight  hours  two  modes  of  evacuation  were 
established — one  by  the  lung,  possibly  by  a  vicarious  secretion — 
the  other  by  perforation  of  the  integuments. 

The  second  stage  of  the  case  may  be  held  to  commence  at  this 
period.  More  than  a  pint  of  puriform  matter  continued  to  be 
discharged  daily  from  the  orifice.  The  opening  was  about  a 
quarter  of  an  inch  in  length,  and  the  eighth  of  an  inch  in  breadth  ; 
and  the  passage  of  the  external  air  through  it  was  attended  with 
some  remarkable  phenomena.  At  every  inspiration  the  air  rushed 
in,  while  during  expiration  the  integuments  were  puffed  out.  On 
applying  the  stethoscope,  extraordinary  sounds  were  observed  to 
attend  the  passage  of  air  through  the  fistula.  They  were  com- 
pared by  the  reporter  of  the  case  to  a  distant  caterwauling,  while 
they  sometimes  resembled  the  whistling  of  the  wind  through  a 
ruined  house.  It  was  remarked  that  these  sounds  were  only  pro- 
duced for  about  half-a-minute  after  the  patient  sat  up — they  then 
ceased,  and  were  replaced  by  a  feeble  respiratory  murmur.  We 
could  reproduce  them  by  making  the  patient  lie  down  for  a  short 
time,  and  then  resume  the  erect  position.  Her  general  condition 
was  now  improved,  her  appetite  returned,  her  looks  and  sleep  were 
better,  and  her  pulse  95,  and  stronger. 

This  amendment  did  not,  however,  long  continue.  Copious 
discharge  took  place  from  the  opening  whenever  the  patient 
coughed.  She  had  abundant  expectoration  of  a  greenish  mucus. 
The  physical  signs  continued  the  same,  with  occasional  metallic 
phenomena,  heard  posteriorly,  or  in  the  front  of  the  chest.  The 
sounds  of  the  heart  now  became  louder  over  the  left  than  the 
right  side.  There  was  no  sweating,  the  diarrhoea  had  ceased, 
and  the  expectoration  had  lost  its  foetor.  Her  weakness  increased. 
On  the  30th  October,  a  copious  discharge  of  purulent  matter 
mixed  with  blood  escaped  from  the  wound,  leaving  her  in  the 
lowest  state  of  debility.  From  this  period  to  the  time  of  her 
death,   which  occurred  on  the  10th  December,  her  symptoms 


DISEASES  OF  THE    PLEURA.  531 

underwent  but  little  change  ;  copious  discharges  of  foetid  matter, 
often  amounting  to  four  pounds  in  the  day,  took  place  from  the 
orifice.  The  whistling  sounds  and  metallic  phenomena  were 
occasionally  audible  for  a  few  moments  after  she  sat  up — the 
latter  could  be  heard  posteriorly  where  the  respiration  was  bron- 
chial, and  the  sound  clear  on  percussion.  There  was  a  strong 
pulsation  present  at  the  right  sterno-clavicular  articulation  ;  the 
heart's  sounds  continued  loud,  and  it  communicated  its  impulse 
to  the  entire  chest.  Her  appetite  became  good,  but  she  had 
diarrhoea  occasionally.  At  one  time  the  passage  of  air  through 
the  aperture  produced  a  gurgling  sound,  so  loud  as  to  be  audible 
at  a  distance  from  the  patient's  bed. 

Towards  the  close  of  the  case,  the  discharge  greatly  diminished, 
but  owing  to  the  extreme  debility  of  the  patient,  we  made  no 
additional  examinations  of  the  chest.  It  was  observed,  however, 
about  a  fortnight  before  her  death,  that  the  sounds  of  the  air 
passing  through  the  fistula  assumed  a  new  character,  resembling 
in  a  remarkable  manner  the  feeble  cries  of  a  new-born  infant. 
During  the  latter  period  of  her  life,  she  had  neither  diarrhoea,  or 
night  sweats,  and  her  appetite  continued  good.  A  sudden  dis- 
charge of  about  six  pounds  of  purulent  matter  took  place  from 
the  opening  three  days  before  her  death,  and  she  sank  exhausted 
on  the  10th  December. 

Examination. — The  whole  body  was  exceedingly  emaciated, 
and  percussion  over  the  left  side  of  the  chest  elicited  perfect 
bruit  de  pot  fele.  On  turning  the  body  on  the  left  side  about 
three  pints  of  a  thin  blackish  fluid  unmixed  with  puriform 
matter  escaped  from  the  opening.  The  fourth,  sixth,  and  seventh 
ribs  were  so  perfectly  carious  as  to  break  down  under  the  pressure 
of  the  fingers  ;  the  fifth  was  discoloured,  but  resisted  pressure. 
The  left  lung,  greatly  diminished  in  volume,  was  bound  by  strong 
adhesions  to  the  posterior  portions  of  the  chest  and  medias- 
tinum. It  was  covered  with  dark-coloured  lymph.  Some  softened 
tubercle  was  found  in  the  upper  portion  of  the  lung,  but  there 
was  no  abscess  or  cavity ;  nor  could  we  detect  any  pulmonary 
fistula.  The  heart,  pericardium,  and  right  lung  were  healthy, 
but  a  small  false  aneurism  was  found  at  the  arch  of  the  aorta, 
about  the  size  of  a  filbert,  and  presenting  evidences  of  the  des- 
truction of  the  internal  and  middle  coats  of  the  artery.  The  liver 
was  greatly  enlarged,  and  formed  adhesions  with  the  spleen. 

M  M  2 


532  DISEASES  OF   THE   PLEURA. 

This  case,  though  greatly  reduced  from  the  original  report, 
may  be  by  some  considered  as  given  too  much  in  detail,  but  this 
will  not  be  the  feeling  of  the  earnest  student  of  medicine.  It 
exhibits  two  distinct  periods — one  antecedent  to  the  formation  of 
the  external  fistula — the  other  subsequent  to  this  occurrence.  In 
the  first  of  these  periods,  in  addition  to  the  symptoms  and  signs 
of  empyema  following  an  attack  of  pleurisy,  we  observed  some 
unusual  phenomena,  viz. : — 

I.  The  fine  and  superficial  metallic  crepitations. 

II.  The  ticking  sound  corresponding  to  the  action  of  the  heart, 
and  only  occasionally  audible. 

III.  The  strong  pulsations  at  the  right  sterno-clavicular  arti- 
culation, contrasting  strongly  with  the  condition  of  parts  at  the 
left  side. 

IV.  The  metallic  tinkling  in  the  cardiac  region. 

V.  The  occurrence  of  foetid  expectoration. 

VI.  The  extreme  pain  and  tenderness  over  a  large  surface  of 
the  affected  side. 

VII.  The  appearance  of  the  external  abscess,  with  a  gradually 
extending  diastolic  pulsation,  and  a  varicose  state  of  the  cutaneous 
veins. 

The  second  stage  of  the  case  is  marked  by  the  almost  simul- 
taneous occurrence  of  copious  evacuations  by  the  lung,  and  the 
bursting  of  the  external  abscess. 

The  signs  of  pneumothorax  now  became  well-marked,  and 
singular  acoustic  phenomena  are  found  to  attend  the  entrance  and 
exit  of  air  through  the  external  fistula. 

There  are,  however,  some  indications  of  relief.  The  diarrhoea 
nearly  ceases,  and  the  appetite  returns  ;  but  the  patient  gradually 
sinks,  and  finally  dies  exhausted  from  the  discharge,  which  was 
not  only  unceasing,  but  occasionally  took  place  by  a  sudden  erup- 
tion of  a  vast  quantity  of  puriform  and  fcetid  matter. 

It  is  difficult  to  say  whether  the  metallic  phenomena  observed 
during  the  first  period  of  the  case,  were  indicative  of  any  pul- 
monary fistula,  or  whether  they  proceeded  from  decomposition  of 
the  secretion  existing  in  the  pleura.  It  is  true  that  we  dis- 
covered no  fistula  on  dissection,  but  it  is  possible  that  such  might 
have  existed  in  the  earlier  periods  of  the  case,  and  have  become 
obliterated  or  hidden  during  the  progress  of  the  disease.  On  the 
other  hand,  the  absence  of  the  more  ordinary  signs  of  pneumo- 


DISEASES   OF   THE    PLEURA.  533 

thorax  from  fistula,  combined  with  the  foetid  character  of  the 
secretion  from  the  lung,  makes  it  probable  that  the  air  was  pro- 
duced by  the  decomposition  of  the  fluid.  It  is  very  likely  that 
death  of  the  rib  took  place  at  a  very  early  period,  and  that  a 
putrefactive  process  had  engaged  the  whole  of  the  empyema  long 
before  the  occurrence  of  the  external  opening. 

It  is  further  probable  that  the  secretion  from  the  mucous  mem- 
brane, not  only  of  the  lung,  but  also  of  the  intestinal  surface, 
was  more  or  less  vicarious.  On  this  subject  we  will  speak  further 
hereafter. 

The  last  point  in  this  case  worthy  of  the  practical  physician's 
notice,  is  the  temporary  alleviation  of  symptoms  which  followed 
the  discharge  through  the  external  fistula.  Is  this  to  be  accounted 
for  by  assuming  that  the  patient  was  relieved  from  the  pressure 
of  a  vast  quantity  of  fluid  ?  Or  should  we  take  a  less  mechanical 
view  of  the  matter,  and  suppose  that  the  getting  rid  of  a  quantity 
of  putrid  fluid  was  followed  by  relief  of  those  constitutional 
symptoms  which  arise  from  the  absorption  of  a  septic  poison.  It 
is  probable  that  both  causes  acted.  We  see  in  cases  of  para- 
centesis of  the  thorax  in  empyema  with  pulmonary  fistula,  that  a 
temporary  relief  is  sometimes  produced,  although  the  lung  is 
unable  to  expand — a  circumstance  which  sometimes  misleads  the 
physician  by  inducing  him  to  believe  that  the  operation  was  suc- 
cessful or  at  leash  justifiable.  And,  on  the  other  hand,  we  know 
that  in  gangrene  of  the  lung,  suspension  of  putrefactive  action  is 
followed  by  great  alleviation  of  the  constitutional  symptoms. 

I  think  we  may  divide  cases  of  empyema  into  three  classes  : 
in  the  first,  absorption  and  cure  take  place  ;  the  second  differs 
from  the  first  in  this,  that  although  inflammatory  action  ceases, 
absorption  does  not  take  place,  and  a  condition  similar  to  chronic 
abscess  is  induced,  an  unchanging  passive  condition ;  while  in 
the  third  case,  we  may  observe  a  constant  pathological  activity 
tending  to  the  reproduction  of  morbid  secretion,  to  the  dis- 
organization of  the  surrounding  parts,  to  the  irritative  nutrition, 
or  to  venosis  of  the  ribs,  and  attended  by  various  efforts  of 
nature  to  get  rid  of  the  purulent  secretion.  The  vicarious 
secretions,  the  oedema  of  the  surface,  the  perforation  of  the 
lung,  the  mortification  or  hyperosteosis  of  the  rib,  the  formation 
of  the  subcutaneous  abscess  with  or  without  destruction  of  the 
pleura,  are  all  indicative  of  an  unceasing  pathological  process, 


534  DISEASES   OF  THE    PLEURA. 

the  symptoms  and  signs  of  which,  though  reducible  to  a  general 
expression,  greatly  vary  not  only  in  different  cases,  but  also  at 
different  periods  of  the  same  case  ;  nor  can  we  always  find  on 
dissection  the  explanation  of  the  various  and  singular  phenomena 
which  have  occurred  during  life  ;  for  where  the  disease  exists 
for  a  great  length  of  time,  successive  changes  are  constantly 
occurring,  while  the  disease  process,  in  developing  new  altera- 
tions, obliterates  the  signs  of  former  changes.  I  have  made  use 
of  the  expression  "  effort  of  nature  "  rather  because  it  is  com- 
monly used  than  from  any  belief  that  it  implies  any  special  new 
or  directly  sanative  vital  action.  If  there  be  any  meaning  in 
the  term,  vis  medicatrix  nature,  it  must  be  that  it  implies  an 
influence  antagonistic  to,  and  therefore  different  from  that  of 
disease.  But  in  closely  studying  these  cases  of  evacuations  of 
the  fluid  of  empyema  by  solutions  of  continuity  it  appears  that 
the  result  in  question  follows  from  the  continuation,  and  perhaps 
aggravation  of  the  original  disease,  rather  than  from  the  setting 
up  of  any  new  process.  Practically  we  find  that  in  these  cases 
the  disease  has  been  either  unusually  violent  or  improperly 
treated  at  the  commencement.  The  diseased  action  once  set 
up,  seems  never  to  cease  or  change,  and  it  appears  difficult  to 
call  that  a  sanative  process  which,  while  it  may  indeed  cause  an 
evacuation  of  the  fluid,  converts  the  whole  side  of  the  chest  into 
a  bony  cuirass,  sets  up  mortification  of  the  ribs,  and  hopeless 
disorganization  and  atrophy  of  the  affected -lung.  These  results 
then  are  less  to  be  considered  as  efforts  of  nature  than  as  the 
disorganization  of  uncured  and  progressive  inflammation. 

There  are  other  important  points  illustrated  by  the  case  of 
Egan  ;  the  simulation  of  tubercular  abscess,  the  pulsation  of 
the  empyematous  tumour,  the  development  of  a  local  emphy- 
sema in  the  walls  of  the  chest,  and  vicarious  secretion  from  the 
mucous  membrane  of  the  lungs. 

As  to  the  first,  it  appears  probable  that  pending  the  existence 
of  a  chronic  empyema,  two  conditions  may  arise,  which  will 
cause  the  development  of  the  signs  of  a  pulmonary  cavity ;  and 
yet  on  dissection  no  satisfactory  evidence  of  such  a  lesion  shall 
be  discovered.  Air  may  really  exist  in  the  compressed  lung, 
and  after  exhibiting  the  usual  signs  become  obliterated,  either 
by  compression  or  other  pathological  causes,  so  that  on  dissec- 
tion it  will  be  impossible  to  demonstrate  that  any  such  lesion 


DISEASES   OF   THE   PLEURA.  535 

had  existed.  But  this  appears  to  be  the  exceptional  case,  and 
there  can  he  hut  little  douht,  that  in  most  instances,  when, 
in  combination  with  a  decided  case  of  empyema  exhibiting  the 
signs  of  excentric  pressure,  we  find  distinct  and  circumscribed 
gurgling,  the  sign  is  caused  by  a  copious  secretion,  which  is 
generally  vicarious,  in  the  compressed  lung.  There  is  some- 
times added  bronchial  respiration,  easily  mistaken  (under  the 
circumstances)  for  cavernous  breathing,  and  the  voice  may  be 
almost  articulate,  so  that  the  simulation  of  the  signs  of  cavity 
is  so  complete  as  easily  to  deceive  an  observer,  who  is  not  aware 
of  these  facts.  Indeed,  so  complete  is  the  resemblance  of  the 
signs  to  those  of  a  cavity  that  even  an  experienced  stethoscopist 
is  obliged  to  trust  for  his  opinion  as  to  their  cause  less  to 
their  actual  character  than  to  the  circumstance  of  co-existing 
empyema. 

The  communication  of  impulse  to  the  fluid  of  empyema  has-, 
been,  I  believe,  in  most  cases  observed  when  the  effusion  occu- 
pied the  left  side.  At  least  such  cases  as  I  have  seen  and  read 
of  were  of  this  description.  But  it  is  by  no  means  impossible 
that  a  pulsating  empyema  might  occur  on  the  right  side.  Such 
an  occurrence  might  be  expected  if  the  heart  was  greatly  dis- 
placed towards  the  left,  and  especially  if,  in  addition,  its  action 
was  much  excited. 

The  pulsations  are  of  two  kinds — general  and  local.  In  the 
first,  the  whole  sac  pulsates ;  in  the  second,  this  sign  appears  to 
be  confined  to  the  tumour,  which  has  made  its  way  through 
the  ribs,  constituting  the  "  empyema  of  necessity  "  of  authors. 

Dr.  M'Donnell  has  published  three  remarkable  cases  of  the 
latter  form  of  disease,  to  which  he  has  given  the  name  of  "pul- 
sating empyema  of  necessity."  One  of  these  cases  occurred  in 
the  Meath  Hospital,  and  two  were  under  the  care  of  Dr.  Graves 
in  private  practice. 

In  the  first  of  these  cases,  the  patient  had  laboured  under 
chronic  pleuritic  effusion  for  about  ten  weeks,  when  the  signs  of 
external  pointing  became  manifest.  A  small  tumour,  whenever  the 
patient  coughed,  shewed  itself  below  the  nipple,  where  previously 
there  had  been  tenderness,  but  without  dislocation  or  oedema. 
When  she  lay  on  the  left  side  the  tumour  became  enlarged,  but 
receded  when  she  turned  on  the  right.  It  had  a  distinct  pulsation, 
and  it  soon  increased  in  size.     In  about  a  fortnight  it  equalled  that 


53G  DISEASES   OF   THE   PLEURA. 


O 


of  an  orange.  The  tumour  was  red  and  shining,  and  had  a  strong 
diastolic  pulsation,  which  was  equally  vehement  at  every  point. 
There  was  neither  soufflet  nor  fremitus.  In  a  few  days  the 
tumour  hurst,  and  an  external  fistula  was  established,  with  the 
signs  of  pneumothorax.  After  some  time  she  sank,  exhausted, 
from  the  discharge.  Dissection  shewed  the  lung  compressed, 
shrivelled,  and  hound  down  by  strong  adhesions.  Its  upper 
portion  contained  softened  tubercles.  The  fourth  and  sixth 
ribs  were  carious  and  their  periosteum  in  a  state  of  slough. 
The  external  integuments  were  separated  from  the  ribs  for  a  space 
of  about  two  inches  in  diameter. 

In  Dr.  M'Donnell's  second  case,  two  pulsating  tumours 
existed ;  one  over  the  region  of  the  heart's  apex ;  the  other 
posteriorly,  and  appearing  between  the  tenth  and  eleventh  ribs, 
at  a  distance  of  about  two  inches  from  the  spine.  Both  these 
tumours  had  the  size  of  a  Seville  orange,  and  presented  some 
enlarged  veins  around  their  bases.  They  had  a  visible  diastolic 
pulsation,  without  bruit  de  soufflet,  or  thrill,  and  the  force  of  the 
anterior  tumour  was,  when  I  saw  the  patient,  extremely  great.  Dr. 
M'Donnell  observed  that  percussion  on  one  tumour  caused  evident 
fluctuation  in  the  other.  The  integuments  were  not  inflamed 
or  certematous,  nor  was  any  pain  felt  by  the  patient  when  these 
tumours  were  handled.  The  affected  side,  when  Dr.  M'Donnell 
saw  the  patient,  was  not  increased  in  size,  nor  had  it  the  barrel 
shape  so  often  observed  in  empyema.  Mr.  Cusack  saw  this 
patient  in  consultation  with  Drs.  Graves,  M'Donnell,  and 
myself,  and  the  tumours  were  successively  punctured.  It  was 
found  that  though  the  pulsation  was  greatly  diminished,  it  still 
was  perceptible  in  the  collapsed  state  of  the  abscess,  and  that 
after  some  time  the  anterior  tumour  pulsated  as  strong  as  in 
the  first  instance.  After  a  period  of  some  weeks  this  patient's 
health  greatly  improved,  but  he  finally  sank  with  symptoms  of 
phthisis.     There  was  no  dissection. 

The  third  case  was  also  an  example  of  double  pulsating  tumours, 
presenting  in  the  same,  or  nearly  the  same,  situations,  as  in  the 
last  example,  and  like  it,  characterized  by  the  diastolic  throb, 
and  absence  of  soufflet  or  fremitus.  To  complete  the  resem- 
blance, these  tumours  were  indolent,  and  unattended  by  any 
indication  of  integumental  disease.  The  case  appeared  originally 
to  have  been  one  of  empyema  and  pneumothorax. 


DISEASES   OF   THE   PLEUKA.  537 

If  we  now  take  a  review  of  these  three  cases,  we  find  in  them 
examples  of  localized  pulsating  tumours,  where  the  impulsive 
force  was  communicated  by  a  dislocated  heart.  In  one,  the 
pathological  condition  of  parts  was  peculiar,  as  shewn  by  the 
rapid  disorganization,  the  perforation  of  the  integuments,  and  the 
caries  of  the  ribs  ;  while  in  the  two  last,  the  pathologic  process 
appears  to  have  been  arrested,  leaving  an  abnormal  condition  of 
a  purely  mechanical  nature.  We  cannot  yet  say  with  certainty 
whether  in  these  cases  the  diastolic  pulsation  was  communicated 
to  the  contents  of  the  pleural  sac ;  but  that  it  must  have  been  so 
to  a  certain  degree,  although  perhaps  imperceptible  to  observation, 
appears  clearly  from  the  fact  that  the  superficial  tumours  ex- 
hibited this  strong  pulsation,  a  pulsation  which  we  cannot  but 
believe  to  have  been  analogous  to  that  of  false  aneurism,  and 
produced  by  the  operation  of  the  same  hydrostatic  law. 

Our  practical  and  anatomical  knowledge  of  this  condition  is 
limited ;  but  comparing  these  pulsating  tumours  with  false 
aneurisms,  we  find  a  certain  resemblance  in  the  mechanical 
relations  and  conditions  of  both  ;  in  both  we  have  a  sac  con- 
taining fluid,  and  communicating  by  a  fistula  with  another 
reservoir  also  containing  fluid.  Here,  however,  the  analogy 
becomes  less  distinct,  inasmuch  as,  that  in  aneurism,  the  second 
reservoir  or  the  artery  exhibits  a  current  of  fluid,  while  in 
empyema  there  is  no  current,  but  simply  a  succession  of 
impulses  from  without.  And  accordingly  we  find  that  as  yet 
no  case  has  been  observed  of  murmur  or  fremitus  in  these 
pleural  aneurisms,  if  we  may  use  such  a  term. 

This  communicated  pulsation  in  empyema  may  also  be  classed 
with  that  of  the  fluid  or  semi-fluid  cancers  which  lie  in  contact 
with  great  vessels,  the  phenomena  of  which,  as  occurring  in  the 
thorax,  I  first  described  some  years  since. 

"We  are  yet  unable  to  say  why  it  is  that  in  one  case  of  the  em- 
pyema of  necessity  there  should  be  pulsation,  while  in  another 
this  condition  is  absent';  but  it  must  not  be  forgotten  that  in 
many  cases  we  only  observe  and  record  the  maximum  state  of 
phenomena,  whose  existence  is  overlooked  in  their  minor  degrees 
of  development,  from  inattention  on  the  one  hand  and  from  defi- 
ciency in  our  means  of  observation  on  the  other.  On  this  subject  it 
is  interesting  to  remember  that  in  the  second  case  a  feeble 
pulsation  remained  in  the  tumour  after  it  was  punctured. 


538  DISEASES   OF   THE    PLEUEA. 

We  must  then  admit  three  cases  of  empyematous  pulsation. 

I.  Pulsating  tumour  with  progressive  disorganisation  of  the 
integuments,  indicated  by  pain,  tenderness,  a  red  and  shining 
state  of  the  skin,  and  terminating  speedily  in  external  fistula. 

II.  Pulsating  tumour  of  a  very  chronic  nature,  without  integu- 
mental  irritation,  and  apparently  exhibiting  no  tendency  towards 
external  fistula.  The  duration  of  this  condition  may  be  very 
considerable. 

III.  Pulsation  of  the  entire  empyematous  sac,  occurring  with- 
out any  subtegumental  abscess.  Of  this  very  singular  condition 
the  following  is  a  striking  example  : — 

Obs. — Acute  pleurisy  with  effusion — passage  into  the  chronic 
condition — dislocation  of  the  heart  to  the  right  side — great  accu- 
mulation of  fluid,  attended  by  diastolic  pulsation  of  the  entire 
left  side  of  the  thorax — operation  of  paracentesis  thrice  repeated — 
return  of  the  pulsation  ivith  each  accumulation  of  fluid. 

