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'T.
NATIONAL LIBRARY OF MEDICINE
        Bethesda, Maryland
             Gift of
     Worth B. Daniels, Jr., M.D.
       In memory of his father
       Worth B. Daniels, M.D.
     {
.  1
 
'£,**- 
 
A
             TREATISE
                 ON THE
DISEASES OF THE  CHEST,
         in which they are described
             according to their
    ANATOMICAL CHARACTERS,
               AND their

         established on a new principle
               by means op
  ACOUSTICK INSTRUMENTS.
               rDith $iattg.

       TRANSLATED FROM THE FRENCH OF
         R. T. H. LAENNEC, M. D.
                 WITH
           A PREFACE AND NOTES,
        BY JOHN FORBES,  M. D.
  PHYSICIAN TO THE PENZANCE DISPENSARY, SKCRETART OF THE ROYAL
        GEOLOGICAL SOCIETY OF CORNWALL, &C. &C.
         FIRST AMERICAN EDITION.
      PHILADELPHIA:
JAMES WEBSTER, 24 S. EIGHTH STREET.
       William Brawn, Printer.
           1823. 
r-
wr .




 Q.A.
®) 
                   TO





MATTHEW B VILLIB, M. D, F. R. S.





        PHYSICIAN TO THE KING,




                &c. &t. isfc.





             THIS WORK,





            INTENDED TO IMPROVE





PATHOLOGICAL AND PRACTICAL MEDICINE,





               IS inscribed,




   AS A TRIBUTE DUE TO HIS ACKNOWLEDGE!;




         SUPERIORITY IN BOTH THESE




              BRANCHES OF





           MEDICAL SCIENCE,




      AND IN TESTIMONY OF THE RESPECT




             AND GRATITUDE




                   OF





          THE  TRANSLATOR 
 
TABLE OF  CONTENTS.
Translator's Preface   -.........1
Author's Preface    -----......25
           PART FIRST—PATHOLOGY.




                    BOOK FIRST.

                 OF THE LUNGS.

Chap. I.  Phthisis Pulmonalis.......    33
         Sect. I. Anatomical or essential characters  -    ib.
              2. Occasional changes—curability of \     A9
                 Phthisis.......$     **
              3. Expectoration  in Phthisis-Vomicae -  - 55
Chap. II. Peripneumony..........59
     III. Gangrene op the Lungs.......64
     IV. Haemoptysis, or Pulmonary Apoplexy  - -  - 69
      V. Pulmonary  Catarrh, or Bronchitis   - -  - 74
         Sect. 1.  Acute  ---------- i6.
              2.  Chronic..........76
Chap. VI. Dilatation of the Bronchia.....79
     VII Emphysema of the Lungs......82
    VIII. (Edema  of the Lungs --------92
      IX. Accidental Productions in the Lungs   -   - 99
         Sect. 1.  Of  these in general.....- ib.
              2.  Cysts.........100 
?1
FABLE OF CONTENTS
                                                    Page
Chap. IX.  Sect. 3 Hydatids  -  -.......102
               4. Osseou3 Concretions, &c.   -  -  -  - 104
               5. Melanosis  ---......109
               6. Medullary Tumour   ------ 117


                     BOOK SECOND.

                  OF THE PLEURA'

Chap. I.   Pleurisy........ -  -  -  - 122
          Sect. 1. Acute Pleurisy.......ib.
               2. Chronic Pleurisy  -.....- 129
               3. Contraction of the Chest   -  -  -  - 131
               4. Gaugiene of the Pleura     -  -  -  - 139
               5. Circumscribed Pleurisy.....140
Chap. II-  Hydrothorax..........151
     III.  H^mathorax......-  -  -  -155
     IV.  Accidental Productions in the Pleura -  - 156
      V.  Pneumo-thorax......---169


                      BOOK THIRD,

      OF  THE HEART AND ITS APPENDAGES.

Chap. I   Diseases of the heart.......165
          Sect. 1. Hvpeitrophia........ib.
               2. Di!a»a!i*>n of the Ventricles  -  -  -  - 167
               3. Diiafation  ui<h Hvpeitrophia of the ^   ^ .,
                   Ventn (es   -----  -    J>
               4. DilatafMMi of the A'.i'icles   ~  ~  "  - 168
               5. Phr.nl Dilatation of  the Heart   -  - 170
               6. Im'Hii.iion of the Heart.....171
               7. Softening of, tht Heart  -   -  -   -  -  ib.
               8 Atrophy of. the Heart   -   -  -  -  - 173
               9 >"atty Degeneration of the Heart  -  - 174
              10. Ossification of the Heart   .... - 176
              II. Carditis.........177
              12. Ossification of the Valves     -  -  - 180
              13. Accidental Productions.....18-2 
TABLE OP CONTENT;
vu
Chap. I.   Sect. 14.  Polypus   -.......- 183
               15.  Excrescences on the Valves  -  -  - 185
               16.  Red colour of internal Membrane   - 188
               17.  Malformation of the Heart   -  -  - 192
               18.  Displacement of the Heart   -  -  - 193
               19.  Effects on other Organs    -  -  -  - 194
               20.  Causes   -   -   -  -.....195
Chap. II.  Diseases op thk Pericardium.....197
          Sect.  1.  Pericarditis........ib.
                2.  Hydro-pericardium......201
                3.  Accidental Productions     ...  - 202
Chap. III. Aneurism of the Aorta  ------- 204
PART SECOND.—DIAGNOSIS
Introduction............. 209
General Remarks on the Diagnosis of Diseases of the Chest  ib.
Discovery and nature of Mediate Auscultation  -  -  -  - 211
Exploration of the Voice..........214
---------------- Respiration    --------  i&.
----—----------Circulation.........218
Phthisis Pulmonalis..........-  -  - 219
Peripneumony    ---------.-'__ 227
Gangrene of the Lungs...........230
Haemoptysis  --------_...__ 231
Pulmonary Catarrh  -------.-... 232
Dilatation of the  Bronchia  ---------- 236
Emphysema of the Lungs..........237
(Edema of the Lungs   ----------- 238
Accidental Productions in the  Lungs   ------- 239
Pleurisy...........-  -  -  - 241
Hydrothorax  --............246
Haemathorax  ---..........-  -  ib.
Acci'l'-ucti Productions in the  Pleura.....-  -  ib.
Pneumo-thorax   ---..........247
Exploration of  the heart.........252 
riii
TABLE OF CONTENTS.
                                                        Page
 Extent of Pulsation............  252
 Impulse of Pulsation    --....._---  255
 Sound of Pulsation...........  -  256
 Rythm of Pulsation  ---.........257
 Palpitation............-  -  260
 Irregularity of Pulsation    --  -   -   -   -  -   -  -  -261
 Intermission of Pulsation   ----------   i&.
 Symptoms common to all Diseases of the Heart -   -  -  -  264
 Hypertrophia of ihe left Ventricle     -------  266
 ■---------right Ventricle.......267
 Dilatation of the left Ventricle    ........268
 ■----------------'right Ventricle......-  -   ib.
 Dilatation with Hypertrophia of the Ventricles  -   -  - " -  269
 Dilatation of the Auricles   .------*--  270
 Softening of the Heart......-----271
 Carditis   -  -  -  ,-,...........#•
 Ossification of the  Valves.........- 272
Pericarditis   -------------- 273
Hydro-pericardium  ---....._._. 275'
Aneurism of the Aorta   ----------- 276
Appendix -----......---" ^9
Notes    ..........._.-- 301
Explanation of the plates  ---------315 
          TRANSLATOR'S  PREFACE.