A  gentleman,  aged  about  twenty-five,  was  attacked,  after 
attending  the  races  at  Newmarket,  with  symptoms  of  acute  in- 
flammation of  the  left  pleura,  which  in  a  short  time  passed  into 
that  fallacious  state  of  latency,  so  fertile  a  source  of  dangerous 
error  to  the  patient  and  the  physician.  After  some  weeks,  how- 
ever, the  symptoms  of  accumulation  became  too  manifest  to  be 
overlooked,  and  he  was  again  placed  under  medical  care,  yet  with- 
out any  impression  being  made  on  the  disease.  He  came  to 
Dublin  with  the  left  pleura  completely  filled,  the  lung  compressed, 
and  the  heart  pulsating  two  inches  to  the  right  of  the  sternum. 
Notwithstanding  this  great  amount  of  local  disease,  his  consti- 
tutional symptoms  were  but  trifling,  his  strength  was  consider- 
able, his  appetite  excellent,  and  his  spirits  and  sleep  unimpaired. 
It  soon  became  manifest  that  nothing  could  be  expected  from 
medicine,  for  the  period  at  which  its  effects  could  have  been  bene- 
ficial had  long  passed  by.  We  found  that  a  general  but  not  very 
violent  pulsation  could  be  felt  over  the  whole  of  the  left  side.  It 
was  not  stronger  in  one  portion  than  another,  nor  did  there  appear 
any  tendency  towards  the  formation  of  an  external  abscess.  The 
side  was  dilated  to  a  considerable  extent,  absolutely  dull  on  per- 
cussion ;  while  the  suffering  of  the  patient  from  the  mechanical 
pressure  of  the  fluid,  was  every  day  increasing. 

The  chest  was  punctured  in  the  usual  situation,  and  several 
pounds  of  a  serous  fluid  drawn  off.  The  operation  was  followed  by 


DISEASES   OF   THE   PLEURA.  539 

great  relief  of  the  clyspncea.  The  pulsation  of  the  side  ceased, 
and  the  anterior  portion  of  the  chest  became  sonorous  on  per- 
cussion. The  sound,  however,  was  not  that  caused  by  a  healthy 
lung,  but  rather  of  that  tympanitic  character  which  we  observe 
in  cases  of  empyema  and  pneumothorax,  when  a  thin  stratum  of 
air  is  interposed  between  the  liquid  and  the  parietes  of  the  chest. 
It  was  however  found  that  little  or  no  change  took  place  in  the 
position  of  the  heart,  nor  did  the  stethoscope  indicate  any  decided 
expansion  of  the  compressed  lung. 

Notwithstanding  these  circumstances  the  patient  experienced 
extraordinary  relief  for  many  days,  so  much  so,  indeed,  as  to  in- 
duce him  to  believe  that  his  disease  had  been  finally  removed. 
He  went  into  society,  and  took  active  exercise  daily  :  but  it  soon 
became  evident  that  the  effusion  was  on  the  increase.  The  tym- 
panitic sound  anteriorly  disappeared,  and  was  replaced  by  com- 
plete dulness,  and  the  pulsation  of  the  affected  side  became  not 
only  manifest,  but  increased  daily,  until  it  reached  a  degree  of 
violence  never  presented  before  the  operation.  The  throbbing  of 
the  side  could  be  seen  when  the  patient  was  dressed,  or  even  when 
he  lay  in  bed  covered  with  bed  clothes.  When  the  hand  was  placed 
on  any  portion  of  the  left  side,  an  impulse  as  strong  as  that  of  a 
large  false  aneurism  was  perceptible.  This  was  equally  observable 
in  the  acromial  region,  as  in  the  lateral,  and  most  inferior  portion 
of  the  chest.  The  heart  pulsating  in  the  right  mammary  region 
conveyed  the  idea  of  a  somewhat  excited  action  ;  there  was  at  least 
greater  excitement  than  is  ordinarily  seen  in  dexiocardia. 

The  operation  was  a  second  time  performed,  though  with  a 
*  diminution  of  the  resulting  benefit ;  the  fluid  now  drawn  off  was 
more  turbid,  and  the  quantity  removed  not  less  than  from  seven 
to  eight  pounds.  This  second  operation,  like  the  first,  was  fol- 
lowed by  temporary  relief,  and  by  the  same  modification  of  the 
physical  signs.  The  heart,  however,  seemed  fixed  in  the  right  side 
of  the  chest — at  least  it  certainly  never  passed  the  mesian  line. 
A  third  time  the  chest  filled,  and  with  greater  rapidity  than 
before,  and  the  pulsation  became  so  violent  as  to  disturb  the 
patient's  rest  from  the  throbbing  of  the  side.  It  is  difficult  to 
convey  an  idea  of  this  extended  diastolic  pulsation. 

At  the  urgent  entreaty  of  the  patient,  the  operation  was  a 
third  time  performed,  and  a  vast  quantity  of  sero-purulent  matter 
mixed  with  the  colouring  particles  of  the  blood,  was  withdrawn. 


540  DISEASES   OF    THE    PLEEKA. 

On  this  occasion,  however,  but  little  relief  was  afforded ;  the 
system  was  evidently  giving  way ;  the  fluid  re-accumulated  ; 
irritative  fever  set  in ;  and  the  throbbing  of  the  side  was  re- 
established, though  not  with  the  same  violence  as  before.  The 
patient  sunk  exhausted,  and  with  bronchial  effusion. 

The  operations  in  this  case  were  performed  by  Mr.  Cusack,  but 
after  the  result  of  the  first  puncturing  of  the  chest,  neither  that 
eminent  surgeon  nor  I  entertained  any  hopes  of  the  patient's 
recovery.  For  the  non-expansion  of  the  lung,  while  the  heart 
remained  little  if  at  all  changed  in  its  position,  to  say  nothing  of 
the  rapid  refilling  of  the  pleura,  were  grounds  for  the  most  un- 
favourable prognosis  ;  the  subsequent  operations  were  performed 
solely  with  a  view  of  giving  the  patient  some  temporary  relief. 

The  great  interest  in  this  case  consists  in  the  occurrence  of  the 
extraordinary  diastolic  throbbing  of  the  affected  side.  Of  the 
force  of  this  pulsation,  it  is  difficult  to  convey  an  idea,  exceeding 
as  it  did  in  strength  and  extent  that  of  the  largest  aortic  aneu- 
risms I  have  ever  seen,  and  the  force  of  this  pulsation  was  always 
observed  to  be  at  its  maximum,  when  the  effusion  and  conse- 
quently the  pressure  was  at  its  greatest  height.  The  diminished 
throbbing,  in  the  latter  stages  of  the  case,  may  be  attributed  to 
the  lessening  energy  of  the  heart ;  and  it  appears  not  improbable 
that  this  communicated  pulsation  does  really  occur  in  many  cases 
of  empyema,  with  dislocation  of  the  heart,  but  remains  unrecog- 
nized, either  from  its  feeble  development,  or  from  the  fact  that 
observers  being  ignorant  of  its  existence  take  no  pains  to  dis- 
cover it. 

In  cases,  such  as  Egan's,  where  the  heart  was  to  the  right  of 
the  sternum,  and  pulsations  could  be  seen,  felt  and  heard  in  the 
left  submammary  region,  I  have  no  doubt  that  the  sounds  were 
those  of  the  heart  transmitted  across  the  lymphic  effusion  ;  but 
it  is  still  a  question  whether  sounds  similar  to  those  of  aneurism 
do  really  attend  pulsations  of  an  empyema. 

Connected  with  the  subject  of  the  external  pointing  of  an 
empyema,  the  development  of  a  local  emphysema  in  the  walls  of 
the  chest,  is  a  condition  deserving  of  some  special  consideration. 
It  would  appear  that  in  certain  cases  the  attempt  at  the  formation 
of  an  external  abscess  is  abortive,  or  at  least,  that  after  a  certain 
period  the  evidences  of  the  latter  condition  disappear,  while  those 
of  the  original  effusion  remain  unchanged.     Some  peculiar  cir- 


DISEASES   OF   THE    PLEURA.  541 

cumstances  attend  this  effort,  especially  the  coexistence  of  the 
sign  of  an  aeriform  secretion  in  a  circumscribed  portion  of  the 
chest,  corresponding  to  the  situation  of  the  threatened  abscess. 
Good  reasons  exist  for  believing,  whatever  may  be  the  source  of 
this  gaseous  secretion,  that  it  is  influenced  in  its  quantity  and 
motions  by  the  respiratory  acts.  Its  existence  is  made  manifest 
by  an  emphysematous  crackling  over  the  part  affected,  by  crepi- 
tation of  a  metallic  character,  and  evidently  superficial,  and  lastly, 
by  those  extraordinary  acoustic  phenomena,  which  were  observed 
in  the  case  of  Mason.  With  respect  to  the  source  of  this  air,  we 
are  in  doubt,  and  we  are  not  yet  in  a  position  to  say  whether  it 
proceeds  from  a  pure  secretion,  or  is  communicated  through  some 
fistula,  or  solution  of  continuity,  between  the  bronchial  tubes 
and  the  pleura.  I  had  once  an  opportunity  of  witnessing  a  case, 
where  a  tortuous  fistula  had  been  established,  in  consequence  of 
some  adhesion  of  the  lung  between  the  bronchial  tubes  and  an 
external  abscess. 

The  patient  had  suffered  from  symptoms  of  tubercular  disease, 
and  had  for  some  time  presented  the  ordinary  signs  of  cavity  in 
the  upper  portion  of  the  lung.  He  became  affected  with  pain  and 
swelling  of  the  soft  parts  of  the  shoulder ;  the  tumefaction  ex- 
tended in  a  short  time  as  far  as  the  apex  of  the  scapula.  When 
I  saw  this  patient  he  presented  an  oblong  flattened  tumour 
extending  from  the  acromial  to  the  infra-scapular  region.  On 
percussion  this  tumour  rendered  an  exaggerated  bruit  dc  pot  fele, 
while  the  touch  conveyed  the  idea  of  a  large  quantity  of  liquid 
and  air.  A  singular  metallic  gurgling  sound  was  everywhere 
audible,  and  the  volume  of  the  tumour  as  well  as  the  physical 
signs  were  influenced  by  the  cough  and  respiration.  The  signs 
of  the  pulmonary  cavity  remained  unchanged,  while  the  ex- 
amination of  the  lower  portion  of  the  chest  shewed  that  no 
separation  of  the  pleura  had  taken  place. 

On  dissection  a  fistulous  passage  was  discovered,  springing 
from  the  tuberculous  cavity,  and  passing  upwards  from  the 
anterior  edge  of  the  clavicle,  towards  the  acromial  process,  where 
it  opened  into  a  wide  irregular  cavity,  containing  purulent  matter 
and  air,  bounded  by  the  integuments  on  the  one  side,  and  by  the 
layers  of  the  scapular  muscles  on  the  other. 

We  may  now  turn  our  attention  to  the  interesting  subject,  of 
vicarious  secretion  from  the  bronchial  mucous   membrane,   an 


5±'2  DISEASES   OF   THE    PLEUKA. 

example  of  which  is  met  with  in  the  case  of  Egan.  The  late 
Professor  Greene  in  his  memoir  on  Empyema,  details  some 
cases  of  the  empyema  of  necessity,  remarkable  amongst  other 
circumstances,  for  the  fact  that  a  vicarious  secretion  was 
established.  In  his  three  first  cases,  coincident,  or  nearly  so 
with  the  appearance  of  the  tumour,  a  profuse  muco-purulent 
expectoration  existed  ;  but  which  greatly  subsided,  or  altogether 
disappeared  after  the  puncture  of  the  abscess.  No  evidence  of 
pneumothorax  or  pulmonary  fistula  existed  in  these  cases,  nor 
is  there  the  slightest  reason  to  believe  that  there  was  any  per- 
foration of  the  pulmonary  pleura.  In  one  of  these  cases,  when 
the  discharge  from  the  wound  was  temporarily  arrested,  there 
was  a  return  of  the  secretion  from  the  bronchial  tubes  ;  his 
fourth  case  has  this  peculiarity,  that  it  presents  the  same  phe- 
nomena of  vicarious  secretion  as  in  the  former  instances,  which 
also  ceased,  after  the  operation;  notwithstanding  that  both  lungs 
were  studded  with  tubercles,  which  in  the  left  lung,  the  one 
unaffected  by  empyema,  were  actually  in  a  state  of  softening 
to  such  an  extent  as  to  leave  excavations  of  the  size  of  large  peas. 
This  case  is  also  of  great  importance  as  showing  that  the 
expectoration  did  not  proceed  from  a  communicated  abscess  in 
the  lung,  or  from  a  fistulous  communication  with  the  cavity  of 
the  pleura.  Dr.  Greene  expresses  his  opinion  that  its  sudden 
disappearance,  after  an  external  opening  for  the  matter  had  been 
made,  proves  that  it  was  not  the  result  of  bronchitis. 

Another  singular  fact  connected  with  this  subject  has  been 
noticed  by  Dr.  Graves,  who  observed  it  in  two  cases  ;  one  of  which 
he  communicated  to  the  Dublin  Pathological  Society — it  was, 
that  the  fcetor  of  the  expectoration  ceased  on  the  external  opening- 
having  been  effected  ;  and  in  one  of  these  cases,  the  temporary 
closure  of  the  wound  was  followed  by  the  return  of  the  fcetor  in 
the  bronchial  secretion. 

Are  we  to  consider  these  cases  as  examples  of  chronic  bron- 
chitis superadded  to  pleurisy,  or  is  the  copious  discharge  an 
excretion  rather  than  a  secretion  of  the  mucous  membrane  ? 
The  latter  opinion  is  espoused  by  Drs.  Greene  and  Hutton,  both 
of  whom  find  in  the  analogies  of  other  forms  of  purulent  col- 
lections, very  strong  grounds  for  the  adoption  of  it.  And, 
indeed,  to  sum  up  this  interesting  subject,  we  cannot  do  better 
than  insert  here,  some  of  the  conclusions,  to  which  Dr.  Greene 


DISEASES  OF   THE    PLEUKA.  543 

was  led,   from  an  examination  of  the  cases  published  in  his 
memoir. 

"  I.  That  in  cases  of  effusion  into  the  pleural  cavity  a  copious 
and  purulent  expectoration,  is  a  frequent  accompaniment, 
depending,  in  some  instances,  on  a  fistulous  communication 
established  between  the  seat  of  the  collection,  and  a  bronchial 
tube,  and  that  when  such  a  communication  has  taken  place,  it 
may  be  recognized  by  well  known  and  characteristic  signs. 

"II.  But  that,  in  other  instances,  the  expectoration  may  be 
equally  copious,  and  purulent,  while  all  the  physical  signs  of 
such  a  communication  are  absent,  and  where,  consequently,  the 
symptom  in  question  cannot  be  referred  to  such  a  lesion. 

"III.  That  an  expectoration  of  a  similar  character  will  also 
occur  in  some  cases  of  empyema,  uncomplicated  with  tubercular 
excavations,  or  with  abscesses,  the  result  of  pneumonia,  as  can 
be  proved — first,  from  the  absence  of  the  physical  signs  indicative 
of  these  lesions  ;  and  secondly,  by  a  consideration  of  the  follow- 
ing phenomena  : — 

"  IV.  That  remarkable  changes  take  place  in  the  expectoration, 
as  soon  as  a  free  external  outlet  is  afforded  for  the  matter  :  it 
will  be  then  observed  to  have  rapidly  diminished  in  quantity, 
and  to  have  changed  from  the  puriform  to  the  mucous  character, 
and  in  some  instances  to  have  lost  its  fcetor. 

"  V.  That  if  the  external  opening  becomes  closed,  the  expec- 
toration will  again  become  copious,  and  will  re-assume  its 
puriform  character  and  foetor. 

"  VI.  That  as  these  phenomena  cannot  be  accounted  for  on 
the  supposition  that  the  expectorated  matter  is  the  product  of 
bronchitis,  or  that  it  is  received  into  the  bronchial  tubes  by  their 
communication  with  purulent  deposits  in  the  lung,  or  with  the 
collection  in  the  pleural  sac,  an  explanation  must  be  sought  for 
in  some  general  law  which  establishes  a  reciprocity  of  morbid 
actions  between  serous  and  mucous  surfaces. 

"  VII.  That  many  examples  of  the  force  of  this  law  are  afforded 
in  what  have  been  termed  '  critical  evacuations ' ;  as  for  instance, 
where  morbid  collections  in  the  peritoneum  have  been  suddenly 
transferred  to  the  intestinal  mucous  surface,  independently  of  the 
processes  of  adhesive  inflammation  and  ulceration  ;  and  that 
there  is  no  reason,  a  priori,  why  this  law  should  not  occasionally 
obtain  between  the  respiratory,  serous,  and  mucous  membranes. 


544  DISEASES   OF   THE   PLEURA. 


-) 


"  VIII.  That  a  recollection  of  this  law  may  be  of  practical 
importance,  because  in  cases  where  the  physical  signs  of  cavities 
in  the  lung  are  obscure,  we  should  not  allow  our  opinion  to  be 
biased  in  favour  of  these  lesions,  by  taking  the  expectoration, 
however  copious  and  purulent,  into  consideration,  inasmuch  as 
it  may  be  the  result  of  the  general  law  just  referred  to,  and  if  so, 
should  not  form  a  ground    of    objection    to    the    operation   of 

paracentesis. 

"IX.  That  even  when  the  physical  signs  of  a  cavity  appear  to 
be  better  marked,  they  may  be  still  deceptive,  owing  first  to  the 
great  accumulation  of  matter  in  the  bronchial  tubes ;  and, 
secondly,  to  the  compressed  condition  of  the  lung  around  them, 
whereby  the  natural  phenomena  of  the  voice  and  respiration 
are  so  modified,  that  when,  combined  with  the  loud  gurgling 
rale  in  the  tubes,  they  may  be  mistaken  for  the  signs  of  a  cavity. 

"  X.  That  these  fallacious  signs  will  be  found  in  greatest 
intensity  at  the  root  of  the  lung,  and  will  disappear  more  or  less 
quickly  after  the  operation,  in  proportion  to  the  power  of 
expansion  possessed  by  the  lung,  when  the  fluid  in  the  pleura, 
which  is  the  cause  of  the  compression,  is  removed. 

"  XI.  That  one  of  the  grounds  for  diagnosis,  in  such  cases,  is 
the  proximity  of  the  signs  to  the  root  of  the  lung ;  if  they 
diminish  in  intensity  from  this  situation,  they  will  depend  on  the 
causes  just  assigned ;  if  on  the  contrary  they  are  found  at  the 
apex  of  the  lung,  or  any  part  distant  from  the  root,  they  may 
either  depend  on  cavities,  or  on  an  enlarged  bronchial  tube." 

The  subject  of  the  vicarious  secretion  in  empyema  leads  us 
naturally  to  examine  that  class  of  cases  in  which  an  hepatic 
abscess  is  supposed  to  open  into  the  lung,  and  evacuate  its 
contents,  through  the  bronchial  tubes.  There  seems  to  be  good 
grounds  for  believing  that  these  cases  are  of  two  kinds  ;  in  one, 
certainly,  a  direct  passage  through  the  diaphragm  takes  place  ; 
on  this  subject,  we  must  refer  to  where  we  speak  of  perforating 
abscess  of  the  lung ;  in  the  second  class,  there  is  no  solution  of 
continuity  of  the  diaphragm  or  lung,  but  the  latter  organ  takes 
on  the  vicarious  action.  Dr.  Corrigan  in  the  Transactions  of  the 
Pathological  Society  of  Dublin,  has  recorded  a  case,  in  which 
there  was  no  perforation  of  the  pleura,  yet  where  the  lung  secreted 
a  matter  of  the  same  nature,  as  that  which  was  found  in  the 
hepatic  abscess. 


DISEASES   OF  THE    PLEURA.  545 

When  a  patient,  who  has  already  been  labouring  under  empyema, 
with  or  without  those  sufferings  which  arise  from  the  mechanical 
pressure  of  the  fluid,  is  suddenly,  and  for  the  first  time,  attacked 
with  the  symptoms  of  suffocative  catarrh,  attended  by  copious 
expectoration  of  purulent  fluid,  we  may  suspect  that  a  fistulous 
passage  has  been  formed  between  the  pleura  and  bronchial 
tubes.  In  forming  this  diagnosis,  however,  we  must  not  neglect 
the  possibility  of  it  being  a  case  of  the  vicarious  secretion  just 
now  spoken  of. 

The  fluid  discharged  in  these  cases  is  sometimes  inodorous 
and  sometimes  foetid ;  after  the  lungs  have  recovered  from  the 
first  shock  of  the  accident,  and  especially  if  the  discharge  have 
not  the  gangrenous  fcetor,  a  favourable  result  may  be  anticipated. 
Even  in  the  case  in  which  the  fluid,  as  originally  discharged,  has 
the  gangrenous  odour,  and  where  this  condition  is  developed  after 
a  certain  period  of  time,  recovery  not  unfrequently  takes  place. 

I  am  not  in  a  position  to  state  what  proportion  of  these  cases 
presents  for  a  time  the  signs  of  fistular  pneumothorax.  Reason- 
ing, a  priori,  we  should  say  that  this  complication  would  neces- 
sarilv  occur  in  all  cases,  but  I  think  it  almost  certain  that  we 
may  have  the  opening  of  an  empyema  into  the  lung  without 
consequent  pneumothorax.  When,  however,  it  does  occur,  it  is 
temporary,  and  we  hence  derive  a  distinction  between  the  cases 
of  empyema  and  pneumothorax,  most  important  in  relation  to 
prognosis. 

First.  Formation  of  the  fistula  from  without,  inwards,  as  in 
the  case  of  a  simple  empyema  bursting  into  the  lung. 

Secondly.  Formation  of  the  fistula  from  within,  outwards,  as 
where  a  tuberculous,  or  gangrenous  cavity,  perforating  the 
pulmonary  pleura,  directly  induces  an  empyema  and  pneumo- 
thorax. 

In  the  first  of  these  cases,  a  cure  is  possible  and  probable ; 
in  the  second,  from  obvious  considerations,  such  a  result  is 
hardly  to  be  expected. 

Of  the  first  form,  the  following  case  is  a  good  illustration  : — 

Case. — Obs. — Acute  pleurisy  passing  into  the  chronic  stage — 
opening  of  the  empyema  through  the  lung — extraordinary  fcetor 
of  the  discharge — -fistular  pneumothorax — signs  of  recovery,  with 
singular  contraction  of  the  side. 

A  gentleman,   aged    23,    after  having   been    attacked   with 

N  N 


546  DISEASES  OF  THE   PLEURA. 

symptoms  of  acute  pleurisy,  presented  the  usual  phenomena 
of  chronic  indolent  effusion  into  the  left  pleura.  The  disease 
resisted  treatment,  and  the  side  remained  extensively  dull,  when 
he  suddenly  hegan  to  expectorate  foetid  muco-purulent  fluid  in 
great  quantities.  I  saw  him  soon  after  this  change  in  the 
symptoms.  So  intense  was  the  foetor,  that  the  odour  could  he 
perceived  in  every  part  of  his  large  mansion.  He  was  in  a  state 
of  extreme  weakness,  and  consumed  by  a  low  remittent  hectic. 
The  weather  was  extremely  hot,  and  the  sufferings  of  the  patient 
from  fever  and  exhaustion  so  great  as  to  cause  the  most  serious 
apprehensions.  I  recommended  a  tonic  regimen,  and  that  he 
should  be  brought  out  every  day  into  the  open  air.  Pills  of  chlo- 
ride of  lime  and  opium  were  also  prescribed,  with  a  view  of  correct- 
ing the  septic  action.  It  was  remarkable  that  on  the  first  and 
second  occasions  of  his  attempt  to  take  the  air  in  an  open  car- 
riage, he  and  his  attendants  were  literally  driven  back  by  the 
myriads  of  flies  which,  attracted  by  the  odour,  pursued  and 
settled  on  his  person  and  equipage.  This  gentleman  finally 
recovered,  but  with  a  degree  of  contraction  of  the  side  and 
depression  of  the  shoulder  greater  than  has  been,  so  far  as  I 
know,  ever  recorded.  Many  years  have  now  elapsed  since  the 
attack,  and  he  has  enjoyed  an  excellent  state  of  health ;  and, 
singular  to  say,  has  presented  no  symptoms  even  of  chronic 
bronchitis,  much  less  of  phthisis,  or  cirrhosis  of  the  lungs; 
his  left  shoulder  has  remained  permanently  depressed  to  the 
extent  of  nearly  three  inches  below  the  right. 

It  is  easy  to  understand  how,  under  the  circumstances  of  this 
case,  the  cure  would  not  be  possible  without  an  extreme  con- 
traction of  the  side.  This  patient  had  a  lung  long  compressed, 
and  diminished  in  volume  by  a  copious  pleuritic  effusion,  which 
was  removed,  not  by  absorption,  but  by  direct  evacuations 
through  the  lung,  an  accident  which  by  the  formation  of  the 
fistula  presented  an  insuperable  obstacle  to  the  re-expansion  of 
the  organ,  so  that  the  extreme  degree  of  contraction  was  a  neces- 
sary condition  of  the  final  removal,  by  the  efforts  of  nature,  of 
the  liquid  and  air  in  the  cavity  of  the  pleura. 

Differential  Diagnosis. — The   diseases  which   may  be    mis- 
taken for  pleuritis  with  effusion,  or  vice  versa,  are — 
Tubercle  of  the  lung. 
Pneumonia,  in  the  stage  of  hepatization. 


DISEASES  OF  THE  PLEURA.  547 

Enlargement  of  the  liver. 

Hydrothorax. 

Cancer  of  the  lung,  or  mediastinum. 

Hydatid  of  the  lung. 

The  cases  generally  mistaken  for  tubercle  are  of  two  kinds ; 
there  is  either  a  circumscribed  and  chronic  effusion,  which  may 
exist  without  much  eccentric  displacement,  or  there  may  be  a 
copious  subacute  effusion  compressing  the  lung,  and  occurring 
in  a  lymphatic  subject. 

In  the  first  case,  we  generally  find  that  the  health  does  not 
suffer  in  proportion  to  the  extent  of  the  disease  as  indicated  by 
the  stethoscope.  The  dulness  is  complete,  as  is  also  the  absence 
of  rale,  and  often  of  respiration ;  although  when  these  signs 
occur  in  the  lower  portion  of  the  chest,  we  have  a  group  quite 
unlike  the  phenomena  of  phthisis  ;  yet  when  they  are  produced, 
by  a  circumscribed  empyema,  at  the  upper  portion,  as  occa- 
sionally occurs,  the  difficulty  of  diagnosis  is  much  greater.* 

Examples  of  the  second  case  are  by  no  means  unusual;  a 
child  of  the  lymphatic  temperament  is  attacked  with  pain  in  the 
side,  fever,  and  cough.  Phthisis  is  apprehended  from  these 
symptoms,  and  after  a  fortnight  or  three  weeks,  the  whole  side 
is  discovered  to  be  dull.  The  diagnosis  between  this  condition 
and  tubercle  will  be  aided  by  a  due  consideration  of  the  following 
circumstances  : — 

I.  The  absence  of  the  constitutional  suffering  usually  present 
in  cases  of  acute  phthisis. 

II.  The  fact  of  complete  dulness  of  the  side  occurring  in  so 
short  a  time. 

III.  The  lung  being  impermeable,  except  perhaps  in  the  upper 
portion,  where  a  feeble  murmur  without  rale  can  be  heard. 

IV.  The  signs  of  mediastinal  displacement  and  distension  of 
the  side. 

*  I  some  years  since  met  with  a  case  illustrating  the  above  observation.  A  gentle- 
man, aged  45,  while  in  his  usual  state  of  health,  was  attacked  with  hasmoptysis,  which 
recurred  frequently  for  about  a  week,  and  was  followed  by  the  usual  signs  of  tubercular 
consolidation  of  the  right  apex.  He  shortly  after  passed  under  the  care  of  an  eminent 
London  physician,  by  whose  advice  change  of  climate,  and  other  measures  were  resorted 
to,  but  without  avail.  On  examination  of  the  body  after  death,  which  occurred  within 
two  years  from  the  attack,  no  trace  of  tubercle  was  discovered,  but  a  circumscribed 
collection  of  matter  between  the  thickened  pluera  in  the  upper  part  of  the  chest. 
(Ed.) 

N  N  2 


548  DISEASES    OF   THE    PLEUKA. 


HEPATIZATION    OF   THE    LUNG. 


The  case  of  pneumonia  most  likely  to  be  confounded  with 
pleuritic  effusion,  is  the  rapid  typhoid  solidity  already  described. 
In  the  ordinary  variety,  however,  a  doubt  sometimes  exists,  as 
to  whether  the  signs  proceed  from  effusion  or  solidity. 

In  a  case,  seen  for  the  first  time,  with  the  previous  history  of 
which  we  were  unacquainted,  presenting  bronchial  respiration, 
and  with  an  effusion  just  sufficient  to  compress  the  lung,  without 
displacing  the  mediastinum  or  side,  there  might  be  a  difficulty. 
But  such  a  case  is  rare  ;  and  in  the  majority  of  instances,  the 
phenomena  of  voice,  and  the  existence  at  all  periods  of  some 
form  of  crepitating  rale,  in  conjunction  with  bronchial  respira- 
tion, will  distinguish  pneumonic  solidity  from  liquid  effusion. 


ENLARGEMENT    OF    THE    LIVER. 

An  enlarged  liver  may  dilate  the  side  and  cause  dulness  of 
sound  up  to  fourth  rib ;  in  most  cases,  however,  the  dulness 
only  extends  to  a  little  above  the  mamma.  The  following  cir- 
cumstances will  assist  in  diagnosis. 

T.  The  absence  of  intercostal  paralysis,  or  protrusion. 

II.  The  clearness  on  percussion  of  the  upper  and  middle  por- 
tions of  the  chest. 

III.  The  loudness  of  respiration  in  the  postero-inferior 
portion,  which  is  much  greater  than  could  be  anticipated  from 
the  amount  of  dulness. 

IV.  The  absence  of  lateral  displacement  of  the  heart  and  the 
existence,  in  many  cases  at  least,  of  the  vertical  displacement 
upwards.  This  is  principally  seen  when  the  left  lobe  of  the 
liver  is  engaged. 

V.  The  fact  of  the  interlobular  fissure  being  parallel  with  the 
mesian  line ;  for,  in  displacement  of  the  liver,  the  pressure 
being  exercised  on  the  right  lobe,  the  interlobular  fissure  is 
directed  towards  the  left  side,  and  forms  a  considerable  angle 
with  the  mesian  line. 

VI.  We  find  in  cases  of  hepatic  tumour,  without  pleuritis,  that 
the  dulness  of  the  postero-inferior  portion  of  the  side  disappears 
on  the  patient  taking  a  deep  inspiration,  returns  upon  expiration, 


DISEASES   OF  THE   PLEUEA.  549 

and  remains  fixed  during  ordinary  breathing.  I  have  never  wit- 
nessed this  phenomenon  in  any  case  of  empyema.  I  believe, 
however,  that  the  test  is  not  applicable  when  the  lower  portion 
of  the  pleura  has  been  obliterated  by  adhesions. 

TYPHOID   PLEUPJTIS. 

A  close  analogy  exists  between  this  affection  and  the  different 
forms  of  typhoid  or  asthenic  pneumonia ;  like  that  disease,  it 
occurs  in  the  debilitated,  or  broken  down  habit,  or  is  secondary 
to  typhus  fever,  or  some  other  morbid  constitutional  state ;  it  is 
generally  latent,  and  often  pointed  out  more  by  the  sinking  of 
the  powers  of  life,  than  by  any  new  suffering ;  though  forming 
suddenly  it  is  slow  to  be  removed,  is  seldom  uncomplicated,  but 
rather  one  of  many  secondary  lesions,  and  does  not  admit  of 
active  antiphlogistic  treatment. 

This  secondary  or  typhoid  pleuritis  is  met  with  in  the  follow- 
ing cases  : — 

I.  Typhus,  or  maculated  fever. 

II.  Occurring  in  the  course  of  the  exanthemata. 

III.  In  diffuse  inflammation,  and  in  bad  erysipelas. 

IV.  In  phlebitis,  or  purulent  absorption. 

Pleuritis  must  be  considered  as  a  rare  complication  of  essen- 
tial typhus.  In  those  examples,  which  I  have  witnessed,  it  was 
first  pointed  out,  by  sudden,  and  unaccountable  sinking ;  in  one 
case  the  effusion  occurred  on  the  sixth  day,  and  occupied  a  large 
portion  of  the  left  pleura,  without  pain,  or  distress  of  breathing. 
The  patient  recovered  from  the  fever,  and  the  effusion  was  sub- 
sequently absorbed ;  his  pulse  however  remained  quick ;  cough 
appeared ;  and  phthisis  was  apprehended.  He  was  carried  off 
by  a  sudden  attack  of  encephalitis,  and  on  dissection  the  lungs 
were  found  to  contain  miliary  tubercle  ;  while  the  left  pleura  was 
obliterated. 

In  another  case,  on  the  fourteenth  day  of  a  severe  maculated 
fever,  a  sudden  sinking  was  observed,  and  frottement  discovered 
over  the  left  side.  On  the  next  day,  the  patient,  a  young  female, 
had  the  appearance  of  an  individual  in  cholera ;  she  had  sweated 
copiously,  and  was  covered  with  miliary  eruption  ;  there  was 
severe  orthopnoea  and  she  speedily  sank.  A  double  effusion 
had  existed. 


550  DISEASES    OF    THE    PLEURA. 

The  left  pleura  contained  a  large  quantity  of  whey-coloured 
fluid ;  while  in  the  right,  the  effusion  was  more  sanguinolent 
and  serous.  In  both  lymph  occurred  in  a  reticulated  form  over 
the  whole  serous  membrane,  and  also  in  the  pericardium. 

Similar  circumstances  occur  in  puerperal  fever.  Dr.  Lee 
mentions  three  cases  in  which  the  symptoms,  during  life,  were 
exceedingly  obscure,  yet  where  copious  effusions  occurred,  and 
the  pleura  was  covered  with  false  membrane.  In  one  the 
pleura  had  given  way  by  sloughing.  Similar  appearances  have 
been  observed  by  other  authors. 

We  observe  this  form  of  disease  most  frequently,  in  the  erysi- 
pelatous diseases,  particularly  those  of  a  low  type  ;  in  the  diffuse 
inflammations,  and  purulent  phlebitis.  In  these  cases  purulent, 
or  sero-sanguinolent  collections  are  commonly  found  in  the 
pleura,  although  during  life,  symptoms  of  pleurisy  were  either 
absent,  or  very  slightly  marked.  In  some  instances,  however,  I 
have  observed  the  invasion  of  the  disease  to  be  accompanied  by 
severe  pain. 

There  is  an  affection  which  may  be  termed  typhoid  arthritis, 
in  which  this  secondary  typhoid  pleuritis  is  liable  to  occur. 
The  late  Dr.  M'Dowel  was,  I  believe,  the  first  to  describe  this 
disease,  of  which  the  principal  characters  are — the  rapid  tume- 
faction and  suppuration  of  many  of  the  large  joints,  accompanied 
with  a  typhoid  fever,  and  followed  by  affections  of  the  brain, 
lungs,  heart  or  digestive  system.  In  such  cases  I  have  more 
than  once  observed,  purulent  collections  in  the  pleura,  lung,  and 
pericardium. 

TREATMENT    OF    PLEURITIS. 

It  is  scarcely  necessary  to  allude  here  to  the  treatment  of  that 
mild  form  of  the  disease  which  is  known  as  dry  pleuritis — a 
disease  not  so  often  a  primary  idiopathic  affection  as  an  inter- 
current disease,  or  as  one  coming  on  during  the  convalescence 
from  other  and  often  totally  different  affections. 

It  is  characterised  by  the  want  of  severe  constitutional  symp- 
toms. The  pain  is  often  trifling  or  may  be  wanting,  the 
respiration  but  little  disturbed,  and,  in  many  cases,  would  elude 
detection  but  for  its  characteristic  physical  signs,  which  are 
the  dry  rubbing  sound,  with  clearness  on  percussion.     In  such 


DISEASES    OF    THE    PLEURA.  551 

cases,  it  is  often  only  necessary  to  watch  the  patient,  so  that  we 
may  not  be  surprised  by  the  occurrence  of  a  liquid  effusion,  a 
circumstance,  however,  by  no  means  of  common  occurrence. 

In  most  of  these  simple,  dry  cases  the  disease  subsides  spon- 
taneously ;  but  its  disappearance  will  be  accelerated  by  the  use 
of  a  few  leeches,  or  slight  counter-irritation,  or  the  application 
of  poultices  to  the  side.  Should  the  disease  not  yield  to  these 
simple  measures,  change  of  air  should  be  advised,  and  small 
doses  of  the  iodide  of  potassium  given  in  some  of  the  prepara- 
tions of  bark  or  sarsaparilla. 

But  the  treatment  of  pleurisy  with  effusion  requires  a  more 
decided  course  of  action,  and  we  must  endeavour  to  bring  about, 
in  as  short  a  space  of  time  as  possible,  that  remission  of  the 
constitutional  symptoms  which  is  indicated  by  the  cessation  of 
febrile  heat  and  over- excitement  of  the  pulse.  Yet  I  am  not  an 
advocate  for  the  free  or  indiscriminate  use  of  the  lancet  in  this 
disease.  Every  day's  experience  will  make  the  observing  prac- 
titioner in  this  country  more  and  more  cautious  in  the  adoption 
of  copious  general  blood-lettings. 

As  we  cannot  specify  the  cases  in  which  bleeding  from  the 
arm  is  really  proper  or  imperative,  it  must  suffice  to  point  out 
such  circumstances  as  should  induce  us  to  use  the  lancet  in  acute 
pleurisy.     They  may  be  stated  to  be — 

I.  The  existence  of  a  high  inflammatory  fever,  with  a  strong, 
hard  pulse,  and  excited  action  of  the  heart. 

II.  The  fact  that  the  disease  is  in  a  very  early  stage,  and  occur- 
ring in  a  person  of  good  constitution,  and  one  who  has  been 
previously  healthy.  We  cannot  specify  any  exact  time  beyond 
which  the  remedy  should  not  be  used,  but  the  fact  that  some 
effusion  has  already  occurred  is  not  to  deter  us  from  bleeding, 
which  is  a  measure  the  fitness  or  unfitness  of  which  is  to  be 
regulated  much  more  by  the  constitutional  state  and  the  period 
of  duration  of  the  disease  than  by  the  results  of  physical  examina- 
tion. 

I  believe  that  even  when  we  determine  on  the  use  of  the 
lancet,  it  must  be  looked  on  less  as  our  main  remedy  than  as  a 
preparative  of  other  treatment ;  and  it  will  generally  be  found 
that  one  or  two  moderate  bleedings  will  suffice.  It  appears 
certain  that  after  the  first  or  second  bleedings  we  must  trust  to 
other  means,  and  take  great  care  not  to  lower  the  strength  too 


552  DISEASES    OF   THE    PLEURA. 

much.  There  is  much  more  danger  from  over  depletion  in  this 
disease  than  in  acute  pneumonia ;  but  there  will  be  little  danger 
of  error  on  this  point  if  the  practitioner  is  impressed  with  the 
opinion  that  he  is  to  consider  bleeding  more  as  a  preparative 
for  other  remedies  than  as  the  chief  remedy. 

Local  bleeding  may  be  performed  by  cupping  or  leeching, 
When  the  pain  is  severe,  and  the  covering  of  the  chest  very 
spare,  cupping  will  be  found  inconvenient  and  painful,  and 
leeches  should  be  used.  It  is  a  good  practice  to  apply  them  in 
relays,  and  to  use  poulticing  between  the  periods  of  application. 

There  are  few  measures  of  more  immediate  advantage  than 
the  diligent  employment  of  large  warm  poultices.  In  most  cases, 
when  they  are  used,  the  poultice  is  too  small.  It  should  cover 
a  large  portion  of  the  side.  We  shall  find  linseed  meal  or  bran 
the  best  materials.  I  prefer  the  first,  and  the  poultice  should 
be  spread  on  oiled  silk,  and  this  again  covered  with  flannel. 
The  spongio-piline  may  also  be  used,  but  I  have  found  it  more 
advisable  in  cases  of  abdominal  than  of  thoracic  inflammation. 

The  general  rules  as  to  the  application  of  blisters  need  scarcely 
be  here  repeated,  as  all  admit  that  their  use  during  the  early 
inflammatory  tension  is  improper.  I  once  saw  in  a  case  of  acute 
pleuro-pneumonia,  where  a  blister  had  been  applied  at  a  very 
early  stage,  a  perfect  mass  of  the  blister  exhibited  on  the  lung 
by  an  extreme  vascularity  of  the  surface.  But  when  depletions 
by  general  or  local  bleedings,  or  both,  have  been  performed,  and 
the  heat  of  surface  and  violence  of  the  pain  lessened,  we  may 
use  repeated  blistering  with  great  advantage.  It  is  excellent 
practice  to  lay  a  poultice  over  the  blistering  plaister,  as  well  as 
over  the  dressing  of  the  blistered  surface. 

The  use  of  mercury  must  be  left  to  the  discretion  of  the 
attendant,  and  if  he  can  cure  our  patient  without  its  employment 
it  will  be  all  the  better.  Under  most  circumstances,  we  should 
employ  it  with  caution,  and  not  force  on  its  use  if  we  find  a 
resistance  to  its  ordinary  action.  In  the  anaemic  and  scrofulous 
conditions,  and  in  persons  who  have  had  near  relations  the  sub- 
jects of  consumption,  he  should  try  to  cure  the  disease,  at  least 
in  its  acute  stage,  without  employing  mercury. 

In  some  cases,  and  I  believe  the  number  to  be  greater  than 
many  might  suppose,  the  disease  will  disappear,  as  shewn  by 
the  returning  sonoriety  of  the  chest  in  a  short  time  after  the 


DISEASES   OF   THE   PLEURA.  553 

use  of  the  treatment.  This  may  be  especially  looked  for  when 
all  pain  has  subsided  and  the  pulse  has  become  natural.  But 
in  others  the  dulness  remains  obstinate,  and  if  the  case  be 
neglected,  the  effusion  may  insidiously  increase,  till  a  great 
amount  of  eccentric  pressure  is  produced.  This  increase  of  the 
effusion  often  goes  on,  without  any  corresponding  constitutional 
symptoms.  The  entire  side  becomes  dull  from  the  clavicle  to 
the  lowest  portion,  and  the  life  of  the  patient  may  be  placed  in 
the  greatest  jeopardy  from  the  want  of  respiration.  This,  how- 
ever, is  not  the  most  common  case,  and  is  seldom  met  with 
where  the  disease  has  been  recognized  and  properly  treated  at  an 
early  period.  In  most  of  these  latter  cases  we  find  dulness  to 
remain  occupying  one-half  or  two-thirds  of  the  affected  side,  and 
our  efforts  must  be  steadily  devoted  to  remove  this  condition. 

If  the  patient  has  not  had  mercury  in  the  earlier  periods  of 
the  case,  it  will  generally  be  proper  to  give  the  medicine  in  a 
mild  form  until  a  very  slight  action  is  produced.  We  may  give 
three  grains  of  mercury  with  chalk  combined  with  two  of  Dover's 
powder  three  or  four  times  in  the  day.  Or  we  may  use  poultices 
over  the  side,  with  mild  mercurial  ointment.  When  a  slight, 
but  evident  mercurial  action  is  produced,  the  remedy  is  to  be 
omitted,  and  the  patient  allowed  to  rest  for  one  or  two  days. 

We  may  often  observe  in  cases  where  mercury  has  pro- 
duced its  effects  on  the  mouth  a  remarkable  diminution  of  the 
symptoms  and  the  sufferings  of  the  patient.  This  is  not  always 
attended  with  immediate  signs  of  absorption,  for  wTe  may  find  the 
line  and  amount  of  dulness  remaining  unchanged ;  and  I  believe 
that  the  effusion  may  be  in  some  cases  actually  on  the  increase. 

We  may  then  commence  the  use  of  iodine  externally  and 
internally.  The  tincture  of  iodine  is  to  be  brushed  over  the 
surface  every  morning,  or  every  second  morning,  according  as 
the  patient  bears  it.  I  advise  the  morning  as  the  best  time,  for 
it  sometimes  happens  that  pain  and  itching  follow  the  applica- 
tion, which  would  interfere  with  the  rest  were  the  remedy  used 
at  bed  time.  Small  doses  of  the  iodide  of  potassium  should  be 
given  in  a  diluted  form.  I  find  that  from  five  to  eight  grains  of 
the  remedy  given  three  times  a  day  will  be  generally  sufficient ; 
and  if  the  kidneys  be  inactive  we  may  combine  with  it  a  diuretic, 
such  as  juniper,  broom,  and  the  spiritus  setheris  nitrici. 

A  good  form  in  many  cases  is  that  of  Lugol's  mineral  water, 


554  DISEASES   OP   THE   PLEURA. 

which  we  may  prepare  by  adding  one  grain  of  iodine  and  five  or 
ten  grains  of  iodide  of  potassium  to  a  pint  of  water.  The  whole 
of  this  should  be  taken  in  the  day ;  it  often  acts  as  a  good 
diuretic  where  the  early  inflammation  has  been  severe.  We 
should  use  the  iodide  in  larger  doses,  as  specified  above.  Should 
the  action  of  the  heart  be  excited,  the  preparations  of  digitalis, 
such  as  the  infusion  or  tincture,  may  be  advantageously  added 
to  the  medicine.  And  we  must  not  forget  to  support  the 
patient's  strength  by  proper  nourishment. 

In  this  way  we  shall  find  in  most  cases  that  the  dulness  will, 
after  a  few  days,  begin  to  lessen,  and  finally  disappear,  with  or 
without  the  occurrence  of  the  dry  friction  sound  indicative  of  the 
re-apposition  of  pleural  surfaces. 

It  sometimes  happens  that  the  process  of  absorption  seems  to 
come  to  a  standstill,  and  resists  the  treatment.  Our  best 
course  will  then  be  to  apply  a  blister,  which  may  be  dressed 
with  mercurial  ointment ;  and  again,  when  the  parts  are  healed, 
to  use  the  iodine  lotion.  I  have  considerable  confidence  in  this 
mode  of  treatment.  The  curative  effects  of  iodine  after  the  use 
of  mercury  are  well  exemplified  in  such  cases. 

Pending  the  absorption  of  the  fluid,  or  for  some  time  subse- 
quent to  its  removal,  the  patient  may  be  liable  to  very  profuse 
night  sweats,  which  often  have  an  extremely  weakening  effect. 
Against  this  condition  I  have  found  that  opium  is  the  best 
remedy;  and  the  powers  of  this  medicine  in  controlling  the 
perspirations  are  often  most  remarkably  seen.  I  have  known 
the  tendency  to  perspire  to  continue  for  more  than  six  weeks 
after  the  side  had  become  clear  on  percussion,  so  that  the  opiate 
had  to  be  administered  every  night.  The  omission  of  the 
remedy  was  certain  to  be  followed  by  the  most  profuse  sweatings, 
while  on  the  nights  on  which  it  was  used  no  perspiration 
occurred.  Opium,  too,  has  the  power  not  only  of  preventing 
but  of  checking  the  symptoms,  as  where  a  copious  sweat  has 
occurred,  which  if  not  interfered  with  would  continue  the  whole 
night,  we  found  that  the  use  of  the  medicine  promptly  put  an 
end  to  the  discharge.  A  draught  containing  from  twelve  to 
twenty  drops  of  the  sedative  solution  of  opium  will  generally  be 
found  sufficient. 

Another  symptom  which  is  occasionally  troublesome  is  the 
excited  action  of  the  heart.     I  have  not  been  able  to  connect 


DISEASES   OF    THE    PLEURA.  555 

this  condition  with  any  anatomical  change  of  the  organ  ;  and  its 
history  and  physical  signs  are  more  those  of  a  functional  than  an 
inflammatory  disease.  We  find  simply  that  the  heart  begins  to 
act  with  great  force,  and  that  the  patient  complains  of  palpita- 
tion, and  of  the  increased  action  of  the  carotids  and  temporal 
arteries.  The  action,  though  forcible,  is  regular,  and  I  have 
never  found  that  any  valvular  murmur  attended  it.  This  is 
to  be  met  by  modifications  of  the  patient's  diet,  by  the  omission 
of  any  stimulatingimedicine,  such  as  iron,  bark,  or  iodine,  and 
by  the  exhibition  of  digitalis,  or  hydrocyanic  acid,  in  properly 
adjusted  doses.  Cases  may  arise  in  which  the  use  of  a  few 
leeches  or  a  blister  might  be  employed  with  advantage. 