  V?  One of my principal motives for undertaking the labo-
      rious task of translating the following work, having been
      the hope of rendering its most valuable contents conve-
(*   y niently  accessible to the English reader, I must not now
      swell either its size or  price by a voluminous  Preface.
      I shall,  therefore, confine myself to  saying a few  words
      on the nature of the original treatise, and on my method
      of translating it.
        M. Laennec has long been known as an ingenious and
      industrious man, and as a faithful observer.  His oppor-
      tunities  for studying the class of diseases treated of in
      the present work have been, probably, never  equalled;
      and I think it will be allowed by those acquainted with
      his writings, that their value is proportioned to the extent
      of his opportunities.  He. himself informs us that  he
      has been engaged in pathological researches for eighteen
      years; and when  we consider the facilities with which
      these can  be prosecuted in the French capital, we must
      be prepared to expect a work of  great  value, as the
      result of such great  advantages.   That the present
                                1
 
2
TRANSLATOR'S PREFACE.
 treatise is well entitled to this character I think no one
 who has perused it will deny; as far, at least, as regards
 the pathological part of it.  Indeed, the facilities for the
 prosecution of this department of knowledge in France,  *
 are so very superior to those in England, that we ought
 rather to be surprised that our own country has in any
 case excelled the former, than that we should  be occa-
 sionally obliged, as in  the present instance, to look to it  • t
 for information.  In explanation of this remark I shall
 here quote the words of a late writer, who has given us
 much information  respecting the state of medicine  and
 medical institutions on the Continent.   " All the hospi- \
 tals of Paris are under the direction of a general  adrni-   ;
 nistration; and from the office of this board, where  me-
 dical men attend during a certain  part of the day to  ,
 examine them, patients are sent to the different hospitals.  .
 This  plan may be attended with some  inconveniences  •  '
 to the  patients, but  has not a few advantages to the  v
 practice  of  medicine.  Through means of this arrange-
 ment the physician of any hospital, whose attention is
 turned  more  particularly to  any disease or  class of
 diseases, by  application to the central office  may have
 such diseases sent  to his own hospital.   Thus a much
 greater  number of cases of the  disease, which is the
 object of his particular inquiry, is  brought under his
 observation in  a given time (an object  of no small  im-
 portance) than could otherwise,, or might indeed ever,
have been.   To this plan we  perhaps  owe, in a great 
TRANSLATOR'S PREFACE.
3
 measure, the excellent works of Corvisart and Bayle,
 and that of Dr. Laennec on the diagnosis of the diseases
 of the chest.   The fatal cases are generally examined
 after death. Dr. Fouquier told me, that for twelve years
 that he had been physician to La Charite, no patient had
 died without being examined "*
   In the  original  work, the  system  of arrangement is
 founded on  the new principles of diagnosis introduced
 by the author; consequently the pathology and diagnosis
 of the various diseases are blended together,  and the
 former  very generally  made  subservient to  the latter-
 As I have thought this method attended by a great many
 disadvantages, both in a pathological and practical point
 of view, I have taken the liberty,  in the  translation,  of
 re-arranging the  work  throughout,—separating, almost
 entirely, the pathology from the diagnosis, and arranging
 the various diseases under the  head of the affected organ.
 Thus, instead of  having, as in the original, the diseases
 marshalled  under four heads according as they are re-
 cognised by the exploration of the Voice—the Respira*
 tion—the Rattle—and  the Circulation,—and the Diag-
nosis of each disease conjoined and mingled  with its
 description; we have, in the first place, an entire sepa-
ration of the descriptive from  the diagnostic parts; and3
secondly, a  subdivision  of each of these according to
the respective localities  of the diseases, as affecting the

 * Dr. Clark's Medical Notes on Climate, &c. pp. 127 and 130, 
4
TRANSLATOR'S PREFACE.
Lungs, Pleura, and  Heart.  By this means, the work*
in place  of appearing, as in its original form, a system
of Diagnosis,  with the pathological part subservient to,
and partly concealed  by it, is now  restored to what I
humbly conceive it ought always to have been, viz. two
independent treatises,—the one on Pathology; the other
on Diagnosis,—mutually adapted to each other, yet each
complete of itself, and not necessarily connected with
the other.  In its present condition, therefore, the work
will be found  equally available to the practitioner as a
system of pathological anatomy,  whether he adopts or
rejects the  author's  diagnostics; while, in the original
form, these  two departments were  so interwoven with
each  other,  that,  without a previous study of the one,
the other could not be well understood.  In this respect,
then, I consider both the author  and the English reader
as obliged  to  me;—inasmuch  as, without in the least
altering either the  facts of the pathology or the diagno-
sis, I have rendered  them  both much more accessible,
and placed them in a clearer, closer, and more connect-
ed point of  view.
   In respect of the  character and  value of these two
classes of facts, as contained in the treatise now  trans-
lated, I must here  be permitted to say a few words.  It
will be seen from the author's Preface,  an abridgment
of which follows, that, in his description of the diseases,
he has almost exclusively confined himself to'the ana-
tomical character  of these.   His reasons for so doing 
TRANSLATOR'S PREFACE.
5
are stated in the same place, and are principally to  be
traced to the nature  of his new  diagnostic measures,
which, unlike the usual symptomatological distinctions,
are, in most cases,  immediately connected  with, and
necessarily dependent  on the physical alterations which
constitute the disease.
   Hitherto, unquestionably, the attention of nosologists
has been too  exclusively fixed on mere external symp-
toms, without reference to the  internal  conditions of
which these were the sign.  It is true  that  there are
many diseases with the pathology  of which we  are un-
acquainted,  and  in  distinguishing  which,  we must,
therefore, content ourselves with the external symptoms
merely, without any  constant  and direct reference of
these to stmie organic lesion as their source.   This is
the case at present, I apprehend, with many varieties of
fever, and many  of the affections called nervous and
functional.  In some of these instances, I presume,  our
present  inability  to trace  the  morbid derangements to
their source, depends merely on our faulty and imperfect
investigations hitherto, and will, no doubt, be  eventually
removed;  in others, however, the physical local lesions
are in all probability too minute and evanescent ever to
become the objects of our actual  perception,  or, if per-
ceptible, too extensive and complicated to permit us to
separate the original and  essential derangements from
those which are merely contingent.  In a philosophical
point of view, indeed, the  primary changes of structure 
6
TRANSLATOR'S PREFACE.
  which constitute the first link in the chain of all diseases,
  must,  in all probability, be' considered as placed effec-
  tually beyond our finding out; and  it may, therefore, be
 objected to the pathological nosologist, that his principle
 is equally erroneous with that of the mere symptomato-
 logist;  inasmuch as  the former, like the latter, merely
 lays  hold  of one link of the chain, the  beginning of
 which  they are both ignorant of; and the only superiority
 of the  former being that his link is  nearer the primary
 one.
   In answer to this it  may be stated, that this allowed
 superiority is a  most important  one, and almost all that
 is contended for.   Although it is the object of the pa-
 thologist, unquestionably, to trace morbid phenomena to
 their very  sources; still it is true that  this is rarely, if
 ever, attainable; and although, in many diseases, we are
 willing  and ready to imagine certain changes of func-
 tion or structure, anterior to those  that are cognisable
 by our imperfect senses, in most cases we are obliged to
 be content, both theoretically and practically,  with the
knowledge of such alterations as can be recognised by
our senses.  In the case of a deranged  state of the sys-
tem depending on some external local cause, such as an
inflammation or ulcer, we are in most cases satisfied, if
we can trace the  general  derangement to the local le-
sion, although it is only the obvious physical qualities of
this which  we can understand with  any  degree of cer-
tainty.  In like manner, in  the study of internal dis- 
TRANSLATOR'S PREFACE.
7
eases, we are very well contented if  we can ascertain
the condition of the local lesion, that is, the change of
structure that would be obvious to our senses if the part
could be submitted immediately to our inspection.
   At all events, we cannot hope, in the present state of
our knowledge, to understand any morbid conditions of
parts better than those which  are immediately the ob-
jects of our senses; consequently, our  constant aim  must
be to endeavour to come as near this knowledge as pos-
sible in such conditions as are  not the objects of these;
and  the more completely this is effected, the nearer are
we to the attainment of the only sure  guide in the treat-
ment of disease.  So  far, then, I think, it must be ad-
mitted, that a knowledge of their anatomical characters
forms the most essential part of our  knowledge of dis-
eases,  and  the only sure guide in practice; and conse-
quently, that, in such cases  (internal  diseases)  as those
in which this anatomical or essential character is hidden
from our view, the perceptible signs which can certainly
indicate its presence to us, must be considered as of pa-
ramount importance.
   It is in this point of view,  then, that I consider the pa-
thology of M,  Laennec,  and the diagnostic measures
founded on this, as pre-eminently valuable.  Almost  all
other diagnostic signs are furnished by symptoms, which,
for the most part,  have only a remote connexion with
the morbid lesion, and  are, indeed, frequently present in
other and very different diseases.   M. Laennec's diag- 
8
TRANSLATOR'S PREFACE.
nostics, on the contrary, are the immediate and almost
physical  result of the individual derangement of parts;
and if they shall be proved by the experience of others
to be as certain  and invariable as he affirms, there can
be no question of his having conferred  on Medicine, by
their discovery, one of the greatest benefits with which
it has ever been enriched.  Of  the uncertainty of the
common signs of internal diseases in general, and espe-
cially of chronic diseases of the chest, every practitioner
must be well aware; and every one who has  had much
experience in morbid dissections must haye^bften endur-
ed the mortification  of finding his diagnosis falsified by
the actual condition of the parts  after death.
  It is hot intended, by the foregoing remarks, that the
study of the general symptoms is useless in the diagnosis
of diseases; but merely that, as these are frequently un-
certain in their indications, more direct and surer signs
are desirable;  and, further, that whatever system of di-
agnosis we adopt, we ought always to keep in view the
anatomical character of the disease (where this is known)
as the substance whose presence the symptoms denote,
and without which they  are nothing.   In this point of
view the descriptions of M.  Laennec appear  to  me to
excel those of every other writer on pathological  ana-
tomy, inasmuch as he traces the progress of the organic
lesions from their commencement to their termination;
while almost all other writers on morbid anatomy, how-
ever correct  or minute, give us merely detached and 
                 TRANSLATOR'S PREFACE.              9