So  much  has  been  written  on  the  subject  of  operation  in 
empyema  that  it  will  be  unnecessary  for  me  to  do  more  than 
simply  indicate  those  conclusions  to  which  I  have  been  led,  by 
such  observations  as  I  have  had  an  opportunity  of  making  on 
this  matter.  That  the  operation  is  often  a  justifiable  one,  is  not 
to  be  denied,  and  cases  occur  where  from  the  rapid  accumulation 
of  fluid  and  the  consequent  urgency  of  the  symptoms,  no  choice 
is  left  us  but  to  puncture  the  chest  as  the  last  resource  of  art. 

But  it  appears  to  me  that  in  the  majority  of  cases  requiring 
operation,  there  has  been  some  error  of  omission  or  commission 
in  the  early  treatment  of  the  disease.  At  least  it  is  certain  that 
in  every  instance  with  which  I  have  been  acquainted,  the  disease 
was  either  wholly  overlooked  in  the  commencement,  or  improperly 
and  insufficiently  treated. 

The  early  stages  of  inflammation  are  constantly  overlooked  ; 
for  I  believe  that  the  proportion  of  cases  of  pleuritic  effusion 
where  the  early  symptoms  are  insidious,  obscure,  or,  it  may  be, 
wanting,  is  unfortunately  greater  than  those  attended  with  the 
characters  commonly  laid  down  in  books.  The  nature  of  the 
disease  being  unsuspected,  physical  examination  is  not  made,  or 
is  performed  in  a  careless  manner,  and  so  the  disease  creeps  on, 
every  day  becoming  more  intractable,  not  only  to  medical,  but 
surgical  treatment. 

Again  it  often  happens  that  even  where  an  acute  pleurisy  has 
been  recognized  and  treated,  the  subsidence  of  the  pain,  dyspnoea, 
and  fever  is  taken  as  a  proof  that  the  patient  is  cured ;  yet  it  too 
often  happens  that  with  the  disappearance  of  the  ordinary  symp- 
toms we  have  really  a  progressive  advance  of  the  effusion ;  we 


556  DISEASES   OF   THE   PLEURA. 

have  scotched  the  snake  not  killed  it,  and  the  very  relief  afforded 
by  lulling  the  patient  and  his  attendant  into  a  false  security, 
actually  increases  the  danger. 

It  will  occasionally  happen  that  the  effusion  will  advance 
steadily  for  several  days,  notwithstanding  the  use  of  proper 
treatment,  until  the  sufferings  of  the  patient  from  its  pressure 
become  extreme.  This  I  believe  to  be  a  proper  case  for  para- 
centesis ;  yet  I  have  known  a  case  of  pleurisy  in  which,  on  two 
occasions,  the  urgency  of  the  patient's  sufferings  seemed  to  call 
for  surgical  interference,  yet  in  both  of  which  it  was  found  that 
the  dyspnoea  subsided,  after  lasting  about  twelve  or  fourteen 
hours ;  so  that  although  everything  was  got  ready  for  the 
operation,  it  was  thought  better  to  postpone  it.  This  was  a 
case  of  pleurisy  of  the  right  side,  which  set  in  somewhat 
insidiously,  but  yet  one  in  which  treatment  was  employed  at 
an  early  period.  This  case  ultimately  did  well,  perfect  absorp- 
tion having  been  effected,  with  but  a  very  slight  degree  of 
contraction  of  the  side  attending  the  cure. 

In  considering  the  operation  for  empyema  I  have  dealt  with 
that  case  in  which  no  extracostal  tumour  or  abscess  (empyema  of 
necessity)  is  formed.  Most  of  the  recorded  cases  of  successful 
operation  have  been  of  the  latter  kind.  A  question  may  still  be 
raised  as  to  whether  the  occurrence  of  an  empyema  of  necessity 
is  in  itself  a  sufficient  reason  for  immediate  operation.  I  have 
seen  the  curious  phenomenon  of  the  retrocession  of  these  tumours, 
and  it  appears  justifiable  to  say  that  in  determining  on  the 
performance  or  non-performance  of  the  operation,  we  must 
take  other  circumstances  into  consideration,  besides  the  mere 
appearance  of  the  external  tumour.  If  there  be  but  little  consti- 
tutional suffering,  and  if  the  respiration  be  not  much  disturbed, 
we  may  safely  wait.  But  on  the  other  hand,  if  there  be  an 
increasing  dyspnoea,  or  severe  hectic,  if  there  be  great  suffering  of 
the  opposite  lung  from  eccentric  pressure  ;  and  if  the  bronchial 
tubes  are  overloaded  by  vicarious  secretion,  which  sometimes 
threatens  asphyxia,  then  no  doubt  can  exist  as  to  the  fitness  of 
the  operation. 

I  have  no  experience  of  the  employment  of  caustic  as  a  means 
of  opening  the  empyema  of  necessity.  In  the  ordinary  forms 
there  seems  to  be  no  reason  for  adopting  it.  And  I  believe  that 
in  all  cases  the  lancet,  or  lancet  and  trocar,  will  be  found  greatly 


DISEASES   OF   THE   PLEURA.  557 

preferable.  In  using  the  trocar  and  canula,  we  should  avoid  the 
large  sized  instruments,  as  in  most  cases  the  fluid  will  be  found 
to  have  sufficient  tenuity  to  pass  through  a  very  small  canula. 
It  is  of  importance  that  the  sac  should  not  be  wholly  emptied. 
It  is  better  by  repeating  the  puncture  to  draw  off  the  fluid  by  two 
or  three  operations ;  and  it  sometimes  happens  that  an  operation 
by  which  only  a  moderate  portion  of  fluid  is  withdrawn  is  fol- 
lowed by  a  favourable  absorption  of  that  which  remains. 

With  respect  to  the  admission  of  air  through  the  canula  I 
believe  that  the  apprehensions  entertained  on  this  head  were 
founded  on  a  mistaken  theory  rather  than  actual  experience. 

I  can  only  say  that  I  never  saw  the  operation  for  empyema  per- 
formed, even  where  great  care  was  taken  to  prevent  the  admission 
of  air,  that  a  rush  of  air  did  not  take  place  into  the  pleura 
towards  the  close  of  the  operation  ;  but  I  never  saw  any 
bad  consequences  to  result  from  it.  It  will  generally  be 
found  that  at  first  the  fluid  flows  in  a  continued  stream,  then  its 
force  begins  to  slacken  ;  it  becomes,  as  it  were,  intermitting  in 
correspondence  with  the  respiratory  effort,  and  finally  during  the 
period  of  its  lessened  force,  which  is  that  of  inspiration,  a  rush 
of  air  takes  place  into  the  cavity.  It  is  very  probable  that  the 
proper  period  for  removing  the  canula  would  be  that  immediately 
preceding  this  occurrence,  but  this  rule  has  no  reference  to  any 
danger  that  may  result  from  the  introduction  of  air.  The  cir- 
cumstance may  be  taken  as  showing  that  a  point  has  been  at  the 
time  arrived  at  when  there  is  no  further  expansion  of  the  lung. 

We  apply  to  the  operation  of  paracentesis  of  the  chest  the 
same  rules  which  now  guide  us  in  tapping  the  belly.  When  I 
was  a  student  the  latter  operation  always  appeared  to  me  to  be 
one  of  the  most  dangerous  kind ;  the  great  proportion  of  those 
who  were  tapped  for  the  first  time  falling  victims  to  acute  perito- 
nitis, and  such  a  result  was  to  be  expected,  a  large  trocar  was 
used,  and  the  greatest  exertions  made  to  evacuate  every  drop  of 
the  fluid ;  the  patient  was  turned  on  his  side,  or  almost  on  his 
face.  The  belly  was  compressed  by  a  roller,  which  was  tightened 
as  the  liquid  flowed  from  the  canula,  or  it  was  kneaded  by  the 
hands  of  the  assistants.  The  very  violence  of  these  proceedings 
would  be  sufficient  to  cause  inflammation,  to  say  nothing  of  the 
effect  of  bringing  into  contact  two  serous  surfaces,  which  had  so 
long  been  separated.      The  operation  is  now  comparatively  safe, 


558  DISEASES   OF   THE   PLEDBA. 

owing  to  our  using  a  small  trocar,  to  our  avoiding  all  unnecessary 
manipulations,  and  to  the  most  important  circumstance  that  the 
surgeon  does  not  seek  to  remove  the  whole  of  the  fluid. 

We  are  not  yet  in  a  position  to  lay  down  any  rule  drawn  from 
a  sufficient  number  of  cases  as  to  the  propriety  of  closing  or 
keeping  open  the  wound.  But  it  appears  there  is  less  advantage 
to  be  expected,  when  the  fluid  is  serous,  from  keeping  the  wound 
open,  than  when  the  discharge  is  purulent. 

PASSIVE    OR    MECHANICAL   EFFUSIONS. 

The  advance  of  medicine  has  shewn,  that  so  far  from  idiopathic 
hydrothorax  being  a  common  affection,  it  is  in  reality  one  of  the 
rarest  of  pulmonary  diseases.  I  have  never  seen  any  case  of  it. 
Almost  every  instance  in  which  it  was  supposed  to  exist  has 
turned  out  to  be  bronchitis,  pneumonia,  congestion,  oedema  of  the 
lung,  Laennec's  emphysema,  or  morbus  cordis.  We  owe  much 
to  Laennec  for  his  discovery  of  this  most  important  fact. 

But  the  mechanical  effusions  are  much  more  common,  yet 
even  these  are  rarer  than  might  be  supposed  ;  and  we  shall  ob- 
serve effusions  into  every  cavity  of  the  body,  except  the  pleura. 
And  it  must  not  be  forgotten,  that  there  are  no  symptoms  peculiar 
to  this  disease  :  even  in  the  dropsical  diathesis,  the  symptoms,  as 
given  in  nosological  works,  depend  much  more  on  other  diseases. 

In  most  respects,  the  physical  signs  agree  with  those  of 
empyema.  But  there  is  one  remarkable  exception  ;  I  have  never 
observed  dilatation  of  the  intercostal  spaces,  or  protrusion  of  the 
diaphragm.  And  this  fact,  among  others,  I  have  adduced  as  an 
argument  in  favour  of  my  views  of  the  cause  of  muscular  dis- 
placement in  empyema. 

In  general,  where  the  serous  effusion  is  not  too  copious,  we 
observe  the  change  of  sound  varying  with  the  position  of  the 
patient.  In  one  instance,  however,  I  have  seen  an  exception  to 
this ;  it  was  the  case  of  a  multilocular  hydrothorax,  the  septa 
being  formed  by  previous  and  old  adhesions. 

Lastly,  mechanical  hydrothorax  may  be  confined  to  one  pleura. 
I  have  more  than  once  verified  this  fact ;  so  that  the  a  priori 
conclusions  of  Dr.  Darwall  on  this  subject  cannot  be  admitted.* 

*  Dr.  Darwall  gives  the  dulness  and  absence  of  respiration  at  one  side  only,  as  a 
distinguishing  mark  between  empyema  and  hydrothorax.  See  Cyclopedia  of  Practical 
Medicine,  art.  Hydrothorax. 


DISEASES   OF   THE   PLEURA.  559 


ULCERATION   OF   THE   PLEUEA. 


We  may  divide  the  perforations  of  the  pleura  into  two  classes. 

1st.  Those  in  which  the  ulcerative  disease  has  first  engaged 
other  parts,  and  the  serous  membrane  is  perforated  from  its 
posterior  surface. 

2nd.  Those  in  which  the  ulceration  results  from  original. dis- 
ease of  the  pleura,  and  begins  at  its  interior  surface. 

Of  these  cases  the  first  are  by  far  the  most  frequent.  In  this 
category  we  may  enumerate  the  perforations  from  tubercle, 
gangrene,  and  abscess  of  the  lung,  the  ulcerations  from  hepatic 
abscess,  and  from  anthrax  or  other  disease  of  the  thoracic 
parietes,  while  in  the  second  we  have  those  cases  in  which 
purulent  collections  having  formed  from  pleuritis,  are  discharged 
by  an  opening  through  the  costal,  pulmonary,  or  diaphragmatic 
pleura. 

In  the  section  on  Perforating  Abscess  of  the  Lung,  I  have 
given  some  examples  illustrative  of  the  first  variety.  I  shall 
now  examine  the  subject  of  fistulous  openings  in  the  pulmonary 
pleura. 

Tuberculous  ulceration  is  the  most  common  cause  of  ihis 
lesion  ;  or  of  empyema  and  pneumothorax  occurring  in  phthisis, 
next  in  frequency  is  that  resulting  from  gangrene  of  the  lung, 
and  lastly,  those  where  there  is  first  simple  empyema,  which  is 
ultimately  complicated  with  pueumothorax  from  the  consecutive 
perforation  of  the  pleura. 

EMPYEMA   AND    PNEUMOTHORAX    OCCURRING    IN    TUBERCULOUS 

PHTHISIS. 

Since  the  discovery  of  the  stethoscope,  a  great  number  of 
cases  of  this  quadruple  lesion  have  been  observed;  and  the 
researches  of  Keynaud,  Louis,  Beau,  Forbes,  and  Houghton, 
have  added  much  to  our  knowledge  of  its  pathology  and 
diagnosis. 

The  disease  may  set  in  with  violent  symptoms,  or  be  so 
latent  that  we  cannot  determine  the  date  of  its  invasion.  In 
the  first  case,  there  may  be  rapid  suffocation ;  but  in  many  in- 
stances, a  period  of  comparative,  and  often  singular  tranquillity 
succeeds  the  first  violent  symptoms. 


560  DISEASES   OF   THE   PLEUKA. 

Like  other  internal  solutions  of  continuity,  this  lesion  is 
Generally  pointed  out  hy  sudden,  new,  and  extraordinary  symp- 
toms. These  proceed  from  the  new  inflammation  of  the  pleura, 
on  the  one  hand,  and  the  collapse  of  the  lung,  on  the  other. 
But  as  pleuritis,  even  under  these  circumstances,  may  he  latent, 
and  as  the  collapse  of  the  lung  varies  much  in  different  cases, 
we  can  understand  how,  in  a  case  without  pain,  and  with  at  first 
but  little  collapse  of  the   lung,    the    suffering  should  he  but 

trifling. 

In  some  cases,  the  collapse  of  the  lung  is  sudden,  and  nearly 
complete  ;  while  in  others  this  is  prevented  by  adhesions  or 
solidity:  the  lung  yields  gradually  to  pressure,  and  even  in 
chronic  cases  may  never  become  completely  impermeable.  This 
is  the  most  common  case. 

The  symptoms  commonly  observed  are  the  following : — A 
sudden,  new,  and  violent  pain,  with  a  sensation  as  if  something 
had  given  way,  is  felt  in  the  lower  portions  of  the  side ;  followed 
by  dreadful  dyspnoea,  suppression  of  expectoration,  extreme 
anxiety,  and  general  collapse.  In  addition  to  these,  there  may 
be  loss  of  voice,  and  impossibility  of  lying  on  one  side.  In  the 
more  violent  cases,  death  may  occur,  with  aggravated  suffering 
on  the  day  of  the  accident ;  but  this  is  rare,  for  a  diminution  of 
symptoms  is  commonly  observed,  and  the  system  accommodates 
itself  to  the  new  condition  of  the  lung.  The  side  becomes 
dilated  ;  the  mediastinum  is  displaced  ;  and  the  peculiar  physi- 
cal signs  of  the  disease  are  manifested. 

As  a  diagnostic  of  perforation  of  the  lung,  the  occurrence  of 
sudden  and  overwhelming  dyspnoea,  accompanied  with  pain,  has 
been  strongly  dwelt  on  by  Louis  ;  but  in  phthisis  these  symptoms 
often  occur  without  any  such  lesion.  Thus,  I  have  frequently 
suspected  a  pneumothorax,  and  yet  found  the  physical  signs 
wanting ;  so  that  we  must  never  trust  to  the  symptoms,  unless 
they  can  be  verified  by  physical  signs.  The  pain  may  occur 
with  every  degree  of  intensity,  and  is  generally  aggravated  by 
lying  on  the  affected  side.  It  is  independent  of  the  -previous 
sensation  of  something  giving  way.  Thus,  in  a  patient  of  mine, 
the  first  sensation  was  that  of  a  sudden  crack,  extending  from 
above  downwards,  and  accompanied  by  a  feeling,  as  if  liquid  was 
shed  out  into  the  chest :  acute  pain  in  the  side  afterwards  set  in. 
Similar  phenomena  have  been  observed  by  others.     In  a  case 


DISEASES   OF    THE    PLEUKA.  561 

recorded  by  Louis,  the  patient,  at  the  moment  of  perforation, 
and  shortly  preceding  the  pains,  felt  as  if  air  was  circulating  in 
the  chest  from  below  upwards,  clearly  attributable  to  the  passage 
of  air  into  the  left  pleura.*  In  the  sixteenth  epistle  of  Mor- 
gagni,  a  case  is  noticed,  on  the  authority  of  Willis  and  Lower, 
which  presented  analogous  phenomena,  both  as  to  the  first 
sensation  of  something  giving  way,  and  the  dropping,  "  stillici- 
dium  "  into  the  chest,  perceptible  not  only  to  the  patient,  but 
also  audible  by  the  bystanders. 

Notwithstanding  the  pain,  it  often  happens  that  the  patients 
lie  on  the  affected  side.  Dr.  Houghton  remarks,  "  that  the 
violence  of  the  pleuritic  pain  forces  the  patients  to  turn  to  the 
sound  side,  in  spite  of  the  increased  oppression  which  the  change 
induces.  We  have  witnessed  a  case  in  which  the  struggle 
between  the  pain,  augmented  by  lying  on  the  affected  side,  and 
dyspnoea,  aggravated  by  changing  to  the  opposite,  was  extremely 
distressing ;  but  here  the  want  of  breathing  triumphed  over  the 
pain,  and  compelled  the  poor  patient  to  endure  the  latter  as  the 
lesser  evil.  When  the  intensity  of  the  pain  has  passed,  if  a 
change  has  taken  place  during  its  continuance,  decubitus  on  the 
affected  side  is  usually  resumed." 

In  several  instances  I  have  observed  a  complete  change  in  the 
character  of  the  cough,  and  a  cessation  of  expectoration.  The 
latter  symptom  seems  peculiar  to  those  cases  in  which  the 
expectoration  had  been  furnished  by  the  lung  which  was  sub- 
sequently perforated.  I  have  seen  a  case  in  which  the  expecto- 
ration, being  previously  copious,  ceased  on  the  occurrence  of 
fistula,  and  only  returned  when  tubercular  ulceration  had  invaded 
the  opposite  lung.  A  gentleman,  labouring  under  this  disease, 
assured  me  that  he  was  often  unable  to  expectorate,  in  conse- 
quence of  the  fluid,  on  reaching  the  trachea,  falling,  as  he 
expressed  it,  down  into  the  opposite  side. 

But  one  of  the  most  singular  circumstances  connected  with 
this  subject,  occurred  in  the  case  of  an  elderly  man,  who  lived 
for  many  months  after  the  occurrence  of  the  fistula.  For  a 
length  of  time  his  principal — indeed  only  suffering,  was  from 
dyspnoea,  occasioned  by  the  increase  of  the  liquid  effusion. 
Whenever  the  symptom  became  too  urgent,  he  relieved  himself 
by  the  extraordinary  manoeuvre  of  placing  his  head  on  the 
*  See  Louis  on  Phthisis,  Dr.  Cowan's  Translation. 
O    O 


562  DISEASES    OF    THE    PLEURA. 

ground,  and  then  elevating  his  heels  against  a  wall  until  the 
reversed  position  was  nearly  vertical,  when  a  vast  quantity  of 
sero-purulent  fluid  was  expectorated,  and  relief  given  for  a  con- 
siderable period  of  time. 

It  was  for  a  long  time  believed,  and  is  still  the  opinion  of 
many,  that  the  occurrence  of  a  pulmonary  fistula  from  any  cause 
was  necessarily  followed  by  pleuritis  and  effusion.  Kecent 
observations  have  shown  that  such  is  not  always  the  case,  and 
that  we  may  have  a  pneumothorax  from  perforation  of  the  lung 
without  its  being  attended  by  empyema.  In  the  year  1840  I 
communicated  to  the  Pathological  Society  a  specimen  of  perfora- 
tive pneumothorax  from  the  rupture  of  a  sub-pleural  vesicle  in  a 
case  ofLaennec's  emphysema.  The  physical  signs  were  well 
marked  during  life,  and  the  pleura  was  found  without  the  slightest 
appearance  of  inflammation,  dry,  pale,  and  transparent.  Con- 
sidering the  source  of  the  rupture  in  this  case,  and  that  no  foreign 
matter  besides  air  was  introduced,  the  absence  of  pleuritis  may 
be  accounted  for.*  But  a  still  more  remarkable  example  is  that 
communicated  by  my  friend,  Mr.  O'Ferrall,  to  the  same  Society. 
The  subject  was  a  female,  aged  40,  who  had  been  admitted  into 
St.  Vincent's  Hospital  in  the  last  stage  of  phthisis.  Two  days 
before  her  death  she  complained  of  a  stitch  in  the  left  side,  which 
was  found  to  be  tympanitic  on  percussion,  both  anteriorly  and 
posteriorly.  Amphoric  resonance  was  present,  but  there  was  no 
metallic  tinkling;  the  heart  was  not  displaced.  In  this  state 
she  lived  for  forty-eight  hours.  The  left  lung  was  found  small 
and  compressed,  containing  a  large  tubercular  cavity,  in  the 
anterior  and  upper  portion  of  which  an  opening  was  discovered 
passing  into  the  cavity  of  the  pleura.  The  latter  was  unusually 
dry,  and  exhibited  no  marks  of  inflammation.  Mr.  O'Ferrall 
observes  that  "this  case  was  remarkable,  as  being  one  of  pure 
pneumothorax,  in  which  there  had  been  no  escape  of  fluid  into 
the  pleural  sac,  because  the  opening  into  the  tubercular  cavity  was 
near  its  upper  part ;  for  there  having  been  no  pleuritic  effusion, 
probably  in  consequence  of  the  short  time  that  the  patient  survived 

*  (In  March,  1865,  Dr.  Stokes  presented  a  similar  example  of  simple  pneumothorax. 
In  this  case  the  patient  survived  the  occurrence  of  the  lesion  for  two  days.  On  dissection 
the  lung  was  found  compressed  and  lying  against  the  spine,  the  pleura  full  of  air,  but 
no  inflammation  or  vascularity  of  this  membrane.  At  the  very  apex  of  the  lung  was 
a  cluster  of  large  and  fully  distended  emphysematous  vesicles,  two  of  which  seemed  to 
have  ruptured  and  collapsed.) — Dub.  Quart.  Journ.,  vol.  xl. 


DISEASES    OF    THE    PLEURA.  563 

the  accession  of  the  pneumothorax,  and  lastly,  from  the  absence 
of  any  displacement  of  the  heart.  As  there  was  also  the  absence 
of  metallic  tinkling,  it  might  be  worthy  of  inquiry  whether  this 
symptom  is  not  to  be  considered  as  connected  only  with  pneumo- 
thorax when  there  is  also  an  effusion  into  the  pleura."  *  The 
great  interest  of  this  case  consists  in  its  exhibiting  the  opening 
of  a  tubercular  cavity  into  the  pleura  producing  pneumothorax 
without  empyema ;  and  both  cases  go  to  prove  that  the  mere 
admission  of  air  into  a  serous  sac  may  be  unattended  by  any 
inflammatory  action.  And  I  am  inclined  to  believe  with  Mr. 
O'Ferrall  that  metallic  tinkling  is  not  a  sign  of  pneumothorax, 
even  though  it  proceed  from  perforation,  unless  we  have  the 
combination  with  liquid  effusion. 

Pursuing  the  consideration  of  these  fistula  we  shall  be  able,  by 
referring  to  their  mechanical  relations,  to  explain  some  remarkable 
circumstances  connected  with  the  progress  of  the  disease,  and 
of  the  amount  of  suffering  and  of  immediate  danger  to  the  patient. 
Duncan  first  published  the  remarkable  observation  that  the 
bronchial  tube  communicating  with  the  fistula  is  found  to  open 
obliquely  from  above  downwards,  the  effect  of  which  is  to  convert 
the  orifice  of  the  opening  into  a  valve  or  valvular  structure. 
Houghton  has  confirmed  this,  and  has  added  that,  as  it  were  to 
aid  in  the  accomplishment  of  this  object,  the  superior  rim  of  the 
opening  is  sometimes  observed  to  be  prolonged  downwards  for  a 
short  space  over  it.  To  the  practical  physician,  however,  it  will 
be  sufficient  if  we  state  that  fistulas  are  of  two  kinds,  the  one 
valvular,  the  other  non-valvular  or  permanently  patent,  and  that 
upon  these  conditions  of  the  opening  depend  many  of  the 
immediate  or  remote  circumstances  of  the  case.  In  comparing 
together  the  recorded  cases  of  this  accident  we  cannot  fail  to 
remark  that  while  in  some  cases  the  symptoms  of  pressure  from 
within  proceed  rapidly  and  uninterruptedly  to  a  fatal  termination, 
in  other  cases  there  is  none  of  this  violence  of  symptoms  at  any 
period,  or  if  there  be,  it  is  only  for  that  short  time  during  which 
the  system  may  be  supposed  to  suffer  from  the  sudden  develop- 
ment of  an  acute  pleurisy  and  an  extravasation  of  air  into  the  sac. 
These  differences  can  only  be  explained  by  reference  to  the  con- 
dition of  the  fistular  opening ;  if  it  be  valvular  so  as  to  impede 
the  exit  of  air,  it  is  plain  that  every  forced  inspiration  will  add  to 

*  Trans.  Path.  Soc.  of  Dublin,  1842-43. 
O   0  2 


564  DISEASES    OF   THE    PLEURA. 

the  amount  of  excentic  pressure,  and  again,  that  as  the  liquid 
effusion  increases,  while  the  air  is  not  permitted  to  escape,  all  the 
worst  effects  of  accumulation  must  be  produced.  Patients  under 
such  circumstances  present  an  almost  uninterrupted  series  of 
sufferings  from  the  moment  of  the  accident  to  that  of  the  termi- 
nation of  life.  But  this  case  fortunately  is  not  the  most  frequent, 
at  least  I  may  say  that  in  my  experience  the  great  majority  of 
patients  within  a  period  of  time  generally  less  than  a  week  exhibit 
a  freedom  from  suffering  which  is  very  remarkable,  there  is  little 
or  no  dyspnoea  when  the  patient  is  at  rest,  nor  is  the  breathing 
much  if  at  all  hurried,  No  signs  of  increasing  pressure  from  air 
are  observed,  and  the  reason  of  this  is  obviously  that  the 
fistula  is  not  valvular,  so  that  the  air  passes  freely  backwards  and 
forwards  from  the  sac  into  the  bronchial  tubes  or  cavity,  or  vice 
versa.  If  under  these  circumstances  the  liquid  effusion  should 
increase,  the  air  is  expelled  in  proportion  as  the  fluid  rises  in  the 
sac.  The  opening  is  permanently  patent,  and  as  the  fluid  rises 
the  air  is  easily  forced  backwards  through  the  fistula.  Indeed 
nothing  can  present  a  greater  contrast  than  these  two  cases, 
the  one  presenting  irremediable  and  extreme  suffering,  which 
advances  rapidly  to  fatal  asphyxia,  the  other  exhibiting  freedom 
from  distress  incredible  to  those  who  have  not  had  a  large 
experience  of  these  cases. 

There  is  reason  for  believing  that  with  the  progress  of  disease 
the  mechanical  relations  of  the  fistula  may  alter,  and  that  an 
opening  which  is  at  first  valvular  may  become  permanently 
patent.  How  far  the  reverse  of  this  is  possible  I  am  not  prepared 
to  say.  Houghton  conceives  that  he  has  observed  an  attempt 
of  nature  to  close  an  old  fistula,  but  without  denying  this  I 
may  say  that  I  have  never  seen  or  heard  of  the  occurrence  of  the 
signs  of  aeriform  accumulation  resulting  from  the  closure  of  a 
fistula  which  had  once  been  open. 

In  these  cases  of  permanently  patent  fistulas  we  distinguish  two 
classes,  in  which  the  progress  of  the  symptoms  is  chiefly  connected 
with  the  amount  of  the  liquid  effusion.  In  one  (and  this  is  a 
fact  of  great  importance,  and  difficult  to  be  explained)  the  liquid 
effusion  after  having  attained  to  a  certain  amount  ceases  to 
accumulate,  and  in  this  way  may  remain  stationary  for  many 
months.  This  is  a  very  common  case.  In  the  second  class, 
however,  a  gradual  accumulation  of  fluid  takes  place  so  as  greatly 


DISEASES   OF   THE    PLEURA.  565 

to  change  the  proportion  between  the  liquid  and  aeriform  contents 
of  the  sac,  and  when  this  passes  a  certain  point  the  distress 
may  become  extreme,  but  it  arises  from  the  pressure  of  the  liquid 
alone,  and  not  from  any  confinement  of  air,  inasmuch  as  from 
the  permanently  open  state  of  the  fistula  the  air  is  expelled  in  pro- 
portion as  the  fluid  rises.  I  have  already  noticed  the  singular  fact 
that  in  some  cases  where  the  liquid  accumulation  had  become  so 
great  as  to  cause  suffering  from  dyspnoea,  the  patient  was  able 
to  evacuate  the  empyema  through  the  pulmonary  fistula.  This 
has  occurred  in  two  cases.  One  of  them  was  that  of  an  old  man, 
who  after  labouring  under  phthisis  for  a  length  of  time  became 
affected  with  empyema  and  pneumothorax  in  the  usual  way. 
In  this  condition  he  lived  for  many  months.  The  fistula  was 
permanently  open,  and  on  several  occasions  he  emptied  the 
sac  of  its  liquid  contents,  and  was  thus  freed  from  the  urgency  of 
his  symptoms.  His  method  was  to  place  himself  in  a  sitting 
position  on  the  edge  of  his  bed,  and  then  to  raise  his  legs 
upwards  on  the  wall  of  his  chamber,  while  he  depressed  the 
throat  till  his  head  touched  the  floor.  In  this  way  the  sero- 
purulent  fluid  poured  from  his  mouth  without  producing  any 
distress,  and  he  would  evacuate  many  pounds  of  liquid  at  a  time. 
This  patient  was  under  my  observation  during  the  entire  period 
of  his  disease. 

If  we  now  inquire  as  to  the  possibility  of  a  cure  by  agglutina- 
tion of  these  fistulas  we  find  that  the  evidence  of  such  having 
ever  occurred  is  very  meagre  and  unsatisfactory.  In  some 
chronic  cases  it  is  true  that  we  experience  great  difficulty  in 
finding  the  perforation  on  dissection,  and  the  possibility  of  an 
occlusion  of  the  fistula  is  not  to  be  denied.  But  if  we  exclude 
the  case  of  original  empyema  opening  into  the  lung  and  confine 
ourselves  to  those  of  fistular  empyema  and  pneumothorax  from 
preceding  pulmonary  disease,  we  shall  find  that  in  most  cases 
the  orifice  once  formed  remains  open  up  to  the  time  of  death, 
and  even  if  a  closure  of  the  fistula  was  probable  or  possible  it 
would  not  follow  that  the  patient  would  be  in  a  much  better 
position,  for  in  the  great  majority  of  cases  he  will  die  of  the 
tubercular  disease  which  affects  both  lungs,  and  indeed  his  entire 
system.  Its  progress  has  been  interrupted  or  modified  by  the 
accident,  but  sooner  or  later  the  disease  becomes  again 
developed. 


5G6  DISEASES    OF    THE    PLEURA. 


i) 


And  this  leads  us  to  consider  the  very  curious  fact  that  in 
many  cases  the  occurrence  of  an  empyema  and  pneumothorax 
is  followed  by  the  suspension  of  many  of  the   constitutional 
symptoms  of  phthisis.     If  the  patient  be  not  overwhelmed  by 
the    immediate   effects    of    the    accident    a    period    arrives    of 
comparative   calm.     The  colliquative  sweats  cease,  the   cough 
becomes  trifling,  and  the   expectoration   disappears.     The  very 
aspect  of  the  patient  changes,  and  his  countenance  loses  the 
characteristics  of  consumption.      The  pulse  becomes  tranquil, 
and,  as  in  the  case  of  the  bricklayer  which  occurred  in  the  Meath 
Hospital,  and  which  was  published  by  Dr.  Houghton,  the  patient 
may  regain  his  flesh  and  strength  to  a  surprising  degree.     In 
this  case  on  more  than   one   occasion   this    singular   improve- 
ment took  place,  and  the  man  returned  to  his  laborious  occupa- 
tion of  a  mason.      I  have  already  alluded  to  another  instance 
of  this  kind  in  the  first  edition  of  this  work.     A  young  man 
of   a   rather    full   habit    became    attacked   with   symptoms    of 
phthisis,  and  after  a  short  time  exhibited  the  usual  signs  of 
tubercular  softening  in  the  supra-anterior  portion  of  the  right 
lung.     The  deposit  appeared  to  be  circumscribed.     He  was  sent 
to  Dr.  Cane,  where  he  remained  under  the  observation  of  my 
lamented  friend  Dr.  R.  Townsend.     In  the  course  of  a  few  months 
it  was  found  that  his  constitutional  symptoms  were  improving. 
There  was  no  evidence  of  any  extension  of  tubercular  deposit, 
and  everything  appeared  to  promise  that  in  this  gentleman's  case 
a  cure  might  be  expected.     At  this  time,  when  the  hopes  of  his 
physician  and  his  friends  were  at  the  highest,  he  was  suddenly 
seized    with   the    symptoms   indicative    of   the    opening   of   a 
softened  tubercle  into  the  pleura.      For  several  days  he  suffered 
from  dreadful  pain  and  from  dyspnoea,  threatening  suffocation. 
The  physical  signs   of  pneumothorax  were  speedily  developed. 
After  some  days,  during  which  the  patient's  life  was  despaired 
of,  the  symptoms  were  mitigated,  the  pain  ceased,  the  respiration 
became    more    tranquil,    and    although    the    existence    of    an 
empyema  and  pneumothorax  was  but  too  evident,  the  patient's 
health  gradually  improved,  until  at  length  he  was  to  all  appear- 
ance in  a  much  more  promising  condition  than  he  had   been 
previous  to  the  accident.     He  returned  to  Dublin  at  the  com- 
mencement of  the  summer  presenting  all  the  appearances  of  the 
most  perfect  and  indeed  flourishing  health  ;  he  had  become  fatter 


DISEASES    OF    THE    PLEUEA.  567 

and  more  muscular  than  he  was  previous  to  the  original  illness, 
his  breathing  was  quiet,  he  was  not  troubled  with  cough,  and  his 
pulse  was  strong,  full,  and  perfectly  regular  in  every  respect : 
he  was  indeed  a  picture  of  health  and  manly  vigour  ;  he 
entered  into  all  the  pleasures  of  society,  and  was  able  to  take 
active  exercise  on  horseback,  and  he  declared  to  me  that  were  it 
not  for  the  annoyance  of  a  splashing  sound  in  his  chest,  which 
attracted  the  attention  of  his  partner  in  the  waltz,  and  of  his 
companions  during  equestrian  exercise,  he  suffered  no  annoy- 
ance whatsoever,  yet,  notwithstanding  all  this,  the  well-marked 
metallic  tinkling,  the  amphoric  resonance,  the  tympanitic  sound 
on  percussion,  and  the  loud  sound  of  fluctuation,  all  revealed  the 
terrible  and  complicated  disease.  So  confident  was  this  patient 
of  his  restoration  to  health  that  he  renewed  a  matrimonial 
engagement  which  had  been  broken  off  on  the  occasion  of  his 
first  illness.  After  some  time  I  lost  sight  of  this  gentleman. 
Under  the  impression  that  his  liver  had  become  implicated  he 
employed  a  course  of  mercury,  and  soon  afterwards  sunk.  It  is 
probable  that  the  liver  had  become  displaced  by  paralysis  of  the 
diaphragm. 

Of  the  temporary  suspension  of  the  symptoms  of  phthisis  in 
cases  of  perforation  there  have  been  now  many  examples.  If 
the  perforation  has  occurred  in  a  case  where  tubercle  was  not 
yet  deposited  in  great  quantity,  and  above  all,  where  it  had  not 
yet  appeared  in  the  opposite  lung,  the  accident  in  question 
really  produces  a  temporary  cure  of  consumption.  The  diseased 
lung  is  compressed,  its  nervous  and  vascular  supply  nearly  cut 
off,  and  hence  the  morbid  processes  going  on  in  it  are  averted, 
and  it  is  possible  that  the  new  irritation  of  the  pleura  may  have 
a  beneficial  action.  But  I  have  never  seen  a  real  cure  of  the 
original  disease,  although,  as  in  the  case  which  Dr.  Houghton 
has  published,  the  patient  was  to  all  external  observation  free 
from  constitutional  disease  on  more  occasions  than  one.  A  man 
under  these  circumstances  may  live  for  months,  or  for  more  than 
a  year,  but  he  ultimately  sinks.  This  result  appears  to  spring 
from  various  causes.  Thus  it  may  happen  that  after  remaining 
for  a  great  length  of  time  in  a  passive  and  unchanging  state 
the  liquid  effusion  begins  at  last  to  increase,  until  at  length  life  is 
perilled  by  its  pressure.  Again,  a  slow  tuberculous  process  may 
become  developed  in  the  opposite  lung,  and  the  patient  presents 


568  DISEASES    OF   THE    PLEUEA. 

then  the  usual  progressive  symptoms  of  phthisis.  And  lastly, 
the  lymph  lining  the  perforated  pleura  itself  may  become  trans- 
formed into  tubercular  matter.  This  I  once  saw  well  exem- 
plified in  the  case  of  an  unhappy  soldier  who  had  twice  under- 
gone severe  punishment  in  the  West  Indies,  from  the  effects  of 
which  he  appeared  never  to  have  fully  recovered.  He  was 
brought  to  Europe,  and  having  attempted  the  life  of  his  officer, 
was  tried  and  sentenced  to  transportation.  His  health  was  fast 
giving  way,  and  when  the  permit  of  his  transportation  arrived  he 
was  found  to  be  too  ill  to  bear  removal.  He  was  brought  to  the 
Meath  Hospital,  and  I  found  that  he  had  pneumothorax  with 
fistula,  but  we  were  not  able  to  determine  the  date  of  the 
accident.  It  had  doubtless  been  of  long  standing.  The  wretched 
man  sunk,  and  we  found  the  whole  of  the  left  pleura  lined  with 
a  thick  layer  of  lymph  of  a  yellowish  colour.  This  presented  on 
the  sectional  face  an  irregular  and  flocculent  surface,  but  when 
viewed  through  the  pleura  was  seen  to  be  connected  with  a 
congeries  of  tuberculous  matter,  extending  over  all  parts  of  the 
sac  and  shining  through  the  pleura.  They  appeared  like  split 
peas,  closely  approximated,  and  gave  a  striking  illustration  of  the 
tuberculous  transformation  of  effused  lymph. 

This  suspension  of  the  constitutional  symptoms  of  phthisis 
consequent  on  the  collapse  and  compression  of  the  lung  may  be 
analogous  to  the  suspension  of  a  similar  condition  after  the 
removal  of  a  diseased  joint  or  a  cancerous  tumour.  To  all  these 
cases,  at  all' events,  there  is  one  thing  in  common,  namely,  that 
a  suspension  of  constitutional  symptoms  follows  the  removal 
of  the  diseased  portion,  or  what  is  tantamount  to  that,  its  being 
placed  in  a  new  condition.  As  might  be  expected,  the  cessation 
of  the  phthisical  symptoms  is  best  marked  when  the  collapse  or 
compression  of  the  lung  has  been  most  complete.  But  this 
sudden  and  extreme  collapse  of  the  lung  is  not  so  common  an 
occurrence  as  might  be  expected  from  theoretical  considerations. 
I  have  often  observed  that  the  disappearance  of  all  signs  of 
pulmonary  expansion  on  the  affected  side  was  a  gradual  process, 
and  we  may  see  many  cases  in  which,  notwithstanding  the  ex- 
istence of  the  signs  of  fistular  pneumothorax,  the  evidences  of  a 
pulmonary  cavern  still  remain.  In  these  instances  the  fistula 
has  occurred  in  the  advanced  periods  of  the  case,  when  the  lung 
has  been  much  disorganized,  and  when,  doubtless,  adhesions, 


DISEASES   OF   THE   PLEUKA.  569 

more  or  less  decided,  have  been  formed.  The  diminution  of  the 
volume  of  the  lung  in  such  cases  is  less  owing  to  a  sudden 
collapse  than  to  a  gradual  process  of  compression  and  atrophy, 
while,  on  the  other  hand,  when  the  perforation  occurs  in  an 
early  period  of  the  disease,  as  from  a  superficial  suppurating 
tubercle  when  the  amount  of  deposit  in  the  lung  is  but  trifling, 
and  adhesions  but  slightly  if  at  all  developed,  the  collapse  of  the 
lung  is  much  more  sudden  and  complete.  It  is  also  probable, 
although  I  cannot  state  this  from  actual  observation,  that  in 
such  cases  the  suspension  of  the  symptoms  of  phthisis  will  be 
more  decided  and  of  longer  continuance.  If  we  confine  our- 
selves to  those  cases  in  which,  as  Laennec  has  demonstrated  the 
tubercular  matter  appears  by  successive  crops  or  eruptions,  we 
shall  find  that  perforation  of  the  pleura  is  rarely  produced  in 
connexion  with  the  first  production  of  the  heterologous  deposit. 
Pathological  anatomy  has  shewn  that  in  most  cases  the  seat  of 
the  fistula  is  at  a  point  considerably  below  the  superior  portion 
of  the  lung.  I  once  saw  an  example  of  fistular  pneumothorax 
from  a  perforation  which  occurred  almost  at  the  summit  of  the 
lung.  Such  a  case,  however,  appears  to  be  extremely  rare, 
inasmuch  as  the  complete  adhesions  which  commonly  surround 
the  summit  of  the  lung  in  the  early  stages  of  phthisis  clearly 
tend  to  prevent  the  occurrence  of  this  unfortunate  accident. 

It  is  next  to  be  observed  that  cases  of  this  complication,  that 
is  to  say,  where  a  tuberculous  abscess  opens  into  the  pleura, 
present  a  certain  variety  in  their  history  and  symptoms.  In 
studying  this  disease  we  may  derive  some  light  from  examining 
cases  of  perforation  of  the  intestine,  and  the  analogies  of  the 
two  classes  of  cases  will  be  found  much  more  strict  than  has 
been  hitherto  supposed.  In  both  we  find  that  the  perforation  is 
often  attended  with  the  symptoms  peculiar  to  internal  solutions 
of  continuity,  namely,  that  they  are  new,  sudden,  violent,  and 
dangerous.  But  in  both  classes  of  cases  we  find  perforation  of 
the  hollow  viscera  to  occur  under  different  circumstances  from 
those  now  specified  ;  and  we  have  the  pneumothorax  and 
pleurisy  on  the  one  hand,  and  the  pneumoperitoneum  and  peri- 
tonitis on  the  other,  produced  in  a  manner  almost  completely 
latent.  This  is  more  remarkably  the  case  with  respect  to  the 
thorax  than  the  abdomen,  and  there  is  nothing  more  common 
than   a  discovery  by   the   physician  of  a  fistular  empyema  in 


570  DISEASES    OF    THE    PLEURA. 

pneumothorax  in  persons  who  were  quite  unaware  of  the  ex- 
istence of  such  a  lesion,  or  who  had  not  suffered  any  unusual 
symptoms  at  the  time  of  its  occurrence. 

If  we  now  examine  the  symptoms  of  the  first  variety  we  find 
them  to  he  the  sudden  supervention  of  a  new  and  extraordinary 
pain  of  the  side.  This  is  not  unfrequently  produced  during  a  fit 
of  coughing,  or  any  other  condition  which  induces  forced  and 
violent  respiration.  The  patient  feels  as  if  he  was  ahout  to  die 
from  suffocation,  and  in  many  cases  a  fearful  struggle  for  life 
marks  the  early  period  of  the  aeriform  effusion.  How  much  of 
this  difficulty  of  hreathing  depends  on  the  sudden  pleurisy,  or 
on  the  collapse  of  the  lung,  is  not  yet  determined.  If  we  com- 
pare such  cases  with  those  where  foreign  bodies  are  impacted 
in  the  main  bronchus  of  either  lung,  we  cannot  help  believing 
that  the  terrible  suffering  in  certain  cases  of  perforation  is  owing 
to  something  besides  the  sudden  occlusion  of  one  lung.  It 
is  rather  to  be  attributed  to  the  nervous  excitement  and  spasm 
not  only  of  the  affected  lung  but  of  the  opposite  lung,  as  well 
as  the  occurrence  of  sudden  and  extensive  pleurisy.  As  happens 
in  perforative  peritonitis  the  escape  of  a  foreign  substance 
into  the  serous  sac  produces  at  a  bloiv  an  extensive  inflamma- 
tion. 

We  may  inquire,  does  the  entrance  of  the  air  assist  the 
inflammation  ?  This  is  a  difficult  question.  We  know  that  the 
entrance  of  air  by  the  canula  during  paracentesis  is  a  matter  of 
trivial  moment ;  but  the  cases  are  different,  vitally  and  me- 
chanically. In  the  one  the  air  enters  a  sac  which  has  been 
previously  diseased,  covered  with  lymph  and  semi-organized 
deposits ;  while  in  the  other  it  is  forced  into  a  pleura  which  has 
never  before  felt  the  presence  of  any  foreign  body  or  fluid  what- 
soever. This  may  make  some  difference  in  its  susceptibility 
to  inflammation  from  the  entrance  of  air. 

The  liquid  foreign  matter  sent  from  the  lung  into  the  sac  will 
consist  of  tubercular  matter,  pus,  and  bronchial  mucus.  We 
might  believe  on  comparing  these  substances  with  the  contents 
of  the  intestinal  tube  that  they  were  of  a  less  irritating  nature, 
for  we  know  that  in  addition  to  the  bile  and  mucus  of  the  tube, 
the  ingesta  often  escape  into  the  peritoneal  sac.  But  the 
secretions  in  advanced  phthisis  are  not  without  acridity.  It  is 
a  curious  fact  that  in  many  of  the  perforative  cases  the  expectora- 


DISEASES    OF   THE    PLEUBA.  571 

tion,  which  before  had  been  copious,  almost  altogether  ceases, 
and  thus  the  patient  continues  for  a  great  length  of  time.  We 
are  not,  however,  to  believe  that  this  is  wholly  to  be  attributed 
to  the  passage  of  the  secretions  into  the  sac  through  the  fistula, 
but  rather  that  there  is  an  amount  of  secretion  from  the  whole 
surface  of  the  diseased  lung,  both  as  regards  its  cavities  and 
bronchial  surface.  This  is  one  of  that  group  of  circumstances 
which  contribute  to  the  fallacious  appearance  of  recovery  from 
consumption  exhibited  by  many  patients  who  have  suffered  from 
this  accident.  I  have  observed  cases  in  which  the  expectoration, 
which  had  been  previously  copious,  ceased  altogether  on  the 
occurrence  of  the  fistula,  and  only  returned  when  the  opposite 
lung  had  become  affected  with  tubercular  softening. 

But  that  in  some  cases  a  dropping  of  the  secretions  of  the 
diseased  lung,  through  the  fistula  and  into  the  sac,  takes  place 
appears  sufficiently  certain.  I  have  known  a  case  in  which 
this  appeared  to  be  felt  by  the  patient,  who  laboured  under 
tubercular  softening  in  both  lungs.  When  he  coughed  he 
declared  that  it  often  happened  that  he  was  unable  to  expecto- 
rate from  the  matter,  as  he  expressed  it,  falling  down  into  the 
opposite  side. 