 isolated descriptions of the parts as they are found on
 dissection.   And he  not only traces  the  progressive
 change of structure in  the organ, but connects every
 successive step of the change with external signs indi-
 cative of its existence.   In short, (if his new diagnostics
 are as certain as he affirms) he may be said to have re-
 alized the wish of the ancient philosopher, and to have
 placed a window in the breast through which we can see
 the precise state of things within.
   But independently of the value of a correct knowledge
 of the anatomical character of diseases as leading to  a
 correct diagnosis, this is  no less important as tending to
 the improvement of therapeutics.   Without  knowing
 the disease, of course we must be totally incompetent to
 treat it.   Every one admits this as self-evident; yet how
 often does it  happen, when we fancy that we do truly
 know a disease, at least  so far as to name it correctly,
 and to discriminate it from others,—that our  knowledge
 is merely the knowledge of a name; or of phenomena
 not essential to the real disease; or, lastly, the  belief of
 the existence of a condition of parts which is totally dif-
 ferent from that which truly does exist!  In this case
 our nosological knowledge is of very little use;  or tends
 merely to satisfy our own minds without benefiting  our
 patient.
  In every case where  the physical characters of the
morbid  lesion  are  known, these  ought invariably  to
form the groundwork of  every description of disease :
                          2 
10
TRANSLATOR'S PREFACE.
of these all the external symptoms must be considered
as merely the  signs ;  and in all our therapeutic mea-
sures, these must be kept constantly in view, and the re-
moval of them considered as  the  abiding object of  all
our labours.  These remarks apply only to such  affec-
tions as are treated of in the present work, viz. affec-
tions which are usually denominated organic, and which
may more  properly be called structural:  those whose
anatomical character is as yet unknown, or which consist
in mere disorder of function, or in such minute altera-
tion of the animal fibre as  to be imperceptible to our
senses, must be studied differently; and this  is not the
place to enter upon the subject.
  Although not strictly within the scope of the present
remarks, there is one other point in the diagnosis of in-
ternal diseases which I would beg leave to impress upon
the minds of the younger part of the profession as of the
greatest importance.   Of this I have always  been con-
vinced;  but it is at present more immediately  and more
forcibly suggested by the consideration of the measures
of M. Laennec. What 1 allude to is—the examination
of the external parts of the body in the case of internal
disease. How often have I known plain and obvious dis-
eases entirely mistaken  and  mistreated, for months,—
even years,—merely from the practitioner's neglecting
this simple but necessary measure !  In every case  of
disease, whether its seat be in the head, trunk or extre-
mities,  we ought to examine the suspected part freed 
TRANSLATOR'S PREFACE.
u
from covering, or at least from every species of covering
that can impede the necessary examination,—always by
the hand, and often by the eye; and wherever the case
is at all doubtful, we must endeavour to overcome the re-
pugnance of our patients to the measure, however great
this may be, and  however natural and proper we may
feel it to be, in certain individuals.  In this endeavour,
if properly  conducted, I  may  venture to  say that we
shall rarely  fail.  From the neglect of this precaution I
have known peritonitis and enteritis mistaken for simple
colic;—disease of the heart for disease of the stomach;—
and  derangements depending on curvature of the spine
treated  for years  as a mere nervous  affection, and, in
other cases, as organic disease of the heart, lungs, or
diaphragm!

               ----■      vestis adempta est;
      Qua posita, nudo patuit cum corpore crimen.
  As another branch of the same mode of investigating
diseases, I may here notice the  necessity of our strictly
examining all discharges from the natural passages of
the body, more especially if we  have reason to sus-
pect disease in these, or the parts immediately connected
with them.  In such cases we must never trust to the
reports of patients themselves or their attendants,  as we
are almost always sure of being misled by their prejudice
or ignorance, both as to the quality and quantity of the
excreted  matters,   i would further  add  the internal 
 12             TRANSLATOR'S PREFACE.

 examination of some of these passages, by the hand or
 instruments, in every case attended  by the slightest un-
 certainty.   How often  are diseases of the uterus, rec-
 tum and  bladder, mistaken,  from the omission of this
 very  simple precaution, and how much misunderstood
 are often  the  disorders of the  alimentary canal,  and
 even of the lungs, for want of attention to the character
 of their secretions!   In short, the more closely we can
 trace the  symptomatic derangements to their source, in
 every part of the body, the  more likely are we to un-
 derstand the real nature of these, and the less liable are
 we to be misled by the numerous sympathies, which, in
 almost every disease, constitute a prominent part among
 the more  obvious phenomena.
   As to the individual descriptions of disease contained
 in the present work—I  doubt not that the most learned
 English reader will find in them many things  that are
 new to him.  At the same time  he will find several an-
 nounced as such, and their discovery claimed for  France,
 which have been long familiar to the British pathologist.
 Indeed, I  am sorry to be  obliged to remark, that, like
 most of his  countrymen, the present author is too much
 disposed to  overlook the advances, made in science by
 other nations, and to claim for French literature  false
 and  surreptitious  honours, which that country's un-
 doubted titles to desert ought to  teach her to despise.
   In respect of the general merits of mediate ausculta-
tion as a means of diagnosis, I am disposed to coincide 
TRANSLATOR'S PREFACE,
13
in the high opinion of the author; due allowance being
made for the natural partiality of a discoverer. My own
experience, of course, has been, comparatively with that
of the author, quite insignificant; and has, in every case,
but  one, wanted the only sure seal of merit—morbid
dissection:  although, therefore, it would have been both
unphilosophical and indecorous to have allowed the few
results obtained by me, had they been opposed to those
of M. Laennec, to weigh in any respect against the im-
mense experience of that gentleman,—it must be satis-
factory, at  least, to know, that they have, as far as they
go, coincided with his in every respect.  I am sorry to
say that it  is only within the last few months that I have
given the new methods of diagnosis a fair and continu-
ous trial; and I am the more sorry, as I am daily more
and  more  convinced  of  their extreme value.  It is in
chronic cases, more especially,  that the method of M.
Laennec will be  found of the greatest  advantage;  and,
exclusive of the unimpeached testimony of the author, I
have no doubt whatever from  my own experience of its
value, that it will be acknowledged to be  one of the
greatest discoveries in medicine by all those who are  of
a temper,  and in circumstances, that will enable them
to give it a fair trial.   That it will ever come into gene-
ral  use,  notwithstanding its  value, I  am extremely
doubtful;  because its  beneficial  application  requires
much time, and  gives a good  deal of trouble both  to
the patient  and the  practitioner; and because its whole 
u
TRANSLATOR'S PREFACE.
  hue and  character is foreign, and  opposed  to  all our
  habits and associations. It must be confessed  that there
  is something even  ludicrous in the picture of a grave
  physician formally listening through a long tube applied
  to the patient's  thorax, as if the disease within were a
 living being that could communicate its condition to the
 sense without.   Besides, there is in this method a sort
 of bold claim and pretension to certainty and  precision
 of diagnosis, which cannot, at first sight, but be some-
 what startling to a mind deeply versed in the knowledge
 and uncertainties of our art, and to the calm and cau-
 tious habits  of  philosophizing  to  which  the  English
 Physician  is accustomed.   On all these accounts, and
 others that might be  mentioned, I conclude, that the
 new method will only in a few cases  be speedily adopt-
 ed, and never generally.  In all hospitals, however, both
 civil and military, and in the public services of  the army
 and navy,—in all of which situations  the  above-men-
 tioned obstacles  to its  employment  scarcely exist,—I
 should hope that  its adoption will be less tardy  and par-
 tial.  It is to them, especially, that it is adapted; it is
 in them that  its merits  can be put to the test;  and it is
 to be hoped that  if its value is  once acknowledged in
 them,  no minor  objections of mere  inconvenience or
 formality will be permitted  to effect its exclusion from
 general practice.
   Notwithstanding that M.  Laennec's  invention has
been before  the  public nearly two years,  I fear it has 
TRANSLATOR'S PREFACE.
15
received but few, and these unsatisfactory, trials in this
country.
  Among  all my medical friends,  Dr.  Duncan,-Jun.
Professor of Materia Medica in Edinburgh,  and Dr.
James Clark, now  of Rome,* are the only ones who
appear  to  have  given  the  practice  a fair trial.   Dr.
Duncan's report of its merits is most satisfactory; and,
as his experience has been considerable, and in a field
favourable to correct observation, and affording frequent
opportunities of proving by morbid dissections the cor-
rectness of opinions,—it is to be hoped that the inven-
tion will shortly receive from such high authority a new
title to  the consideration  of  the  public.  In a letter
which I have just received from  Dr. Duncan, he  in-
forms me that he has made great use of the stethoscope,
and is satisfied that it greatly facilitates the diagnosis of
diseases of the chest.  As might  have been  expected,
the  novelty of the  measure excited  much scepticism,
and some ridicule at first,  but the accuracy of the diag-
nosis obtained by it, soon compensated for and removed
these.  Speaking of the stethoscope, Dr. Duncan says,