One  of  the  forms  of  the  metallic  tinkling  is  manifestly 
produced  by  a  dropping  from  the  upper  portion  of  the  chest 
into  the  fluid  below.  But  whether  this  dropping  proceeds 
from  the  secretions  of  the  diseased  pulmonary  pleura,  or  from 
the  secretions  which  pass  through  the  fistula,  or  from  both 
these  sources,  it  is  difficult  to  determine. 

To  return  to  the  pain  attendant  on  the  accident.  It  may 
exhibit  every  degree  of  intensity — and  it  is  sometimes  at  the 
first  moment  attended  with  the  sensation  of  something  cracking 
or  giving  way,  and  next  of  the  pouring  out  or  shedding  of  a 
fluid  into  the  sac.  "  The  violence  of  the  pleuritic  pain,"  says 
Dr.  Houghton,  "  forces  the  patient  to  turn  to  the  sound  side  in 
spite  of  the  increased  oppression  which  the  change  induces. 
We  have  witnessed  a  case  in  which  the  struggle  between  the 
pain,  augmented  by  lying  on  the  affected  side,  and  dyspnoea 
aggravated  by  changing  to  the  opposite,  was  extremely  dis- 
tressing, but  here  the  want  of  breathing  triumphed  over  the 
pain,  and  compelled  the  poor  patient  to  endure  the  latter  as 
the  lesser  evil.     When  the  intensity  of  the  pain  has  passed,  if 


572  DISEASES    OF   THE    PLEURA. 

a  change  has  taken  place  during  its  continuance,  decubitus  on 
the  affected  side  is  usually  resumed." 

But  the  indication  of  the  accident  by  the  occurrence  of  a 
group  of  extraordinary  and  painful  symptoms  is  by  no  means 
so  constant  as  many  would  suppose  ;  and  there  is  nothing  more 
common  in  clinical  experience  than  the  discovery  of  a  pneumo- 
thorax and  empyema  in  persons  who  are  supposed  to  be  simply 
phthisical,  and  who  are  not  able  to  refer  to  any  special  symptoms 
as  having  attended  the  perforation. 

We  need  not  dwell  at  any  length  on  the  physical  phenomena 
of  this  condition.  The  two  most  important  are  the  amphoric 
respiration  and  the  sound  of  fluctuation.  Next  in  value  may  be 
placed  the  want  of  vesicular  respiration  over  a  large  extent  of  the 
side,  as  also  that  of  the  different  rales  which  existed  before  the 
collapse  of  the  lung.  The  less  the  lung  has  been  disorganized 
before  the  perforation  the  more  complete  will  be  the  dis- 
appearance of  its  proper  phenomena.  I  have  known  a  case  in 
which  apparently  but  a  single  tuberculous  concretion  existed. 
It  was  superficial  and  produced  a  fistula,  followed  by  a  speedy 
and  complete  disappearance  of  all  the  pulmonary  signs.  On 
the  other  hand,  where  the  lung  has  contained  a  great  quantity 
of  tubercle,  attended  as  is  commonly  the  case  with  local 
adhesions,  its  volume  will,  of  course,  be  much  less  diminished, 
and  its  proper  signs,  more  or  less  modified,  may  continue  to 
exist.  We  have  more  than  once  observed  the  co-existence  of 
well-marked,  cavernous  respiration  and  gurgling  in  the  upper 
portion  of  the  lung  with  all  the  signs  of  fistular  pneumothorax 
in  their  usual  situations. 

The  next  in  importance  of  the  physical  characters  is  the 
metallic  sound  given  to  all  the  acoustic  phenomena.  The 
sound  of  the  voice,  the  sounds  of  the  heart,  the  vesicular 
murmur  and  rales  in  the  affected  lung  (when  they  exist)  may 
all  exhibit  the  metallic  character,  or  it  may  be  confined  to  but 
one  or  two  of  them.  As  to  the  metallic  tinkling,  properly  so 
called,  we  have  already  observed  that  one  form  of  it  at  least 
seems  to  be  produced  by  the  dropping  of  fluid  from  the  upper 
portion  of  the  cavity.  Single  metallic  sounds  are  thus  pro- 
duced which  occur  at  irregular  periods  and  without  any 
synchronism  with  the  motion  of  the  chest.  The  second  form 
is  more  singular,  and  is  held  by  recent  authors  to  depend  upon 


DISEASES    OF   THE    PLEURA.  573 

the  bursting  of  bubbles  of  air  on  the  surface  of  the  fluid.  This 
is  occasionally  synchronous  with  inspiration,  and  conveys  the 
idea  of  the  successive  breaking  of  a  series  of  extremely  minute 
bubbles.  It  is  highly  probable  that  these  bubbles  proceed 
from  the  secondary  cribriform  perforations  to  which  I  have 
alluded.  If  this  be  true  we  ought  not  to  find  the  phenomena 
in  question  at  the  early  periods  of  these  cases,  but  on  this 
point  I  have  no  certain  observation  to  produce. 

As  might  be  expected,  percussion  affords  valuable  assistance 
in  the  diagnosis  of  this  disease.  But  the  results  obtained  are 
various.  The  universal  and  exaggerated  tympanitic  resonance 
is  not  often  met  with,  especially  in  chronic  cases  and  where 
the  fistula  is  not  valvular.  More  or  less,  however,  of  this 
character  will  be  generally  discovered.  It  is  generally  most 
evident  about  the  middle  third  of  the  chest.  The  sound  of 
the  upper,  portions  being  modified  by  the  lung,  and  of  the 
lower  by  the  liquid  effusion.  It  is  very  remarkable,  however, 
that  in  certain  cases,  were  we  to  be  guided  by  the  sound  on 
percussion,  we  would  conclude  that  no  liquid  whatever  existed 
in  the  cavity,  the  sound  continuing  morbidly  clear  down  to 
the  lowest  portion  of  the  thoracic  region ;  yet  in  such  cases  on 
making  the  Hippocratic  succussion  we  are  astonished  at  the 
evidence  of  a  great  quantity  of  liquid.  This  can  be  only 
explained  by  supposing  that  there  is  a  paralysis  of  the 
diaphragm,  and  that  the  liquid  is  to  a  great  degree  contained 
in  the  pouch  thus  formed  which  looks  towards  the  abdominal 
cavity.  As  connected  with  the  entire  subject  I  do  not  know  a 
circumstance  more  curious  than  that  now  stated. 

It  is  not  always  an  easy  matter  to  produce  the  sound  of 
fluctuation  in  these  cases.  In  some  persoDS  it  is  true  that 
almost  any  swaying  motion  of  the  body  will  cause  the  sound. 
In  others  the  patient's  own  exertions  are  necessary,  and  it  is 
done  by  a  sudden  jerking  and  semi-rotatory  motion  of  the 
trunk.  I  have  seen  cases  where  the  sound  could  not  be  pro- 
duced while  the  patient  sat  in  bed,  but  when  he  was  placed 
on  a  wooden  form  or  chair  it  was  always  easy  to  produce  the 
sound. 

When,  as  sometimes  happens,  the  liquid  effusion  increases 
to  a  great  amount,  both  the  sound  on  percussion  and  the 
tympanitic   resonance    disappear.     Percussion    may  then   give 


574  DISEASES   OF    THE    PLEURA. 

a  dull  sound,  or  what  is  more  common,  we  have  over  the 
anterior  portions  the  muffled  tympanitic  sound,  or  what  we 
have  elsewhere  called  the  tympanitic  dulness. 

Let  us  now  examine  some  cases  of  this  affection.  The  first 
case  recognized  in  Dublin  after  the  introduction  of  mediate 
auscultation  is  recorded  by  my  lamented  friend  Dr.  Richard 
Townsend.  This  case  gives  so  clear  an  idea  of  the  physical 
phenomena  of  the  disease  that  I  consider  an  abstract  of  it  to  be 
desirable  in  this  place. 

In  this  case  the  patient,  a  tall  man,  aged  30,  had  laboured 
under  symptoms  of  pulmonary  disease  for  more  than  five 
months,  when  he  was  seen  by  Dr.  Townsend.  He  was  up  and 
dressed,  but  he  complained  of  weakness  and  want  of  breath 
when  he  walked.  He  was  emaciated,  and  had  profuse  night 
sweats,  diarrhoea,  thirst,  and  anorexia.  Pulse  120,  respira- 
tions 30  in  the  minute.  There  was  cough  with  mucous 
expectoration,  but  the  sputa  had  considerably  diminished  for 
three  weeks,  from  which  period  was  also  dated  the  aggravation 
of  the  dyspnoea.  The  right  side  of  the  chest  appeared  con- 
siderably more  dilated  than  the  left,  especially  at  its  inferior 
portion,  anteriorly  and  laterally.  Over  this  dilated  surface 
percussion  elicited  a  clear  hollow  sound.  In  this  space,  too, 
the  respiratory  murmur  was  perfectly  inaudible,  but  imme- 
diately after  coughing,  a  peculiar  sound  resembling  the  vibra- 
tions of  a  porcelain  jar  when  gently  struck  was  distinctly  heard 
in  a  space  corresponding  to  the  posterior  convexilus  of  the 
sixth,  seventh,  and  eighth  ribs.  This  sound  was  not  produced 
either  by  inspiration  or  speaking.  Percussion  did  not  produce 
the  sound  of  fluctuation,  although  the  patient  said  he  felt  water 
dashing  against  his  side.  In  the  superior  part  of  the  same 
side  of  the  chest  the  dilatation  was  scarcely  if  at  all  perceptible. 
The  sound  on  percussion  was  not  particularly  sonorous,  and  the 
respiratory  murmur  was  audible  posteriorly.  At  the  left  side 
the  sound  on  percussion  was  natural,  though  considerably  duller 
than  at  the  right ;  the  respiration  was  distinctly  audible  all  over 
the  lung,  except  in  the  space  corresponding  to  the  superior  lobe, 
where  cavernous  respiration  and  cough  with  perfect  pectoriloquy 
were  to  be  found.  He  had  no  pain.  The  cough  was  peculiarly 
deep  and  hollow.  In  this  case  the  sound  on  percussion  was 
found  to  be  hollow  inferiorly  even  in  the  region  usually  occupied 


DISEASES    OF   THE    PLEURA.  575 

by  the  liver.  He  did  not  recollect  any  sudden  aggravation  of 
his  symptoms  about  the  period  when  his  breathing  became 
materially  affected,  nor  did  he  ever  suffer  much  pain  of  the 
right  side.  In  fact  the  left  side  for  the  last  three  months  gave 
him  uniformly  the  greatest  uneasiness  of  the  two.  In  a  few 
days  percussion  showed  that  the  liquid  was  accumulating  in  the 
right  pleura.  Above  the  sixth  rib,  however,  the  sound  on  per- 
cussion was  hollow,  and  the  ordinary  respirations  sounded  like 
the  blowing  of  air  into  a  bottle.  Expectoration  was  followed  by 
a  musical  sound  like  that  of  the  vibrations  of  a  fine  wire 
chord.  The  sound  like  the  ringing  of  a  porcelain  jar  attended 
the  cough,  and  a  certain  degree  of  the  same  character  was 
produced  in  speaking.  At  this  time  percussion  produced  the 
usual  sound,  but  it  could  not  be  heard  unless  by  the  stethoscope, 
although  the  sound  zvas  audible  to  the  patient.  When  he  was 
suddenly  raised  from  the  recumbent  position  three  or  four 
drops  were  heard  to  fall  successively  from  above  on  the  surface 
of  the  fluid. 

The  thorax  now  became  more  distended,  and  all  the  inter- 
costal spaces  were  protruded.  The  metallic  sounds  were  compared 
by  Dr.  Graves  to  the  tones  of  a  musical  snuff-box,  but  the 
vibrations  of  a  tuning  key  would  convey  the  best  idea  of  the 
sound.  The  patient  soon  afterwards  sunk.  On  removing  the 
sternum  a  vast  unoccupied  space  was  discovered  in  the  anterior 
part  of  the  thorax,  capable  of  containing  fully  two  quarts  of 
water.  This  space  had  been  occupied  by  air.  Just  above  the 
surface  of  the  liquid  which  occupied  the  posterior  portion  of  the 
thorax  appeared  the  lung,  closely  compressed  against  the  spine, 
and  seemingly  reduced  to  one-third  of  its  natural  dimensions. 
The  fluid  effused  might  be  in  quantity  about  two  quarts.  It 
was  of  a  yellowish  green  colour,  tolerably  clear  at  its  surface, 
but  rendered  turbid  at  bottom  by  numerous  fragments  of  opaque 
puriform  flocculi  of  albumen.  The  nozzle  of  a  bellows  beino- 
introduced  into  the  trachea,  air  was  found  to  pass  freely  through 
the  lung,  appearing  in  bubbles  on  the  surface  of  the  fluid. 
This  was  done  before  the  lung  was  touched.  The  whole  surface 
of  the  lung,  except  when  it  was  attached,  was  coated  with  an 
albuminous  exudation  of  a  dirty  white  colour  of  several  lines  in 
thickness.  Its  surface  was  crumpled,  and  not  unlike  the  rind 
of  a   shrivelled    apple.      The    costal,    mediastinal,    and    dia- 


576  DISEASES    OF    THE    PLEURA. 


0 


phragmatic  portions  of  the  pleura  were  still  more  thickly 
coated  with  this  exudation,  which  though  firmly  attached  to, 
and  apparently  incorporated  with  the  subjacent  pleura,  might 
by  careful  dissection  be  separated  from  it,  leaving  the  membrane 
underneath  in  a  state  of  perfect  integrity.  The  fistulous  orifice, 
capable  of  receiving  the  little  finger,  was  discovered  at  about 
two  inches  from  the  summit  of  the  upper  lobe.  It  had  a  well- 
defined,  rounded,  and  nearly  cartilaginous  margin.  A  probe 
introduced  passed  readily  through  a  series  of  small  tubercular 
cavities  into  one  of  the  principal  bronchia.  At  intervals  of  half 
an  inch  below  this  fistulous  orifice  existed  three  small  oval 
superficial  ulcers  which  did  not  appear  to  communicate  with  the 
bronchia.  They  were  evidently  formed  by  softened  tubercles 
developed  immediately  below  the  pleura,  for  on  different  parts  of 
the  lung's  surface  there  were  several  oval  nests  of  tubercles, 
some  not  yet  softened,  others  quite  soft  and  elevating  the  pleura, 
through  which  they  had  not  as  yet  forced  a  passage.  Posteriorly 
and  near  the  root  of  the  lung,  about  the  base  of  the  superior 
lobe,  was  another  fistulous  opening  of  half  an  inch  in  diameter, 
which  communicated  by  a  long  sinuous  passage  with  a  large 
tubercular  abscess  occupying  nearly  the  upper  lobe.  This 
passage  was  lined  all  through  with  a  highly  vascular  membrane, 
exactly  similar  to  that  which  lined  the  tubercular  abscess. 
Into  the  latter  was  traced  one  of  the  principal  bronchial 
divisions,  the  entry  of  which  into  the  cavity  was  within  a  few 
lines  of  that  of  the  sinuous  passage  above  described.  The  left 
lung  exhibited  tubercular  deposits  in  all  their  stages,  from  the 
miliary  to  the  suppurative,  and  the  heart  and  abdominal 
organs  had  the  appearances  usually  observed  in  cases  of 
advanced  phthisis. 

I  have  given  this  case  at  some  length  not  only  because  it  was 
the  first  instance  in  which  this  complicated  lesion  was  diagnosed 
in  this  country,  but  because  it  furnishes  such  an  accurate 
picture  of  the  physical  signs  of  the  affection.  It,  too,  is  illus- 
trative of  some  important  features  in  the  history  of  the  disease, 
not  only  with  respect  to  symptoms,  but  also  in  connexion  with 
the  pathological  changes.  No  distinct  aggravation  of  suffering 
marked  the  occurrence  of  the  fistula,  and  indeed  the  only 
circumstance  which  appears  to  indicate  the  time  of  its  occurrence 
was  the  diminution  of  the  expectoration  and  a  certain  increase 


DISEASES    OF    THE    PLEURA.  577 

of  the  difficulty  of  breathing.  The  patient  referred  his  sufferings 
principally  to  the  opposite  side,  and  in  point  of  fact  had  no  pain 
referrible  to  any  portion  of  the  right  pleura. 

Anatomically  considered  the  case  is  interesting  as  exhibiting 
not  only  two  fistulas,  both  of  which  appeared  to  be  permanently 
patent,  but  also  those  oval  depressions,  on  the  pulmonary 
surface,  the  nature  of  which  we  cannot  yet  positively  declare ; 
the  first  of  these  circumstances  tends  still  further  to  render  this 
disease  analogous  to  the  perforation  of  the  digestive  tube,  in 
which  case  there  is  nothing  more  common  than  the  existence 
of  several  fistulas.  It  is  yet  to  be  determined  whether  by  any 
of  the  resources  of  physical  diagnosis  we  may  be  enabled  to 
pronounce  upon  the  existence  of  more  than  one  of  these  false 
passages. 

The  following  cases  were  published  in  the  first  edition  of 
this  work  : — 

Case  I. — Chronic  Phthisis.  Sudden  Perforation,  with  conse- 
quent Empyema  and  Pneumothorax  continuing  for  five 
months. 

A  female,  aged  25,  after  labouring  under  phthisis  for  several 
months,  felt,  during  a  fit  of  coughing,  a  sensation  as  of  a  sudden 
crack,  extending  from  above  downwards,  followed  by  the  feeling 
of  something  having  been  shed  out  into  the  cavity  of  the 
chest.  The  usual  symptoms  of  empyema  and  pneumothorax 
set  in,  and  at  the  end  of  a  fortnight  the  heart  pulsated  to  the 
right  of  the  sternum.  She  remained  in  a  low,  semi-hectic  con- 
dition for  five  months,  during  which  the  sound  of  fluctuation 
and  the  various  metallic  phenomena  existed  with  but  little 
variation. 

Dissection. — The  left  pleura  contained  upwards  of  a  quart  of 
an  opaque  fluid,  not  by  any  means  putrescent.  The  fistula 
existed  in  the  upper  lobe,  communicating  with  a  tuberculous 
cavity  of  the  size  of  a  pullet's  egg.  The  opposite  lung  was  also 
tubercular. 

Two  interesting  subjects  present  themselves  for  consideration 
in  this  case  :  one,  its  duration,  and  the  other  (not  peculiar, 
indeed)  the  absence  of  putrefaction  of  the  effused  fluid.  The 
patient  lived  five  months  and  thirteen  days  from  the  occurrence 

p  p 


578  DISEASES    OF    THE    PLEURA. 

of  the  fistula.     I  shall  just  now  detail  other  instances  of  a  still 
greater  duration. 

The  absence  of  putrefaction  in  the  effused  fluid  is,  indeed, 
difficult  of  explanation,  when  we  reflect  that  every  circum- 
stance of  heat,  moisture,  and  air  concur  to  favour  such  a  result. 
I  believe  it  to  be  one  of  the  many  facts  which  show  that  organic 
connexion  is  not  absolutely  necessary  for  the  transmission  of 
vitality.  This  absence  of  putrefaction  is  commonly  observed, 
and  would  seem  to  prove,  that  when  decomposition  does  occur, 
it  is  owing  to  some  other  conditions  than  the  entrance  of  air.  Of 
this  the  following  is  a  good  example. 

Case  II. — PhtJiisis,  with  Consecutive  Fistula,  Empyema,  and 
Pneumothorax.  Operation  for  Empyema,  subsequent  Gan- 
grene, of  the  Pleura. 

A  gentleman  under  my  care  for  phthisis  was  attacked 
suddenly  with  overwhelming  dyspnoea,  and  dreadful  anxiety.  I 
saw  him  shortly  after,  and  found  absence  of  respiration  over  the 
lower  portion  of  the  left  side,  without  alteration  of  sound  on 
percussion,  or  metallic  signs  ;  next  day,  however,  these  were 
evident.  The  liquid  effusion  increased,  and  in  about  a  month 
his  sufferings  from  dyspnoea  were  so  severe  as  to  warrant  the 
operation.  In  consultation  with  Mr.  Porter,  I  found  that  the 
effusion  was  already  pointing  externally,  between  the  fourth  and 
fifth  ribs.  The  tumour  was  opened,  and  a  large  quantity  of  fluid, 
without  any  foetor,  given  exit  to.  He  remained,  to  a  certain 
degree,  relieved  for  several  weeks,  when  his  distress  returned,  and 
the  fluid  in  the  pleura  again  pointed  at  the  original  situation.  A 
second  opening  was  made,  and  a  foetid  sanious  fluid  evacuated  *• 
soon  after  this  the  patient  sunk. 

On  dissection,  we  found  an  almost  universal  gangrene  of  the 
pleura ;  there  was  but  little  fluid  in  the  cavity,  but  the  serous 
membrane  was  sphacelated  in  many  situations,  and  several  of 
the  ribs  completely  denuded,  not  only  of  pleura,  but  periosteum. 
The  whole  cavity  exhaled  a  horrible  foetor ;  both  lungs  were 
lull  of  tubercles  :  the  fistula  was  easily  perceptible. 

This  case,  with  others,  leads  me  to  believe  that  the  mere 
entrance  of  air  is  not  the  cause  of  putrefaction  in  the  fluid  after 
operation,  even  in  simple  empyema. 


DISEASES    OF    THE    PLEURA.  579 

Case  III. — Acute  Phthisis,  with  Pneumothorax. 

A  man,  set.  25,  three  weeks  before  admission  was  attacked  with 
severe  pain  in  the  chest,  cough,  and  expectoration.  On 
admission,  he  had  a  continual  harassing  cough,  copious  muco- 
purulent expectoration,  great  dyspnoea,  disturbed  sleep,  with 
night  sweats ;  he  was  much  emaciated  ;  pulse  112  ;  respiration 
44 ;  the  chest  sounded  well  on  percussion ;  bronchitic  rales 
were  heard  throughout  both  lungs,  but  chiefly  in  the  right,  where 
the  respiration  was  very  feeble. 

In  this  state  he  continued  for  ten  days,  when  metallic  tinkling 
was  observed  when  the  patient  inspired,  coughed,  or  spoke, 
extending  over  the  greater  part  of  the  right  side  anteriorly, 
diminishing  posteriorly,  and  entirely  disappearing  in  the  upright 
position  ;  no  cavernous  respiration  or  gurgling ;  sputa  thick, 
and  scanty  ;  cough  not  so  severe. 

The  intercostal  spaces  of  the  right  side  soon  became  prominent, 
with  dulness  on  percussion  ;  decubitus  on  this  side  impossible ; 
integuments  oedematous  ;   superficial  veins  much  enlarged. 

He  died  within  three  weeks  from  the  period  of  perforation. 
The  right  side  of  the  chest  measured  two  inches  more  than  the 
left ;  the  pleural  sac  of  the  right  side  was  distended,  and  covered 
with  a  layer  of  lymph  towards  the  mediastinum ;  the  membrane 
was  in  the  normal  condition  ;  the  sac  contained  a  very  great 
quantity  of  sero-purulent  fluid  and  air;  the  lung  was  exceedingly 
atrophied,  and  coated  with  lymph  ;  it  was  adherent  by  a  small 
strap  to  the  second  rib  anteriorly,  beneath  which  the  fistulous 
opening  was  observed,  leading  obliquely  upwards  into  the  lung, 
and  full  of  caseous  matter ;  the  left  lung  was  tubercular, 
and  adhered  to  the  pleura  ;  there  were  some  slight  interlobular 
adhesions ;  the  pericardium  contained  a  reddish-looking  fluid ; 
the  heart  was  healthy. 

The  interest  of  this  case  consists  in  its  shewing  the  occurrence 
of  death  from  phthisical  pneumothorax  in  so  short  a  time  from 
the  first  illness. 

Case  IV. — Simple  Empyema  from  Injury.      Perforation  of  the 
Lung,  and  consequent  Empyema  and  Pneumothorax. 