  * It is but justice to state, that it was at the suggestion and ear-
nest request of Dr. Clark that I undertook the present  work.  He
was the first to make the practice of M. Laennec known in Eng-
land, in his  excellent  and very amusing work on Climate, &c.;
and it was the high opinion of its value, as confirmed  to me by so
judicious and experienced a physician, that induced me to make
trial of it in my owa practice, 
16
TRANSLATOR'S PREFACE.
" Its use indeed requires tact, or rather experience, to
enable  one to understand the signs it furnishes.  The
information afforded  by it is often obscure and uncer-
tain; so is the touch of the pulse, and all other applica-
tions of our senses in the investigation of diseases.  I
had often heard pectoriloquism before I recognised it."
—I understand that Dr.  Duncan  has gained many
proselytes to the practice among the  students; and I
need scarcely observe, that the adoption of it by a prac-
titioner of such experience and deserved celebrity is a
convincing proof of its value and importance.
  In corroboration of Dr. Duncan's statement I may
also observe, that my first trials of the instrument were
very unsatisfactory, from the doubtfulness  and uncer-
tainty of the results  obtained.   This  however arose
entirely from inexperience, and from not attending pro-
perly to the directions  given for using the instrument.
All  the  uncertainty and apparent difficulty was soon re-
moved by a little practice; and I speedily became con-
vinced  that the results obtained were  of that  distinct
and precise character to justify every expectation of
advantage from their being attended  to  in the diagnosis
of disease.
  In exploring the Respiration, more  particularly, we
must be most careful to keep the  funnel-shaped ex-
tremity  of the instrument very exactly applied to the
chest, by its whole circular  edge, which can only be
done by attending  to  the  author's direction of  holding 
               TRANSLATOR'S PREFACE.             J 7

it as we do a pen, and keeping the hand  quite close to
the patient's chest   We must never attempt to alter the
perpendicularity of  the  instrument, so as to bring its
extremity to suit the convenience of the  ear, but must
bring the ear to it;  and we must be careful not to press
with any  considerable degree of force upon  the instru-
ment, yet, at the same time, apply the ear  quite close to
it, and  with the  meatus directly opposed to its  canal.
All these precautions are necessary on account of the
moderate degree of the respiratory murmur,  which, al-
though in general extremely distinct, is often very low,
and never, except in certain cases of disease,  such as to
be called loud, unless comparatively with its own ha-
bitual condition.   From  the same circumstance, the
injunction of the  author respecting the absence  of all
other noises in the chamber of the patient, is never to
be forgotten; as talking, even in a whisper, in the  room,
or any noise in the street from  wheels, &c.  will  often
effectually mask all perception of the sound  we are at-
tending to.
  In studying  the  action of the heart, also, I would
suggest one caution respecting the statements of the au-
thor as to the extreme distinctness of the sounds. These,
doubtless, are  very  distinct; but  the quickness with
which they succeed each other requires considerable
care, and also experience, to obtain the necessary pre-
cision in recognising them.  This caution is, perhaps,
the more necessary, as we are apt to forget the natural
                         3
* 
 18              TRANSLATOR'S PREFACE,

 briefness  of the heart's  pulsations,  while  perusing the
 graduated and formal description of them  given by the
 author.  In respect of Pectoriloquism, I would request
 attention to the varieties of it called uncertain, lest the
 non-perception of it  in  its very decided character, in
 cases where the conditions said to be productive of it
 may be presumed to exist,—should produce scepticism
 respecting its occurrence at all.
  In all cases I  must caution the young explorer not to
 be  over hasty in condemning the practice.   Let him
 recollect that the discoverer of the method has declared
 that it is only in  hospital practice,—or in a  practice af-
 fording similar facilities of reiterated examination both
 before and after  death,—that it can be properly studied.
 Let him call to  mind how many things in his various
 studies, which seemed impracticable and  false at'first,
 further experience taught him to believe both  easy and
 useful.  Above all let him never forget, that the object
 proposed to be obtained, by the  new method,  is the  im-
provement of the diagnosis of a numerous class of most
 formidable diseases; an object, which, as it involves every
thing that can be most valuable to a medical man,  has a
                 *
right to claim the most zealous and patient attention of
 every one who has at heart either his own  professional
 success, or the welfare of his patients.
  As much and frequent reference is  made in the  fol-
 lowing treatise to the Percussion  of the  Chest, and as
 this practice is but little known in England,  it may be 
TRANSLATOR'S PREFACE.
19
useful to say a few words respecting it in this place.  In
France, and some  other parts of the continent, it is in
habitual  use; and was reckoned, even before the disco-
veries of M. Laennec, of  very  great importance in the
diagnosis of diseases.   Dr. Clark informs us that "a
patient brought into any of the hospitals of Paris with
any  affection  of  the chest, is as regularly submitted to
this  process as the English Physician would  ascertain
the state of the pulse."
   I  am informed by Dr. Baillie and Dr. Duncan, Jun.
that they have both  used this  method  in  many cases,
and  with considerable advantage.  The latter states it
to be of easy application and of  great use.  For a de-
tailed account of this method I must refer to the origi-
nal  work of Avenbrugger,* or  rather to the translation
of it by Corvisartf  At present I shall merely quote a
brief notice of it by the latter in his work on the heart,
and  for  this purpose avail myself of the translation of
Mr.  Hebb.   " This method, recommended by Aven-
brugger, under the name of percussion, consists in strik-
ing  the  chest with the  ends of the fingers  united; in
which case, if the lungs are sound, full of air, and if no
foreign body, either solid or fluid, occupy the interior of
the  thoracic cavity, the sound produced by the percus