A  man,  agtat.  23,  received  a  strain  in  his  right  side,  followed 
by  slight  pain  ;  his  breathing  became  then  affected,  and  the  pain 

p  p  2 


580  DISEASES    OF    THE    PLEUKA. 

distressing.  On  admission,  a  fortnight  after,  he  complained  of 
severe  pain  in  the  right  side,  increased  on  making  a  full  inspira- 
tion ;  some  cough  at  night,  with  pituitous  expectoration ;  skin 
hot  and  dry ;  pulse  110,  full  and  strong ;  can  lie  only  on 
his  back.  On  percussion,  the  chest  sounds  dull  on  the  right  side 
posteriorly,  from  the  scapula  downwards,  and  in  this  situation 
there  can  be  heard  only  a  very  feeble  respiration ;  the  left  side 
appears  healthy,  as  also  the  anterior  part  of  the  right.  There  is 
no  rale  audible  in  any  part  of  the  lungs. 

On  the  next  day,  23rd  of  December,  pain  is  diminished  ; 
can  lie  on  either  side  ;  some  epistaxis  ;  sputa  thin  ;  the  entire 
posterior  portion  of  the  right  lung  is  dull  on  percussion  ;  respira- 
tion feeble,  with  well-marked  egophony  ;  pulse  full  and  soft,  108; 
skin,  cool  and  moist. 

24th.  Had  some  sleep ;  constant  hard  cough,  without  ex- 
pectoration ;  refers  the  pain  to  the  anteroinferior  region  of  the 
chest ;  dulness  continues  posteriorly,  but  the  egophony  has 
disappeared.  While  he  lies  on  the  left  side,  respiration  becomes 
audible  in  the  anteroinferior  and  lateral  regions  of  the  right 
side,  and  disappears  when  he  lies  on  the  back ;  respirations 
30,  chiefly  thoracic. 

25th.  Pain  relieved  by  leeching  ;  respiration  can  be  heard  now 
in  the  infra-mammary  region,  with  frottement ;  the  stethoscopic 
phenomena  of  the  posterior  portion  the  same  as  yesterday. 

26.  Frottement  has  disappeared  ;  posteriorly  the  egophony  has 
returned. 

27th.  Passed  a  restless  night,  from  coughing  ;  this  morning  is 
feverish ;  pulse  strong  and  full ;  dulness  continues  posteriorly, 
with  some  resonance  of  the  voice.  When  the  patient  lies  on  his 
face,  the  respiration  is  more  audible. 

28th.  Gums  sore ;  some  salivation  ;  passed  a  restless  night 
from  cough,  with  mucous  expectoration ;  pulse  96,  strong,  full, 
and  soft ;  the  right  side  is  dilated  nearly  an  inch  ;  no  change  in 
the  stethoscopic  phenomena  since  yesterday. 

March  1st.  Respiration  more  hurried,  with  severe  pain  in  the 
side ;  considerable  tenderness  and  fulness  in  the  region  of  the  liver ; 
pulse  soft,  full,  and  weaker  than  yesterday. 

Four  o'clock  p.m. — Since  the  visit  this  morning  he  has  been 
much  worse ;  the  countenance  is  sunk,  and  the  body  covered  with 
a  clammy  sweat ;  great  prostration  ;  a  copious  expectoration  of 


DISEASES    OF    THE    PLEUKA.  581 

sero-purulent  fluid,  emitting  a  horrible  foetor ;  on  succussion 
fluid  is  heard  dashing  about  in  the  cavity  of  the  pleura  ;  there  is 
great  dyspnoea,  and  constant  cough.  An  operation  to  evacuate 
the  matter  from  the  chest  was  proposed,  but  the  patient  would 
not  accede  to  it. 

2nd.  The  expectoration  has  in  a  great  measure  ceased ;  at  the 
postero-inferior  region  of  the  right  side  the  tintement  metalliquc 
is  heard  ;  dyspnoea  very  great ;  general  sinking.  He  died  in  the 
course  of  the  day.  His  friends  would  not  allow  a  post-mortem 
examination. 

The  above  case  is  an  excellent  example  of  the  evacuation  of  a 
simple  empyema  by  gangrenous  eschar  of  the  pleura.  Active 
treatment  was  employed,  but  without  effect.  The  system  had 
been  brought  under  the  influence  of  mercury  a  short  time  before 
the  perforation. 

That  individuals  have  recovered  by  expectoration  of  the  fluid 
effused  does  not  admit  of  any  doubt.  I  have  myself  seen  a  case 
of  this  kind,  which  was  under  the  care  of  Sir  Philip  Crampton. 
But  that  the  perforation  is  in  all  cases  the  result  of  gangrene 
seems  very  doubtful.  In  the  favourable  cases  it  is  probably  by 
simple  ulceration. 

Case  V. —  Gangrene  of  the  Lung,  Empyema,  and  Pneumotho- 
rax ;  Paracentesis ;  Gangrenous  Destruction  of  the  Costal 
Pleura  ;  Passage  of  the  Fluid  behind  the  Peritoneum. 

A  gentleman,  ret.  36,  generally  very  healthy,  with  a  large, 
well-formed  chest,  had  occasionally  complained,  for  the  last  few 
months,  of  pain  in  the  chest,  at  one  period  very  severe ;  he  had 
been  cupped  and  blistered,  but  without  relief;  at  length  hectic 
symptoms  set  in,  with  restless  nights ;  soon  after  he  felt  as  if 
something  gave  way  in  his  side,  and  immediately  expectorated  a 
horribly  foetid  matter.  A  similar  attack  occurred  in  a  few  days, 
with  the  same  foetid  discharge,  but  accompanied  by  prostration, 
lividity  of  the  countenance,  and  dyspnoea.  I  saw  the  patient 
along  with  Sir  H.  Marsh  and  Sir  P.  Crampton.  We  found  the 
chest  to  contain  air  and  fluid ;  and  in  consultation  made  the 
diagnosis  of  gangrene  of  the  lung,  and  advised  paracentesis. 
The  operation  was  performed  between  the  seventh  and  eighth 
ribs,  a  little  below  and  external  to  the  right  mamma ;  the  with- 


582  DISEASES    OF    THE    PLEURA. 

drawing  of  the  trocar  gave  issue  to  a  quantity  of  foetid  air  ;  a 
probe  was  introduced,  and  met  by  an  elastic  resisting  substance ; 
this  was  apparently  perforated,  and  about  three  quarts  of  dirty, 
grey-coloured,  foetid  fluid  given  exit  to.  Great  relief  followed  the 
operation.  The  patient,  however,  passed  a  wretched  night,  with 
hectic  paroxysms  ;  no  discharge  occurred  from  the  wound. 

17th.  The  trocar  and  canula  were  introduced,  and  a  quart  of 
the  same  foetid  matter  came  away — patient  felt  easier  ;  passed  a 
bad  night. 

18th.  A  pint  of  foetid  matter  was  taken  away  ;  spent  a  most 
uneasy  night,  with  incessant  cough  and  frothy  expectoration,  the 
act  of  coughing  sending  the  foetid  air  and  matter  through  the 
external  opening  in  great  quantities. 

19th.  Much  exhausted ;  said  he  felt  as  if  there  was  a  well  in 
his  chest ;  he  was  sensible  of  a  constant  dropping  of  fluid  ; 
pulse  120 ;  great  weakness  ;  heat  and  soreness  in  the  side. 

20th.  Mr.  Colles  saw  him,  in  consultation  with  the  other 
attendants.  Anodyne  enemata  and  stimulants  were  ordered ;  he 
passed  a  better  night,  but  had  great  dysuria  ;  ordered  mucila- 
ginous drinks. 

21st.  Passed  a  bad  night ;  pulse  144,  and  weak  during  a  fit 
of  coughing,  which  brought  on  the  usual  discharge  from  the 
wound  ;  about  a  cupful  of  blood  gushed  out. 

22nd.  The  introduction  of  a  gum  elastic  tube  gave  exit  to  no 
fluid,  but  a  great  quantity  escaped  while  the  patient  coughed  ; 
the  abdomen  became  tense  and  tympanitic,  with  exacerbation 
of  all  the  symptoms,  and  the  patient  died  in  about  thirty- six 
hours. 

Dissection.  —Externally  the  body  presented  some  livid  marks 
at  the  right  side,  and  a  slight  fulness  in  the  right  inguinal  region 
and  side  of  the  scrotum.  The  right  pleural  sac  contained  above 
a  quart  of  foetid  purulent  fluid ;  the  lung  was  of  a  dark  greenish 
hue,  smeared  with  a  creamy  substance,  its  lower  and  back  part 
destroyed  by  gangrene,  leaving  a  large  greenish-coloured  cavity, 
the  size  of  the  hand.  The  substance  of  the  lung  near  this  was 
easily  broken  down,  and  the  vessels  and  bronchial  tubes  were 
seen  passing  through  it ;  the  remainder  was  gorged  with  a  frothy 
dark  sanies  ;  the  whole  lung  was  reduced  to  half  its  size  ;  some 
adhesions  united  it  to  the  mediastinum,  almost  forming  a  circum- 
scribed cavity  ;  the  costal  pleura  was  in  some  places  highly  vas- 


DISEASES  OF  THE  PLEURA.  583 

cular ;  in  others,  covered  with  lymphy  secretion  ;  in  some  places 
very  tenacious.  In  one  patch,  destroyed  by  gangrene,  the  inter- 
costal muscles  were  laid  bare  for  the  space  of  several  inches,  and 
were  in  one  part  sloughy,  forming  an  opening  at  the  inferior 
and  posterior  part,  at  which  place  nature  had  attempted  an  outlet 
for  the  fluid,  the  latter  having  made  its  way  into  the  cellular 
tissue,  beneath  the  skin,  and  between  the  peritoneum  and  abdo- 
minal muscles,  down  the  side  of  the  abdomen  to  the  scrotum. 
The  general  cavity  of  the  right  side  was  much  diminished  by  the 
liver  having  been  displaced  upwards  by  the  flatus  of  the  intes- 
tines ;  the  liver  was  in  such  close  apposition  with  the  lung  as  to 
be  in  danger  of  being  wounded  by  the  trocar,  thus  accounting 
for  the  fluid  not  coming  off  by  the  canula  in  the  first  instance. 

Case  VI. — Empyema  of  the  Right  Side  ;  opening  by  Anthrax  ; 
Pneumothorax  by  external  Fistula. 

A  labourer,  eighteen  months  ago,  became  affected  with  cough 
and  lmenioptysis.  Seven  months  past  he  received  a  severe  con- 
tusion of  the  right  side,  followed  by  severe  pain  and  cough ;  con- 
tinued ill  for  six  weeks,  with  dyspnoea  aggravated  by  exercise. 
The  dyspnoea  continues,  and  obliges  him  to  lie  constantly  on  the 
right  side.  Four  months  ago  he  perceived  a  tumour  on  the  upper 
part  of  the  abdomen  ;  and,  within  the  last  month,  oedema  of  the 
lower  extremities  has  supervened. 

October  11th.  There  is  perfect  dulness  of  the  whole  right  side, 
from  the  clavicle  to  the  short  ribs,  extending  to  the  left  side 
of  the  sternum  for  its  whole  length.  In  the  right  infra-clavicular 
region  a  feeble  tracheal  respiration,  with  some  slight  sonorous  or 
sibilous  rales,  is  audible.  The  same  can  be  heard  in  the  supra- 
clavicular region.  Over  the  rest  of  the  side  there  is  nullity  of 
respiration.  No  gargouillement,  muco-crepitus,  nor  bronchial 
inspiration  whatever.  The  voice  sounds  strongly  in  the  supra 
and  infra-clavicular  regions.  The  whole  side  is  dilated  somewhat 
more  than  an  inch  ;  the  intercostal  spaces  are  raised,  giving 
complete  smoothness  to  the  side  ;  over  the  left  lung  respiration 
is  completely  puerile.  The  whole  of  the  upper  portion  of  the 
abdomen  is  occupied  by  a  large  and  prominent  tumour,  whosa 
greatest  eminence  appears  along  the  mesian  line,  and  extends 
into  the  left  hypochondrium. 


584  DISEASES    OF    THE    PLEURA. 

20th.  He  complains  of  pain  in  the  lower  portion  of  the  ricrht 
side,  just  below  the  short  rib.  There  is  some  tenderness,  tume- 
faction, and  a  slight  blush. 

November  1st.  The  superficial  veins  of  the  right  side  are 
enlarged ;  the  heart  is  displaced  upwards,  and  about  three  inches 
to  the  left  side. 

Thus  he  continued  for  a  month,  when  the  tumour  was  found 
to  have  increased  in  size,  to  be  quite  soft,  and  surrounded  by  a 
dark,  livid  redness.  A  lancet  was  plunged  into  it,  giving  exit  to 
a  small  quantity  of  bloody  sanies.  Patient  complained  of  great 
pain. 

3rd.  A  serous  fluid  is  constantly  draining  in  great  quantity 
from  the  sore.  The  patient's  lower  extremities  and  abdomen, 
which  were  anasarcous,  are  becoming  rapidly  devoid  of  fluid. 

6th.  Anasarca  nearly  gone.  On  attempting  to  make  a  more 
free  opening  in  the  tumour,  the  patient  lost  about  twelve  ounces 
of  blood  from  the  vessels  of  the  integuments  :  but  the  pain  in  the 
tumour  was  greatly  relieved. 

7th.  The  discharge  is  increased,  and  is  sero-purulent ;  the  right 
side  is  dull,  anteriorly  and  posteriorly,  as  high  as  the  mamma; 
from  that  up  it  is  natural  :  and  over  this  space  respiration  is  dis- 
tinctly audible,  loud,  and  with  something  of  a  tracheal  character 
immediately  below  the  clavicle;  feeble,  as  we  approached  the 
limits  of  the  clear  sound ;  below  this,  nullity  of  respiration.  The 
heart  now  pulsates  in  its  natural  situation.  In  the  abdomen  the 
tumour  formerly  evident,  is  now  not  so  perceptible  to  the  eye, 
but  is  easily  distinguished  by  the  hand,  and  its  boundaries  dis- 
tinctly defined  by  percussion.  The  liver,  especially  the  left  lobe, 
appears  enlarged.  There  is  considerable  heat  of  skin,  and  a 
tendency  to  rigors.     The  patient  sweated  copiously  last  night. 

10th.  Patient  complains  more  of  dyspnoea  ;  anteriorly,  and  in 
the  axilla,  on  a  level  with  the  sixth  rib,  the  sound  of  the  chest  is 
morbidly  clear  :  below  this,  perfect  dulness  ;  nullity  of  respiration 
complete,  except  over  the  root  of  the  lung,  and  in  a  small  space 
to  the  right  of  it ;  here  it  has  a  bronchial  character.  The  cough 
and  voice  are  distinctly  metallic. 

13th.  The  sloughs  have  come  away,  and  the  sore  looks  healthy. 
Patient  complains  greatly  of  dyspnoea,  and  a  "feeling  of  wind 
passing  in  and  out  of  the  hole,"  and  air  can  be  heard  gurgling 
along  with  the  sero-purulent  discharge  ;  but  the  flame  of  a  wax 


DISEASES    OF    THE    PLEURA.  585 

taper  applied  to  the  aperture  is  not  sensibly  affected.  He  con- 
stantly presses  his  hand  strongly  above  the  aperture,  and  says 
this  relieves  his  breathing  very  much.  Had  a  slight  rigor  to-day, 
with  tendency  to  syncope,  and  afterwards  sweated.  The  sero- 
purulent  discharge  continues  ;  and  when  he  sits  up,  or  goes  to 
stool,  it  comes  away  in  gushes. 

14th.  Discharge  has  become  very  foetid  ;  the  fistulous  opening 
appears  near  an  inch  wide  at  its  commencement ;  a  probe  may  be 
introduced  its  whole  length  with  facility.  Compresses  of  dry  lint 
were  lightly  strapped  down  along  the  course  of  the  fistula.  The 
sore  was  dressed  with  nitrate  of  silver  and  dry  lint ;  and,  over  all, 
a  broad  roller  was  applied  to  the  chest,  with  considerable  tight- 
ness, from  which  the  patient  expressed  great  relief. 

15th.  Slept  pretty  well,  without  sweat.  The  discharge  had 
diminished ;  but,  on  the  patient  sitting  up,  and  having  the 
sore  dressed,  fully  a  pint  of  very  foetid  sero-purulent  matter  was 
evacuated,  during  the  flow  of  which  he  complained  of  agonizing 
pain,  compared  by  him  to  burning  by  hot  iron,  and  causing  him 
to  scream  aloud.  The  discharge  was  followed  by  about  an  ounce 
of  bloody  sanies. 

25th.  At  this  time  I  found  that  respiration  was  audible  only 
along  the  spine  and  sternum,  and  confined  to  a  very  narrow 
space ;  the  sound  of  air  making  its  way  through  the  fistulous 
opening,  and  simulating  respiration,  was  generally  audible  over 
the  whole  of  the  right  side;  with  the  metallic  character  as  before. 
The  patient  expired  on  the  29th  December. 

Dissection. — Body  generally  very  much  emaciated ;  oedema  of 
the  lower  extremities.  The  external  sore  and  fistulous  opening 
were  situated  exactly  above  the  last  false  rib,  near  the  spinal 
column  ;  through  these  a  bougie  was  introduced  with  great  facility, 
passing  upwards,  and  to  the  left  side,  appearing  to  enter 
the  right  pleural  cavity.  In  raising  the  sternum,  it  was  necessary 
to  divide  a  considerable  extent  of  old  adhesions,  which  connected 
the  anteroinferior  third  of  the  right  lung  to  the  parietes.  On 
laying  open  the  thorax  completely,  the  left  lung  appeared  per- 
fectly healthy ;  the  right  lung  lay  along  the  spine,  greatly  reduced 
in  volume,  but  of  its  natural  length,  and  connected  to  the  dia- 
phragm by  a  very  firm  adhesion,  about  three  inches  in  breadth.  The 
pleura  was  lined  with  pus,  of  which  the  cavity  contained  four 
ounces,  mixed  inferiorly  with  large  membranous  shreds  of  lymph, 


586  DISEASES    OF    THE    PLEURA. 

among  which  the  point  of  the  bougie  was  seen  protruding,  having 
entered  by  an  opening  large  enough  to  admit  the  tip  of  the  little 
finger,  situated  in  the  most  depending  portion  of  the  cavity, 
about  an  inch  from  the  spine,  in  the  angle  formed  between  the 
diaphragm  and  the  parietes.  No  other  breach  of  continuity 
could  be  discovered  in  the  pleura.  The  substance  of  the  right  lung 
was  carnified,  and  generally  studded  with  tubercles  in  different 
stages.  The  left  lung  was  also  tubercular  in  its  superior  lobe. 
The  liver  was  of  a  dirty  yellowish  colour,  nodulated,  and  greatly 
enlarged ;  the  right  lobe  extending  down  to  the  umbilicus,  and 
the  left  far  into  the  left  hypochondrium. 

This  last  case  is  interesting  as  exemplifying  the  occurrence  of 
metallic  signs  in  pneumothorax  from  external  fistula,  and 
without  the  existence  of  fluid.  The  signs  continued  after  every 
drop  of  fluid  had  drained  through  the  opening  in  the  side.  The 
fact  that  the  presence  of  liquid  is  unnecessary  for  the  existence  of 
metallic  signs,  has  been  already  established  by  Dr.  Williams. 
With  the  exception  of  the  signs  of  dropping  or  bubbling,  all 
that  is  wanting  to  cause  metallic  sounds,  is  a  cavity  of  sufficient 
size  containing  air. 

I  may  here  remark,  that  in  the  early  periods  of  the  disease  the 
lung  may  not  be  completely  fixed.  Thus,  we  may  observe  in 
cases,  in  which,  during  the  erect  position  the  signs  are  evident 
posteriorly  and  superiorly,  that  they  disappear  when  the  patient 
turns  on  his  face,  and  are  replaced  by  vesicular  murmur,  although 
they  continue  in  the  anterior  and  inferior  portions.  This  can 
only  be  explained  by  supposing  that,  as  the  liquid  accumulates 
along  the  mediastinum,  it  forces  the  lung  against  the  posterior 
portion  of  the  costal  pleura. 

We  may  attempt  a  classification  of  cases  of  pneumothorax, 
founded  principally  on  the  nature  of  the  affection  which  has 
preceded  the  fistula.  And  I  wish  it  to  be  understood  that  in 
arranging  these  in  the  order  of  frequency,  I  depend  merely  on 
my  own  experience  of  the  disease. 

I.  In  this  class  of  cases  the  tuberculization  of  the  lung  and 
the  consequent  formation  of  superficial  cavities  precede  the 
formation  of  pneumothorax.  That  the  accident  of  a  fistula  is 
not  more  frequent  is  explained  by  the  great  liability  of  the 
pleura  to  form  adhesions  in  connexion  with  any  subjacent  dis- 
ease.    Were  the  pleura  as  little  disposed  to  this  process  as  the 


DISEASES    OF    THE    PLEURA.  587 

peritoneum,  perforation  of  the  pleura  would  be  one  of  the  most 
common  of  accidents,  and  the  cure  of  consumption  scarcely  pos- 
sible. In  most  cases  the  fistula  is  not  produced  until  the  disease 
has  become  a  chronic  affection.  We  find  it  generally  more 
towards  the  centre  than  the  upper  part  of  the  pleura.  So  that 
it  appears  probable,  if  we  adopt  the  opinion  of  Laennec,  that  the 
tubercle  is  developed  by  successive  crops,  that  the  fistula  is  con- 
nected less  with  the  first  or  second  than  with  subsequent  deve- 
lopments of  the  disease.  There  may  be  more  than  one  fistula, 
but  in  these  cases  it  is  not  likely  that  the  perforations  have 
formed  simultaneously.  Finally,  we  have  in  this  class  of  cases 
those  secondary  fistulaa  forming  from  without  inwards,  and  which 
are  to  be  attributed  to  the  diseased  process  set  up  in  the  pleural 
sac  in  consequence  of  the  chronic  empyema. 

II.  A  gangrenous  eschar  having  formed  in  the  lung  may 
communicate  with  the  bronchial  tubes  on  the  one  hand,  while  it 
perforates  the  pulmonary  pleura  on  the  other.  All  the  mecha- 
nical conditions  of  the  first  form  are  thus  produced ;  and  it 
appears  very  probable  that  the  products  of  the  pleuritic  disease 
have  from  the  first  a  putrefactive  character. 

III.  A  simple  empyema  having  formed  may  open  into  the 
lung.  We  cannot  say  whether  in  every  such  case  a  temporary 
pneumothorax  is  produced,  but  that  such  a  complication  may 
occur,  and  yet  the  patient  subsequently  recover  must  be  ad- 
mitted. I  have  seen  two  remarkable  examples  which  confirm 
this  statement.  But  on  the  other  hand  it  occasionally  happens 
that,  the  fistula  remaining  permanently  open  while  the  lung 
from  its  physical  condition  is  unable  to  expand,  a  permanent 
fistular  pneumothorax  is  established. 

IV.  We  may  have  pneumothorax  by  external  fistula.  A 
patient  is  operated  on  for  empyema ;  a  large  quantity  of  fluid  is 
withdrawn,  while  the  lung  is  either  incapable  of  any  expansion, 
or  can  only  enlarge  itself  to  a  certain  degree ;  the  wound  re- 
mains open,  admitting  air  during  inspiration,  on  the  one  hand, 
and  pouring  out  a  sanious  pus  on  the  other.  There  is  yet 
another  case  of  pneumothorax  in  which  we  have  the  curious 
combination  of  pulmonary  and  intercostal  fistula.  This  condi- 
tion I  have  observed  in  a  case  of  the  ordinary  empyema  and 
pneumothorax  in  a  phthisical  patient.  An  anthrax  formed  on  the 
side  through  which  the  liquid  contents  of  the  sac  drained,  so 


588  DISEASES    OF    THE    PLEURA. 

that  the  singular  combination  of  an  external  and  an  internal — 
fistula  was  produced.  The  patient  inspired  through  two  canals 
— one  the  larynx,  the  other  the  intercostal  fistula. 