   * De Percussione thoracis.  Vienna,-1763.
   t Nouvelle methode pour reconnoitre les maladies internes, &c,
Paris, 1808.  . 
20
TRANSLATOR'S PREFACE.
sion has been  compared  (an exaggerated  comparison)
to that proceeding from an empty barrel when struck.
Where, on the contrary,  a solid  or fluid body fills one
of the cavities of the thorax, or both, the parietes give,
to the extent  so occupied, a  sound  which has  been
characterized by the term  (mat) dull, and which is said
tcr resemble  that excited  by striking the thigh in the
same manner, or with the flat of the hand.   The sound
produced by  percussion in some  diseases of the heart,
is but little less than in a  natural state, and is then the
index of a less decidedly morbid state of the viscera
within.   The knowledge of the degree of sound which
denotes the perfect healthy state of all the organs of the
chest can only  be acquired by practice; and it is that
alone also which enables one, in dfome sort, to judge of
the solidity of the body which  prevents the chest  from
sounding at all; but  in forming a judgment,  every allow-
ance must be made for the natural thickness of the inte-
guments, and for the very  frequent anasarcous state of
those parts, which have, in many cases, led to the belief
that the chest sounded badly, when it was entirely owing
to these circumstances."  (Page 327).
  Before terminating  these prefatory observations, it
will be expected that I should say something respecting
the share which, as translator, I must claim in the pre-
sent character of the treatise.  I have already stated the
changes  which I have made in the arrangement of the
original articles.  The only other alteration of any mo- 
TRANSLATOR'S PREFACE.              21
ment, consists in my having very considerably abridged
the cases, and, also, in a lesser degree, some part of the
diagnostic details.  The  pathological parts are, for the
most  part, fairly translated, only  in  many places  very
considerably condensed, by the  omission of redundant
expressions and repetitions, and by the exclusion of cer-
tain paragraphs  which had no necessary connexion with
the main object of the work.   By these means, the work
is, reduced to one half its original dimensions; and  I am
inclined to believe  that  its intrinsic value has by no
means  suffered in the ratio of  its  diminution.   The
truth,  probably, is,  that medical and other scientific
writings, whose value is altogether independent of style,
may,  unlike the productions in elegant literature, be ra-
ther improved than deteriorated in the hands of  a  judi-
cious translator; inasmuch as he will act as a severe re-
viser  of the style, without any of the prejudices and par-
tialities which so easily beset an  original writer.   With
the translator, no  favourite expression, or well turned
period, or pretty interloping remark, or  elaborated and
long-concocted  yet stupid notion, will find mercy, unless
redeemed by some other more  useful qualities;  yet we
must all allow that these  and  a thousand other things of
no greater moment, often plead  irresistibly with our-
selves during revision,  and to the manifest deterioration
of our writings.   From this cause, then, a work, in be-
ing translated,  may be greatly  condensed, and  yet not
abridged.   The former epithet, I presume, is applicable 
22             TRANSLATOR'S PREFACE.

to the  greater part of the  present translation;  and the
latter only to the cases.  In respect of these, indeed, I
think I have committed an error in this particular; and
if I had the work to do over again, I would make some
considerable alteration in the manner of detailing them.
The truth is—that when I began my translation I was
too little impressed  with the importance of the diagnos-
tic measures recommended in the work; and my object
was rather directed to improve  the pathology at the ex-
pense  of the diagnosis.   In consequence of this, I  must
admit  that several of the cases (in the beginning of the
work more especially) are too much abridged;  and that
some  valuable diagnostic details are thereby excluded.
With the view of making all the amends in my  power, I
have given several of the  more important cases thus
 abridged, more  at  length  in the Appendix; and  have
 added several others  not translated in the body of the
 work.  Indeed  I am now disposed to believe that the
 work  would  have been improved if I had entirely ex-
 cluded the Cases from both Parts of it, and had  given
 them  in one body, and in considerable detail, at the end;
 and should  the translation  (unlike  translations) ever
 reach a second edition, I shall do so still.  As it is, how-
 ever,  I still think  the present arrangement very  supe-
 rior to the original.
    In  respect  of the mere literary execution of my hum-
 ble yet laborious task,—I, of course,  could  have no
 higher aim than that of giving a faithful delineation of 
TRANSLATOR'S PREFACE.
23
my original.   In this, I trust, I have succeeded; and if
I shall be considered to have done so, without much vio-
lation of the idiom of our language,—I shall obtain the
only additional title to credit of which I am  desirous,
and to  which a translator  of a  merely scientific work
can aspire.   At all events,  even should this claim be re-
fused, I fear  the present state  of medical literature in
England furnishes too many examples of bad  writing,
even in original composition, to render the imputation
of a failure very oppressive,  where the permanent dis-
torting influence of a foreign idiom can be adduced in
excuse.
  In the few Notes which I  have  added to the work, I
have noticed some of  the principal English writers who
have treated on the diseases therein described, and have
put down a very few  obvious practical inferences and
suggestions.—My anxiety to keep  the volume within  a
tolerable size has prevented me from enlarging on this
head; and I fear in the few remarks made, the meager-
ness of a private and provincial library, and the too limit-
ed acquaintance of the writer with the literature of his
profession, will be sufficiently conspicuous. 
 
           AUTHOR'S  PREFACE.



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

  * Extract from the Report of the Academy of Sciences'(drawn
 "up by M.  Percy, and signed by him, and MM. Portal and Pelle-
 tan, 29th June, 1818,) on a Memoir of M. Laennec respecting the
 use of Auscultation, more particularly in Phthisis Pulmonalis.
  " The Cylinder, applied to the chest of a  healthy person  who
 sings or speaks, produces  a sort of vibration, which is more
 distinct in some places than others.  But when there exists an
 ulcer in the lungs, the patient's voice then, instead of being heard
 in the usual manner by the exposed ear, reaches the other entirely
through the tube of the instrument. We have ourselves verified
this fact  on several consumptive patients; it appeared to us
striking, and well fitted for furnishing a certain and easy sign of
                           4' 
26
AUTHOR'S PREFACE.
viction  that the mode of exploration detailed in this
work will  be confirmed andl extended* by other ob-
servers.       -. -  %r   ..     ,j>           •%
   It will be  found that of  the  facts narrated  in my
treatise, I have given some  as certain, others as doubtful,
and a few merely as  problematical.   Of  the first class,
if future experience should  invalidate any, I may ven-
ture to believe that the number  will be  few; and I am
even convinced that the greater part of those which I
have stated as doubtful, will be found by further obser-
vation to be constant and certain.
   In  respect of the  pathological details, which  consti-
tute so large a portion  of the work, I think it necessary
to make a few  observations.   The great attention that
has been paid to morbid anatomy, since the commence-
ment of the present  century,  throughout Europe, and
more especially in  Paris, has been productive of many
improvements and  discoveries which are but imperfectly

certain morbid  conditions of the lung, which, in the present state
of medicine, can only be suspected to exist.    *    *   "
   We have also examined, by means of the cylinder, the respira-
tion in different parts  of the chest of a healthy person, and found
it very distinctly audible in every point of this  cavity which cor-
responded with the lungs.  We have also found that the  motions
of the heart were equally perceptible;  and it has,  consequently,
appeared to us, that the assertions of the author, of the possibility
of obtaining, through these two kinds of auscultation,  certain
signs of the several  diseases  ot the heart and lungs, were, at
least, extremely probable," 
AUTHOR'S PREFACE.
27
 known;  and,  indeed, many of which have not at all
 been communicated  to the public, at least by their dis-
 coverers.   On this  account, the present  state of our
 written knowledge is obviously behind our actual know-
 ledge ; and if, in the present work, I had contented my-
 self with merely describing the signs  of  the organic
lesions, without  describing  the lesions  themselves, I
should have often run the risk of being not understood
at  all, or (what is worse) of being misunderstood.  I
have, therefore, felt that the only means left of escaping
this danger, was to give an anatomical description of all
the diseases of which I have noticed the symptoms.  In
fulfilling this task I have endeavoured to render my de-
scriptions concise,  yet, at the  same time, sufficiently
exact and complete to characterise the objects.
   Another  motive  has contributed  to  strengthen  this
resolution:—viz.  the  conviction of the practical utility
of my mode of diagnosis, and  the belief that the surest
way of procuring its more general adoption was to asso-
ciate the exposition of its principles with a description
of the diseases which it indicates, more exact than any
that yet exists.
  Many reasons have induced me to prefer the anatomi-
cal to the mere symptomatical description of diseases.
The former method has the advantage of brevity, per-
spicuity and certainty.  It is, for example,  much easier
to describe tubercles and detail the signs of  these,  than
to define  the  disease by  the  external symptoms only. 
28
AUTHOR'S PREFACE.
and to  arrange its varieties according to their causes,
Emphysema of the  lungs  consists in an  alteration  of
parts which can be described in a  few words, and of
which the signs can be easily recognised; while in stu-
dying asthma, according to the method of Sauvages, we
shall require to write a volume on generalities before we
can arrive at any thing positive.
   It will, perhaps, be objected that the anatomical me-
thod has the  disadvantage  of founding its  species on
distinctions, the chief characters of which can only be
obtained after death: but this objection scarcely merits
refutation.   We might as well say that it is  useless  for
surgeons to  make any distinction between dislocation of
the femur, and fracture  of  its neck; or that it is useless
to separate bronchitis from peripneumony.
   The morbid alteration in  the affected organ is, un-
questionably, the least variable and most positive of the
phenomena  of local disease; it is on the nature  antj
extent of this alteration  that the danger and curability
of diseases always  depend; and it  is this, consequently,
that ought  to be  considered as characterizing them.
On the contrary, the derangement of functions which
accompanies these alterations is extremely variable: it
is  often the same under circumstances entirely different;
consequently, it can rarely serve to discriminate differ-
ent diseases.
   Besides, it is a mistake to consider  the recognition  of
nosological species, founded on the data of morbid ana- 
AUTHOR'S PREFACE.
29
 tomy, as impracticable before death: on the contrary,
 they are often more readily recognised during life, and
 certainly present to the  mind something much clearer
 an4 more  positive,  than any  nosological distinction
 founded on the symptoms merely.   Peritonitis, for ex-
 ample, is assuredly a disease easily distinguished during
 life; and out of twenty  medical men acquainted with
 morbid anatomy called to see a case of it,  not one will
 make a mistake concerning its  nature or  name.   But
 will this be  the case with those  who are accustomed to
 see in diseases  nothing but symptoms?   Of the twenty
 shall we not find one considering the affection as ileus,
 another as hepatic colic, a third as puerperal fever, and
 so on?  The same thing  may be said of peripneumony.
 nephritis, hepatitis, &c.; and I hope that the work now
 submitted to the pflblic will enable us to  say  the  same
 thing of most of the diseases of the lungs, pleura and
 heart.
   Morbid anatomy must,  then, I think, be considered
 as the surest guide of the physician, as well to the di-
 agnosis  as to the cure of diseases.  But it  must not
 be forgotten that it has also its  obscure points.   It is,
no doubt, an easy matter to distinguish striking changes
of structure; but there are many slighter  alterations,
among which it is difficult to ascertain what is healthy
and what diseased;  what cause and what  effect;  and,
lastly, whether the appearances are truly the effect of
disease, or merely an accident of  assimilation, or circu- 
so
AUTHOR'S PREFACE.
 lation, that has taken  place in articulo mortis, or even
 after death.   In these cases we must content ourselves
 with what is clear and distinct;  never forgetting in prac-
 tice the principle of Hoffman—JVunquam aliquid magni
facias ex mera conjectura aut hypothesi; and sedulously
 guarding against  the error of believing that the  mere
 knowledge of the seat and nature of the disease can
 justify our neglecting  its individual character,  as  in-
 fluenced by external circumstances or personal idiosyn-
 crasy.
   From the foregoing observations it will be seen that
 this work is not, like that of Avenbrugger, a simple ex-
 position  of new means  of diagnosis.  Neither can it be
 considered  as a  monography  of  the  diseases of the
 chest,—since I have taken little notice of the ordinary
 and more general symptoms  of the»diseases, and have
 not at all touched upon their treatment.
   In the construction of  my treatise I  have quoted but
 two authors.  The chief object of my researches was,
 in  a great measure,  new; and for the  facts already
 known respecting the diseases of the lungs and heart, I
 have thought it unnecessary to  go beyond the works of
 M. Corvisart and Bayle*  If I have  occasionally dif-

  * Essai sur les maladies et les lesions organiques du coeur, &c.
 par J. N.  Corvisart.  Translated by Hebb. London, Underwood,
 1813.
  Novelle methode'pour reconnoitre les maladies internes de la
 poitrine par la percussion de cette cavite, par Avenbrugger, ouv- 
AUTHOR'S PREFACE.
31
fered from these distinguished  authors, I trust no one
will  misinterpret my motives.  No  one can be  more
sensible  of their merits, both as men  and Physicians,
than myself.   At the very time I question their opinions,
I most willingly confess my great obligations to  them.
It is much easier to improve a  field already cultivated,
than  to reclaim a wild and barren soil.  In respect of
the works of M. Corvisart, more particularly, it is to be
regretted that those of them published by others, are far
from giving a just idea of the  author's merits.  The
uncertainty of the signs of diseases, and the vagueness
of description in these, appear peculiarly striking  to
those who, like  myself, were his  pupils, and habitual
witnesses of the  boldness and precision of his diagnos-
tics.  This defect, no doubt, partly depends on the in-
communicable tact of the physician, which  forms  so
great a part of the art, and which M. Corvisart possessed
in the highest degree.
   I  have hopes that the advantages of my method of di-
agnos •. may be extended,  in some degree, to veterinary
medicine.  Many reasons,  however, exist, why this art
must derive inferior benefit from it. Among these  I may-
mention  the absence of the voice;—the comparative in-
accessibility of the  region of the heart; and  lastly, the
rage  traduit du latin et commente, par J. N. Corvisart.  Paris,
1808.
  Recherches sur la Phthisie  pulmonaire, par G. L.  Baylc.
Paris, 1810.  Translated by Barrow.   1815. 
32
AUTHOR'S PREFACE.
 great indistinctness of respiration in the horse, and pro-
 bably  all herbivorous  animals.   In  cases of  disease,
 however, the  respiration will be  more audible in the
 sound portions of the lungs; as I/ound in a case of perip-
 neumony in a cow,  which I recognised during  the ani-
 mal's  life, as easily  as in the human subject.   In the
 dog, and cat, and probably  in all  carnivorous animals,
 the sound of respiration is as distinct as in man.  Not-
 withstanding these difficulties, I have no doubt that fur-
 ther experience will prove the utility of mediate auscul-
 tation  in  the disease of  animals, especially  if combined
 with percussion of the chest*


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

                    OF

DISEASES OF THE  CHEST.
                  BOOK FIRST.

              OF  THE  LUNGS


                    CHAP. I.

OF PHTHISIS PULMONALIS, OR  TUBERCULAR
          DISEASE  OF THE LUNGS.
                     SECTION FIRST.

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


 1 he existence, in the lungs, of those peculiar productions to
which the name of Tubercles has been restricted by modern ana-
tomists, is the cause, and constitutes the true anatomical character,
of Consumption.
  These bodies, when  first observable  in the substance of the
lungs, have the appearance  of small  semitransparent grains,
greyish or colourless, and varying  from the size  of a  millet-seed
to that of  a hemp-seed : in this,  their  first  state, they may be
called Miliary  Tubercles.   These gradually increase in size, and
become yellowish  and  opaque, at first in the centre and succes-
sively throughout their whole substance.  In their progressive and 
 34               DISEASES  OF THE LUNGS.