There  are  two  points  still  worthy  of  notice  in  connexion  with 
this  subject :  one,  the  question  as  to  how  far  the  mere  rupture 
of  the  pleura  and  effusion  of  air  into  the  sac  is  competent  to 
produce  the  combination  of  empyema  and  pneumothorax,  and 
the  other,  the  supervention  of  this  accident  in  cases  of  protracted 
hooping-cough.  The  possibility  of  the  occurrence  of  fistular 
pneumothorax  without  empyema  is  a  question  on  which  much 
difference  of  opinion  exists.  But  the  case  I  communicated  to 
the  Pathological  Society  in  1840,  establishes  the  possible  occur- 
rence of  such  a  condition.* 

This  case  is  at  all  events  illustrative  of  the  doctrine  that  even 
with  a  violent  solution  of  continuity  of  the  pleura  the  effusion  of 
air  and  collapse,  or  compression  of  the  lung,  are  not  necessarily 
followed  by  inflammatory  action.  And  so  far  as  it  goes  it  tends 
to  support  the  opinion,  which  is  every  day  more  generally  ad- 
mitted, that  the  mere  entrance  of  air  into  the  cavity  of  the 
pleura  is,  so  far  as  it  tends  to  excite  serous  inflammation,  a 
matter  but  of  slight  importance.  In  the  case  in  question  we 
had  fistula,  collapse  of  the  lung,  and  pneumothorax,  and  yet  the 
pulmonary  pleura  was  totally  free  from  the  slightest  mark  of 
inflammatory  action.  In  this  case,  as  in  that  of  the  double 
fistula,  just  now  alluded  to,  there  was  no  pleuritic  effusion,  at 
least  at  a  certain  period  of  one  case,  and  during  the  entire 
progress  of  the  other.  Yet  in  both  these  cases  the  metallic 
phenomena  of  respiration  and  of  voice  were  distinctly  produced. 
The  presence  of  a  liquid  then  is  not  necessary  for  the  production 
of  these  signs.  The  metallic  tinkling  and  the  sound  of  suc- 
cussion  were  of  course  absent,  but  the  essential  characteristics  of 
air  confined  in  an  elastic  cavity  were  present. 

Before  proceeding  to  the  consideration  of  the  medical  treat- 
ment, a  few  observations  may  be  added  which  have  reference  to 
the  subject  in  general,  and  which  may  be  considered  as  supple- 
mentary to  what  has  been  already  said.  Perforative  pneumo- 
thorax and  empyema  may  sometimes  occur  under  unusual 
circumstances.  My  friend  Dr.  Townsend  related  a  case  to  me 
in  which  but  one,  or  at  the  most  but  two,  tuberculous  concre- 

*  See  Trans.  Path.  Soc,  vol.  i. 


DISEASES    OF    THE    PLEURA.  589 

tions  of  a  small  size  existed  in  the  lung ;  and  there  was  little  if 
any  reason  to  suspect  that  the  patient  was  phthisical.  From 
one  of  these  concretions,  which  was  superficial,  the  perforation 
actually  took  place.  The  patient  ultimately  sunk,  although 
the  lungs  could  scarcely  be  said  to  contain  any  tuberculous 
deposit. 

I  have  stated  that  in  most  cases  the  fistula  occurs  at  a  point 
considerably  removed  from  the  summit  of  the  lung — a  circum- 
stance which,  placed  in  connection  with  others,  seems  to  warrant 
the  opinion  that  the  accident  is  very  rare  during  the  development 
and  maturation  of  the  earlier  tubercular  deposits.  I  have, 
however,  seen  one  remarkable  exception  to  this,  in  which  a 
small  cavity  existed  at  the  very  summit  of  the  lung,  and  the 
communicating  perforation  was  within  an  inch  of  the  apex. 
Such  a  case  must  be  considered  as  one  of  extreme  rarity,  as  in 
most  cases  the  secondary  adhesions  are  strong  and  complete 
around  the  summit  of  the  lung.  I  have  witnessed  another  case 
illustrative  of  the  unexpected  occurrence  of  perforative  pneumo- 
thorax. A  young  lady,  several  of  whose  family  had  suffered  from 
phthisis,  was  attacked  with  hooping-cough,  attended  by  a  good 
deal  of  bronchial  inflammation  and  fever.  The  character  of  the 
cough  remained  unchanged,  but  the  febrile  state  with  a  rapid 
pulse  continued  for  many  weeks.  The  medical  attendants  and 
friends  of  the  patient  misled  by  the  persistent  characteristics  of 
the  cough  never  dreamt  of  the  existence  of  any  organic  disease. 
It  happened  however  on  one  occasion  that,  after  one  of  the  ordi- 
nary paroxysms  of  pertussis,  the  patient  was  seized  with  agonizing 
dyspnoea ;  she  was  seen  by  an  eminent  practitioner  of  this  city, 
who  at  once  recognized  that  a  perforation  of  the  lung  had  taken 
place.  I  also  saw  her  within  a  few  hours  after  this  gentleman 
had  discovered  the  nature  of  the  affection,  and  the  patient  had 
then  the  unequivocal  signs  of  pneumothorax  with  liquid  effusion. 
She  died  in  a  few  days — the  opening  being  apparently  valvular, 
and  the  consequent  oppression  and  distention  of  the  chest  causing 
the  greatest  amount  of  oppression  and  suffering.  Here  the 
error  arose  from  the  ignorance  of  two  important  pathological 
facts,  one  that  while  the  apyrexial  hooping-cough  is  generally 
innocuous,  the  complication  of  the  disease  with  fever  of  any  type 
should  always  excite  alarm — nay,  even  if  fever  be  absent,  or  but 
slightly  developed,  yet  if  the  pulse  continue  rapid  in  a  case  of 


590  DISEASES    OF   THE    PLEURA. 

pertussis  there  is  just  ground  for  apprehension.  The  second 
ground  of  error  was  the  overlooking  the  important  fact  that 
where  an  organic  change  succeeds  to  a  specific  disease,  the  pecu- 
liar symptoms  of  the  latter  may  continue  unchanged  up  to  the 
last  period  of  life.  Thus  in  a  case  of  hooping-cough  which 
comes  to  he  complicated  with  tubercle,  it  will  often  happen  that 
the  cough  will  continue  unchanged,  although  the  lungs  are  far 
advanced  in  disorganization.  Ignorant  of  this  fact,  and  also 
ignorant  of  the  great  law  that  specific  diseases,  especially  when 
complicated  with  fever,  are  too  apt  to  be  followed  by  heterologous 
deposits  in  the  viscera,  the  practitioner  continues  blinded  as  to 
the  actual  state  of  his  patient,  or  only  discovers  his  error  when 
the  saving  of  his  patient's  life  and  that  of  his  own  reputation  are 
equally  impossible.  It  is  supposed  that  because  the  patient  has 
hooping-cough  no  other  disease  exists — a  doctrine  by  which  no 
one  who  understands  the  law  of  combination  of  disease  should 
permit  himself  to  be  misled.  I  have  repeatedly  witnessed  cases 
of  fatal  suppurative  phthisis  which  had  commenced  by  hoop- 
ing-cough, yet  in  which  the  peculiar  character  of  the  cough 
remained  unchanged  throughout  the  entire  course  of  the  case ; 
we  may  lay  it  down  as  a  practical  rule,  that  if  in  any  case  of 
hooping-cough  any  of  the  three  following  circumstances  occur, 
we  should  expect  the  occurrence  of  organic  disease,  and  espe- 
cially that  of  tuberculization  of  the  lung. 

lstly.  That  the  cough  preserving  its  special  character  con- 
tinues for  a  period  of  unusual  length. 

2ndly.  That  it  resists  treatment. 

3rdly.  That  it  is  attended  with  rapidity  of  pulse. 

4thly,  and  lastly.  That  a  febrile  state  exists.  This  condition 
may  have  attended  the  cough  from  the  first,  or  may  become 
developed  at  some  advanced  period  of  the  case ;  it  may  be  in- 
flammatory or  irritative,  remittent,  intermittent,  or  truly  hectic ; 
but  in  whatever  form  it  may  occur,  its  combination  with  pertussis 
is  to  be  looked  upon  as  a  source  of  the  most  grave  prognosis. 
In  some  cases  the  local  change  may  be  detected  by  the  stetho- 
scope, while  in  others  little  can  be  found  but  the  signs  of  a 
remittent  or  resistent  bronchitis ;  yet,  even  under  these  circum- 
stances, I  would  impress  strongly  on  the  mind  of  the  practitioner 
that  where  he  has  to  deal  with  a  case  of  hooping-cough  of  long 
standing,   and  complicated  with  fever  of  any  description,   the 


DISEASES    OF    THE    PLEURA.  591 

negative  result  of  a  physical  examination  will  not  justify  him  in 
considering  the  lungs  free  from  organic  disease. 

The  question  of  the  curability  of  pneumothorax  and  empyema 
from  fistula  has  been  mooted  by  Dr.  Houghton  ;  and,  doubtless, 
in  his  case  there  was  an  attempt  towards  cure.  The  records  of 
surgery  shew  that  the  mere  existence  of  fistula  is  not  always 
hopeless ;  but  we  must  draw  a  careful  distinction  between  cases 
of  wounds  of  the  thorax,  where  the  lung  was  previously  healthy, 
and  those  where  the  fistula  has  proceeded  from  idiopathic  lesion. 
We  know  further,  that  the  opening  of  a  simple  empyema  into 
the  lung  has  been  followed  by  recovery;  and  in  such  a  case  the 
chances  are  better.  But  where  the  disease  has  proceeded  from 
the  opening  of  a  gangrenous  or  tuberculous  abscess  into  the 
pleura,  the  chances  of  recovery,  even  without  reference  to  the 
condition  of  the  pleura,  must  be  infinitely  small ;  and,  I  believe, 
there  is  no  recorded  instance  of  such  an  event. 

Finally,  little  is  to  be  hoped  from  an  operation  in  this  disease; 
and  it  should  never  be  undertaken  unless  when  the  distress  is 
distinctly  traceable  to  the  enormous  accumulation  of  liquid,  as 
shewn  by  extensive  dulness  and  diminution  of  the  metallic  signs; 
and  even  in  such  a  case  the  relief  is  much  less  than  might  be 
expected ;  and  there  is  the  greatest  liability  to  gangrene  of  the 
pleura.  This  I  have  repeatedly  verified ;  and  the  rapidity  of 
the  destruction  of  the  serous  membrane  is  truly  singular.  I 
have  given  a  case,  in  which,  previous  to  the  operation,  no 
symptom  of  gangrene  existed,  where  the  fluid  withdrawn  had 
no  fcetor  whatever,  yet  where  the  whole  pleura  was  destroyed  in 
a  few  days ;  the  ribs  were  actually  denuded,  and  seemed  in  a 
state  of  necrosis. 

We  may  here  recapitulate  some  of  the  points  which  have  been 
discussed,  referring  especially  to  those  which  have  a  practical 
bearing,  not  only  on  treatment,  but  also  on  diagnosis  and 
prognosis.* 

1st.  It  is  certain  that  pleuritis  may  occur  under  a  variety  of 
conditions  ;  that  it  may  be  on  the  one  hand  latent,  both  as  to 
local  and  general  symptoms,  while  on  the  other  it  may  be  a 
most  violent  and  manifest  disease. 

*  This  recapitulation  is  compounded  of  that  which  concludes  the  chapter  in  the 
former  edition,  and  of  a  longer  and  more  elaborate  resume  in  the  au'hor's  note  book  • 
care  having  been  taken  to  select  the  most  important  deductions  in  each,  and  po  to 
arrange  them  as  to  avoid,  so  far  as  possible,  needless  repetition.     (Ed.) 


592  DISEASES    OF    THE    PLEURA. 

2nd.  That  even  in  the  latent  and  apyrexial  cases  bad  results  as 
to  the  contraction  of  the  side  or  to  the  subsequent  development 
of  tubercle  may  follow. 

3rd.  That  this  latent,  subacute  form  may  be  a  primary  or  a 
secondary  affection,  and  is  liable  to  be  confounded  with  many 
diseases,  of  which  phthisis  is  the  most  common. 

4th.  That  physical  diagnosis  is  indispensable  in  judging  of 
the  extent,  progress,  retrocession,  or  cure  of  pleuritic  disease. 

5th.  That  these  physical  signs  are  fourfold,  embracing  the 
signs  of  simple  exudation  of  lymph,  the  evidences  of  excentric 
pressure  or  displacement,  of  concentric  displacement,  and  lastly, 
of  intercostal  or  diaphragmatic  paralysis. 

6th.  That  the  dulness  of  a  pleuritic  effusion  generally  occurs 
more  rapidly  than  that  of  pneumonia,  and  is  unpreceded  by 
crepitating  rale. 

7th.  That  these  characters  are  not  always  available  for 
differential  diagnosis. 

8th.  That  as  a  sign  of  incipient  effusion  dulness  is  more 
valuable  when  occurring  at  the  left  than  at  the  right  side. 

9th.  That  when  partial  it  terminates  by  a  well-defined  (trans- 
verse) line. 

10th.  That  the  respiratory  murmur  may  be  totally  ex- 
tinguished, feebly  audible,  or  distinctly  bronchial. 

11th.  That  the  bronchial  respiration  is  to  be  distinguished 
from  that  of  pneumonia  by  the  concurrent  phenomena. 

12th.  That  the  egophonic  sounds  are  extremely  various  and 
inconstant. 

13th.  That  the  absence  of  vocal  fremitus  as  perceived  by  the 
hand  is  an  important  sign. 

14th.  That  when  the  voice  is  acute  and  feeble  this  test  is 
inapplicable. 

15th.  That  the  signs  of  excentric  displacement  are  the  most 
valuable  of  the  physical  indications. 

16th.  That  displacement  of  the  heart  occurs  before  that  of 
the  intercostals  or  diaphragm. 

17th.  That  this  is  not  necessarily  accompanied  by  disturbance 
of  the  heart's  action. 

18th.  That  as  a  sign  of  effusion  dilatation  is  of  more  value 
when  occurring  at  the  left  than  at  the  right  side. 

19th.  That  the  effects  of  excentric  pressure  are  first  seen  on 


DISEASES    OF    THE    PLEUBA.  593 

the  non-muscular  portions  of  the  thoracic  walls,  dilatation  of  the 
mediastinum  and  of  the  ribs  preceding  that  of  the  intercostals 
and  diaphragm,  the  less  vital  portions  of  the  thorax  yielding 
before  the  muscular  structures. 

20th.  That  the  mediastinal  displacement  can  be  ascertained 
by  percussion  as  well  as  by  the  position  of  the  heart. 

21st.  That  the  yielding  of  the  muscular  expansions  implies 
paralysis,  which  may  be  induced  by  two  causes — one  the  effect 
of  active  inflammation  of  a  contiguous  tissue — the  other  long- 
continued  pressure  affecting  the  innervation  and  circulation  of 
the  muscular  tissue. 

22nd.  That  the  period  at  which  the  yielding  of  the  muscular 
structures  takes  place  may  furnish  an  approximative  measure  of 
the  intensity  of  the  inflammation. 

23rd.  That  dexiocardia  in  connexion  with  empyema  is  of  three 
kinds :  (a)  when  the  heart  is  temporarily  displaced  and  returns 
to  its  natural  position,  or  nearly  so,  on  the  absorption  of  the 
fluid ;  (b)  when,  notwithstanding  the  removal  of  the  fluid  by 
operation,  it  does  not  change  its  situation ;  and  (c)  when  in 
consequence  of  the  absorption  of  an  empyema  of  the  right 
pleura  it  is  drawn  over  to  the  right  side  and  there  becomes  per- 
manently fixed. 

24th.  That  after  absorption  of  empyema  of  the  left  pleura  the 
mediastinum  may  be  so  relaxed  as  to  allow  of  the  heart  changing 
its  position  under  the  influence  of  gravitation. 

25th.  That  contraction  of  the  side  is  not  a  necessary  conse- 
quence of  an  empyema,  but  that  the  earlier  it  appears  the 
greater  will  be  the  chance  of  its  diminution  or  ultimate  disap- 
pearance. 

2Gth.  That  it  may  coincide  with  persistent  and  even  increasing 
effusion. 

27th.  That  the  liability  to  permanent  contraction  is  directly 
as  the  violence  of  the  inflammation  and  the  length  of  time  that 
the  disease  has  been  allowed  to  remain  uninfluenced  by  treat- 
ment, and  that  paralysis  and  atrophy  of  the  intercostals  and 
diaphragm  is  an  important  part  cause  of  the  contraction  in  such 
cases. 

28th.  That  besides  the  two  groups  of  acute  and  subacute 
pleurisy  a  third  is  to  be  recognized  in  which  severe  constitu- 
tional and  local  suffering  exist  all  through  the   case.     It  is  in 

Q  Q 


594  DISEASES    OF   THE    PLEURA. 

this  class  that  we  most  usually  observe  complication  with  one  or 
more  local  diseases,  and  also  the  strong  liability  to  pathological 
transformations  in  the  products  of  the  disease. 

29th.  That  in  certain  cases  of  contraction  after  empyema  it 
is  difficult  to  determine  to  what  point  the  absorption  has  gone 
on ;  whether  an  encysted  empyema  remains,  or  whether  a 
pathological  transformation  of  the  products  of  disease  has  really 
taken  place. 

30th.  That  three  causes  appear  to  assist  in  producing  contraction 
of  the  side,  namely,  diminished  volume  of  the  lung,  the  occurrence 
of  a  fistula  from  without  inwards,  as  when  an  empyema  opens 
into  the  lung,  and  the  temporarily  paralysed  state  of  the  inter- 
costal muscles  and  draphragm. 

31st.  That  the  contraction  is  in  certain  cases  truly  concentric, 
and  goes  on  from  below  upwards  as  well  as  from  above  down- 
wards or  without  inwards,  and  that  this  consideration  is  of 
importance  as  bearing  on  the  operation  of  paracentesis,  and 
especially  as  regards  the  place  of  election. 

32nd.  That  when  the  return  of  the  force  of  the  respiratory 
muscles  has  been  long  deferred,  and  the  lung  has  been  bound 
down  by  adhesions,  it  may  act  in  producing  a 'dilated  state  of  all 
the  bronchial  tubes,  and  we  may  thus  explain  the  occurrence  of 
dilated  tubes  in  a  case  of  primarily  cured  empyema. 

33rd.  That  there  are  three  modes  in  which  elimination  of  the 
effused  matter  in  cases  of  empyema  is  observed  to  occur — (a)  by 
absorption,  (b)  by  evacuation  through  the  lung  by  means  of  a 
solution  of  continuity  of  the  pulmonary  pleura,  (c)  by  evacuation 
through  the  external  parietes. 

34th.  That  in  the  case  of  evacuation  through  the  lung,  the 
perforation  of  the  pleura  is  indicated  by  the  signs  of  empyema 
and  fistular  pneumothorax,  more  especially  by  the  sound  of 
fluctuation  on  succussion,  followed  subsequently  by  contraction 
of  the  chest. 

35th.  That  in  the  early  periods  of  perforation,  absence  of 
respiration  may  precede  the  metallic  signs. 

36th.  That  the  metallic  phenomena  may  be  observed  in  the 
dropping  of  liquid,  in  the  breaking  of  bubbles  on  the  surface,  and 
in  the  voice,  respiration,  cough,  rale,  and  action  of  the  heart. 

37th.  That  for  the  production  of  the  metallic  voice,  cough,  and 
rale,  it  is  not  necessary  that  liquid  should  exist  in  the  cavity, 


DISEASES    OF    THE    PLEURA.  595 

.and  that  these  may  be  metallic  in  pneumothorax  by  external 
fistula. 

38th.  That  morbid  clearness  is  not  always  coexistent  with  the 
effusion  of  air. 

39th.  That  (as  pointed  out  by  Dr.  Greene)  vicarious  secretion 
from  the  bronchial  mucous  membrane  is  not  uncommon  in  cases 
of  empyema,  and  sometimes  to  such  an  extent  as  to  lead  to  the 
supposition  that  an  opening  into  the  lung  has  formed,  and  that 
similarly  many  cases  of  the  supposed  opening  of  an  hepatic  abscess 
through  the  lung,  are  examples  of  this  vicarious  discharge  of  pus. 

40th.  That  under  these  circumstances  the  physical  signs 
ordinarily  attributed  to  soften  tubercle  are  often  produced,  and 
liable  to  mislead  the  practitioner  ;  such  are  well-marked  gurgling 
and  large  rale  confined  to  a  certain  portion  of  the  lung. 

41st.  That  this  vicarious  discharge  from  the  bronchial  tubes 
may  cease  on  the  formation  of  an  external  outlet,  and  reappear 
whenever  that  outlet  is  closed. 

42nd.  That  in  the  case  of  evacuation  through  the  integuments 
there  may  be  a  simple  fluctuating  abscess  communicating  with 
the  pleural  sac  (empyema  of  necessity),  or  a  carious  state  of  the 
ribs  may  be  induced,  in  which  case  the  external  fistula  continues 
to  pour  out  matter  which  is  often  foetid,  and  the  result  is 
generally  unfavourable. 

43rd.  That  an  exaggerated  diastolic  pulsation  may  attend  on 
the  empyema  of  necessity. 

44th.  That  pulsation  may  attend  on  empyema  although  no 
local  or  subtegumental  collection  be  formed.  In  other  words,  that 
there  are  two  forms  of  pulsating  empyema.  One  in  which  there 
is  simply  a  large  collection  of  fluid  with  a  displaced  heart,  the 
other  where  the  empyema  of  necessity  has  formed. 

45th.  That  the  pulsations  of  the  empyema  of  necessity  are 
not  accompanied  by  any  murmur  or  fremitus. 

46th.  That  these  pulsating  tumours  may  be  attended  with  an 
inflamed  condition  of  the  integuments,  or  be  perfectly  indolent  so 
far  as  the  condition  of  the  skin  is  concerned. 

47th.  That  in  the  case  of  pulsation  of  the  entire  empyematous 
sac,  the  force  of  the  pulsations  seems  to  be  in  the  direct  ratio  of 
the  amount  of  the  effusion. 

48th.  That  with  regard  to  prognosis,  we  may  draw  a  distinc- 
tion between  those  cases  of  a  fistula  of  the  lung  opening  into  the 


596  DISEASES    OF    THE    PLEURA. 

pleural  sac,  and  those  where  the  reverse  process  takes  place,  as 
when  an  empyema  opens  into  the  lung ;  since  in  the  first  of  these 
cases  the  pneumothorax  is  permanent,  while  in  the  second  it  may 
be  only  temporary. 

49th.  That  tubercle  and  gangrene  are  the  most  frequent  causes 
of  the  first  form,  and  that  of  these,  tubercle  is  by  far  the  most 
frequent  form  of  disease. 

50th.  That  the  signs  of  the  original  tubercular  cavity  may 
continue  long  after  the  perforation  of  the  pleura  and  other  lesions 
have  occurred. 

51st.  That  perforation  of  the  pleura  and  consequent  pneumo- 
thorax is  not  necessarily  attended  with  pleurisy  and  empyema ; 
simple  perforative  pneumothorax  having  been  observed  both  in 
the  rupture  of  dilated  cells,  and  even  in  a  case  of  phthisis. 

52nd.  That  on  the  valvular  or  non-valvular  character  of  the 
fistula,  will  in  a  great  measure  depend  the  amount  of  consequent 
suffering,  and  the  immediate  danger  from  the  accident. 

53rd.  That  the  cases  with  permanently  patent  fistula  may  be 
divided  into  two  classes.  In  the  one  the  amount  of  liquid 
effusion  remains  stationary,  for  a  great  length  of  time,  while  in 
the  other  there  is  a  progressive  increase  of  the  fluid,  so  that  the 
relative  proportions  of  air  and  fluid  are  ultimately  reversed  with 
the  result  of  increasing  the  distress  of  the  patient. 

54th.  That  in  a  case  of  phthisis  with  well  marked  constitu- 
tional symptoms,  the  occurrence  of  fistular  pneumothorax  and 
empyema  has  occasionally  been  followed  not  only  by  long  con- 
tinued suspension  of  the  symptoms  of  phthisis,  but  also  by  great 
improvement  in  the  general  health. 


FINIS. 


LONDON: 

Peikted  by  J  as.  Trdscott  and  Son, 
Suffolk  Lane,  City. 


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