 mutual increase, several unite together so as to form larger masses
 of the same kind, which, like the  individual ones, are of a pale
 yellow,  opaque, and^of the consistence  of very firm  cheese:  in
 this stage they may be named crude or immature Tubercles.
   It is in this stage of their  progress that the substance of the
 lungs, which had been hitherto healthy, begins to grow hard, grey-
 ish, and  semitransparent around the tubercles, by means of a fresh
 production  and seeming infiltration of tuberculous matter, in  its
 first or transparent stage, into the pulmonary tissue.  It also some-
 times  happens that considerable portions of the pulmonary tissue
 put  on this character without any previous development,  of indi-
 vidual tubercles.  Parts so affected  are dense, humid, quite im-
 permeable to air, and exhibit, when cut in<o, a smooth and polish-
 ed surface.   Gradually there are developed in these comparatively
 solid and pellucid masses, an infinity of very minute yellow opaque
 points, which,  increasing in size and number, at  length convert the
 whole diseased space into a tuberculous mass of the kind named
 crude or immature.
   In whatever mode the tubercles have first shown themselves,
 they at length,  after a very uncertain period, become, first, soften-
 ed, and finally liquefied  This change of consistence commences
 in the centre, and progressively approaches the circumference.
   In this stage the tuberculous matter is of two different kinds  in
 appearance:—the one resembling thick pus, but without smell,
 and yellower than the immature tubercle; the  other, a mixed fluid,
 one  portion of  it being very  liquid, more or less transparent, and
 colourless (unless tinged with blood), and the other portion opaque,
 of a caseous consistence, soft and friable   In this last condition,
 which is chiefly observable in strumous subjects,  the fluid perfectly
 resembles whey having small portions of curd floating  in it.
   When the softening of the tuberculous mass is completed, this
 finds its way into some of the  neighbouring  bronchial tubes; and
 as the opening is smaller than  the diseased cavity, both it and the
 latter remain, of necessity, fistulous, even after the complete evacu->
 ation of the tuberculous matter.   It is extremely rare to find only
 one such excavation in a tuberculous lung.   Most commonly the
 cavity is surrounded  by tubercles in different  stages of their pro-
 gress, which, as they successively soften, discharge their contents
 into  it, and thus gradually form those irregular and continuous ex-
 cavations so  frequently observable,  and which sometimes extend
 from one extremity of the lungs to the other.
   Bands, composed of the natural tissue of the organ, condensed,
as it were, and charged with the tuberculous degeneration, fre- 
PHTHISIS PTJLMONALIS.                 35
 quently cross  these cavities, in a manner something resembling
 the  columns  carnece of the ventricles: these are of less dimen-
 sions in their  middle  than at their extremities.  These cross bands
 have often been mistaken for vessels; and M Ba\le himself seems
 to have fallen occasionally into this error, since, he says, that ves-
 sels frequently traverse such cavities; whereas this is, in  my opi-
 nion,^ very  rare  circumstance.   Nay more, I have  never even
 found a vessel of any consequence included  within the  substance
 of these bands.   Neither  is  there  any  example of this  in  M.
 Bayle's work;  and I  only remember to have heard  him mention
 one case where this took place, viz. in a fatal haemoptysis, where
 the ruptured vessel was found crossing a very large cavity. In the
 few  cases where  I have found blood-vessels in  such  bands, they
 constituted only a small  portion of their mass, and  were, for the
 most part, obliterated.   Generally, indeed, they can only be traced
 for a small space into these columns, being soon undistinguishable
 from the pulmonary tissue injected with the tuberculous substance.
 It would appear that the tubercles, during their increase, press on
 one side and separate  the bloodvessels, as we find these sometimes
 of considerable size, lining the internal surface of the cavities,  and
 forming a part of them    These  vessels are generally  flattened,
 but rarely obliterated: their smaller ramifications, however which
 stretch towards the tuberculous excavations, or towards unevacu-
 ated  tubercles, are evidently so, as is proved  by our abortive
 attempts to inject them.   Baillie  and Starck bad already made the
 same observation.   The ramifications of the bronchia, on the con-
 trary, seem rather enveloped than pressed aside by the tuberculous
 matter; and it would  appear that the  pressure soon obliierates theiF
 canal, as they  are hardly ever to be detected in the morbid sub-
 stance.   That they must, nevertheless, have originally  traversed
 the spaces now occupied by the  tubercles, seems  proved by  the
 fact, that in every excavation, even the  smallest, we find  one or
 more bronchial tubes opening into it.   These tubes scarcely ever
 open sideways, but are cut directly across, on a line with the  in-
 ternal surface  of the  excavation; and their direction is such as
 shows them to  have originally crossed this space.
   In proportion as an excavation  discharges its contents, its walls
 become covered with a species of morbid or false membrane, thin,
 smooth*, white, nearly quite opaque, of a  very soft  consistence,
 and almost  friable, so that  it can  readily  be scraped off by the
 scalpel.   This  membrane is generally quite perfect,  covering the
 whole internal surface  of the cavity.  Sometimes, in place of that
just described,  we find a  membranaceous exudation, thinner, more 
36
DISEASES OF THE LUNGS.
transparent, less friable, more intimately connected with the walls
of the  cavity, and,  for the most part, lining these only in part.
When  completely investing the cavity, it presents, in different parts
of its  surface, points here  and there of greater prominence, as if
the exudation had begun in these different spots at the same time.
Frequently we find this second membrane beneath the first, which
last is  then quite loose and lacerated in several places.  Occasion-
ally, also, both these membranes are entirely wanting, and  the walls
of ihe cavity are directly formed by the natural tissue of the lungs,
which, in this case,  is commonly condensed, red, and charged with
tuberculous  degeneration in different stages of its  development.
   From  these  facts it appears to me that the. second species  of
false membrane just mentioned is  only the first  stage of the first
species; and that when this is fully formed it is apt to be  detached
and discharged in a greater or less degree,—forming*one portion
of the sputa expectorated by the consumptive.
   Bayle  thinks that this false membrane secretes the pus expectora-
ted in this disease;—an  opinion which  is founded on  the analogy
existing between it  and thai which forms on the surface of blisters
and ulcers.   It seems certain,  however, to me at least,  that the
greater part of the matter expectorated is the  product  of the bron-
chial  secretion, augmented as this is by the irritated condition of
the lungs.   I do not assert that pus is not formed in these tubercu-
lous excavations  at all,  but I certainly have  observed that  when
these are lined by the soft membrane  described  above,  they  are
often entirely empty, and that, when they do contain any  puriform
matter, this  bears by no means so great a resmblance  to the sputa
as that does which  is contained in the bronchia.
   if the  disease remains long stationary, there are at length deve-
loped,  in different  points under this false membrane,  patches  of
a greyish white colour, semitransparent, of a texture like that  of
cartilage, but somewhat softer, and adhering closely to the pulmo-
nary tissue.   These patches  coalesce as they grow in size, so as
eventually to form a complete lining to the ulcerous excavation, and
this lining seems to  form one continuous  surface with the internal
coat of the bronchial tubes which open into it.
   When this cartilaginous membrane is  completely formed, it is
commonly  white or of a pearl grey; or it has a slight reddish or
violet  tint, which  latter colour is derived from the  colour* of ihe
subjacent tissue being seen through  it   Sometimes, however, even
when the membrane is of considerable thickness, its internal sur-
face is of a rose or red colour, which does not  yield to washing, and
which is therefore  probably occasioned by the vascularity of the 
PHTHISIS PULMONALIS.
3Tf
part, although, in such cases, we are unable to detect any distinct
vessel.
   In some very rare instances we find tubercles  entirely, or al-
most entirely, softened, in  a portion of lung  in other  respects
quite healthy and  crepitous; and, in such cases, (two or three
of which only 1 have met with in eighteen years,) the walls of the
cavity are smooth,  and seem to  be formed  merely by the pulmo-
nary tissue somewhat condensed, there being no accidental mem-
branous production whatever.
   Sometimes, but very rarely, the semi-cartilaginous membrane
is perceptible before the softening of the tubercles, and, indeed,
seems to be of the  same date as themselves.   This is the encyst-
ed  tubercle  of  Bayle.   The texture of these cysts  is  entirely
cartilaginous, only a little  less  solid than cartilage,  and  they
belong, therefore,  to the  class of imperfect cartilages, of which
I have given an account in another place*  They adhere firmly,
by (heir exterior surface, to the  parts which surround them, so as
only to be separable by the knife, or by  forcible detraction.   The
tuberculous matter  contained in  these  adheres strongly  to their
sides, which,  when it is removed, are seen to  be  smooth and po-
lished, though more or less uneven  or  rugged.  These  encysted
tubercles  are more  frequent in the bronchial glands then  in  the
substance of the lungs.
   The above is the ordinary manner in which  tubercles  are  de-
veloped;  but there  are  two other modes, which, although proba-
bly mere  varieties  of the  former, are yet deserving notice.   The
one  is where, in a  lung  containing tubercles in different stages,
we find small portions of  the pulmonary tissue seemingly infil-
trated by a gelatinous-looking matter of a consistence intermediate
between  liquid  and solid,  transparent, and of  a light  greyish or
sanguineous hue.   In these diseased portions  the  cellular struc-
ture of the lung is quite destroyed; but^we  can perceive in them
a multitude of"very small points of a yellowish white  colour  and
opaque,  and  which  are   evidently  portions of the tuberculous
matter which has reached  the second stage of its  progress, with-
out there  being  any surrounding portion  of  the  greyish  substance
which denotes the first stage.
   The second mode of anomalous development of tubercles  ap-
pears likewise to take place  without any previous  formation  of
grey  matter :  at least, if there be such,  the transition  from it  to
the second stage is so rapid that I have never been able to detect
* Diet, des Scienc. Med, 
38
DISEASES OF THE LUNGS.
 its presence.  In this variety we find here and there  in  the  lung
 tuberculous masses of a yellowish white colour, much paler, less
 clear, and differing less from the substance of the lung  than  the
 ordinary immature tubercle.  These masses are irregular, angular,
 and have scarcely ever the rounded form of ordinary tubercles. They
 seem, like  the  variety described in the preceding paragraph, and
 like the diffused grey matter noticed before, to be an infiltration
 of tuberculous matter into the pulmonary tissue, while the proper,
 or rounded, tubercles are foreign bodies which separaie  or  press
 it aside, rather than penetrate it.  These masses may, therefore,
 properly  enough be named tubercular  infiltration of the lungs.
 They  occupy sometimes  a considerable portion  of one  lobe.
 When they reach  the  surface they  occasion  no prominence, on
 the part, nor in  any degree alter its form.  As they increase they
 assume the yellow colour of other tubercles,  and  terminate by
 softening in the  same manner.
   These  three  varieties  of  tuberculous  degeneration  are  often
 found in the same  lung.   Sometimes I have found the last variety
 alone, in  lungs  affected with peripneumony,  and  this  even in
 the heyatised portions.   In these cases, the small number and ex-
 tent of the diseased masses,  and their deep  pale colour, showed
 their formation  to be recent   We must  not, however, conclude
 that the tuberculous degenerations were  here the effect of the in-
 flammation,  since—setting aside  iheir   infrequency  compared
 with the frequency of this disease of the  lungs—I have often had
 occasion to observe this variety of tubercle, and to the same ex-
 tent, in subjects  whose lungs were, in every respect, quite sound.
 Besides, M. Bayle  has completely proved  that  tubercles cannot
 be regarded either  as a termination, or consequence, of inflamma-
 tion.
   It cannot,  indeed, be denied  that  peripneumony,  both acute
 and chronic, sometimes  cq-exists with  tubercles; it is  even  pro-
 bable that this disease may, at  one time,  be  the  Cause of  their
 devolopment in subjects predisposed to  them, and at another, may
 itself be excited  by  the irritation produced  by  a numerous  crop
of these.   Any person at all  accustomed  to  the examination of
bodies after death  must admit  these  positions; yet it is, never-
theless, satisfactorily  proved by a multitude  of facts,  'hat the
growth of  tubercles in  the lungs  most  commonly  takes place
without any previous inflammation, and that, when  inflammation
is found contemporaneous with  these,  it  is generally posterior in
its origin.
   To convince us of the truth of this  observation, we have  only 
PHTHISIS PULMONALIS.
39
   to attend tovthe progress of tubercles in scrophulous glands, which
   we frequently  hnd to remain swollen for a very long time,  with-
   out the least redness, not only of the surrounding  skin, but even
   of the gland itself.  It is often not till after several years that in-
   flammation comes on,  which then seems to accelerate the  soften-
.  ing of the tuberculous  matter.   Sometimes, however,  this takes
   place, and the  matter is even evacuated, without the supervention
   of what can properly  be called inflammation.  When this does
   occur it has evidently its  seat  in the tissues  surrounding  the
   scrophulous gland, and not in the gland itself
      Ano:her proof, equally strong, of what has  just been advanced,
   is afforded by the  simultaneous existence of  tubercles in different
   organs of the same subject.   In  consumptive patients  it  is very
   uncommon to find  the  tubercles confined to  the  lungs : almost
   always they occupy the intestinal coats, at the  same  time, and
   are the cause of the ulceration and consequent diarrhoea so gene-
   ral in the  disease.  There is  perhaps no  organ free from  the
   attack of tubercles, and wherein we do not,  occasionally,  disco-
   ver them in our examination of phthisical subjects.  The follow-
   ing are the parts in which I have met  with  these degenerations,
   and I enumerate   them in the  order of  their  frequency : the
   bronchial,  the  mediastinal, the  cervical,  and   the  mesenteric
   glands ;  the  other glands throughout the body ; the liver—in
   which  they attain a large size, but come rarely to maturation;
   the prostate—in which they are often found  completely softened,
   and leave, after their evacuation  by  the  urethra, cavities of dif-
   ferent sizes; the surface of the peritonaeum and pleura, in  which
   situations they are  found small  and very numerous, usually in their
   first stage, and occasion death  by  dropsy, before they  can  reach
   the  period of  maturation ; the  epididymis,  the  vasa  deferentia,
   the testicle, spleen, heart, uterus, the brain, and cerebellum,  the
   bodies of the cranial bones, the  substance of the vertebrae or the
   point of union between these  and  the  ligaments, the  ribs, and,
   lastly, tumours of the  kind usually denominated  schirrus or can-
   cer, in which the  tuberculous matter is either intimately combin-
   ed with, or separated  in distinct patches from, the other kinds of
   morbid degeneration existing in these.
      Tubercles are found  more rarely in the muscles of voluntary
   motion than in any other  part.   The most  remarkable case of
   this sort I have met with, was that of a consumptive patient who
   had tubercles in almost every situation mentioned above, and who
   had, besides, the ureters so much dilated as to receive the thumb,
   and their internal coat converted into an adhesive layer of  Hiber- 
40
DISEASES OF THE LUNGS.
 culous matter.  In this person the lower extremity of  one of the
 sterno-mastoid muscles was converted into tuberculous matter, firm
 and consistent. In this case the muscular structure was still preserv-
 ed in the parts most  altered.  In  the  parts least altered, and
 which passed by insensible  gradation into  the sound portion, the
 tuberculous matter was in its early stage, grey and semi-transpa-
 rent.  I had particularly  attended to this  man's case  ; he  never
 complained of pain  in  the  ne*ck,  but merely some difficulty  in
 moving it.  At the same time the cervical  lymphatic glands were
 full of tubercles and much enlarged.
   Almost  all the cases given in M. Bayle's  treatise,  afford ex-
 amples of the simultaneous  development of tubercles in different
 parts of the body, without  there being discoverable in the affect-
 ed parts either pain or any symptom  of inflammation.  The same
 is true of the tubercles of the lungs,  which  scarcely ever occasion
 any disorder until they have become  numerous and large.
   From all this it follows, that we must either admit that tuber-
 cles are not a  termination  or a product of inflammation, or agree
 to receive  this word in a sense as general  and vague  as  that  of
 irritation, or even to consider it as  synonymous with  cause:—a
 mode of proceeding  which seems to  possess no  advantage what-
 ever.   There  is sufficient obscurity already in the etiology of dis-
 ease without augmenting this by forced relations.   The above re-
 marks respecting inflammation are equally applicable, as has been
 well shown by M. Bayle, to several  other  diseases, both general
 and local, which have been assigned  as causes of consumption;—
 such, for instance, as Syphilis,  Hooping-Cough,  Eruptions,  Hae-
 moptoe and Catarrh.  These affections  may accelerate the de-
 velopment of  tubercles already existing; they may even some-
 times be the occasion of their development, but this can only be
 in subjects primarily predisposed to  them.   The real cause,  like
 that of all other diseases, is probably beyond our reach.
   M. Bayle does not seem to have been  well acquainted with the
 different modes of development of tubercles, as above  described.
 This appears to be owing to his  not  having paid sufficient atten-
tion to the  grey semitransparent  character of them in their early
stage, and the true relation between  these and the  yellow opaque
 tubercles.
   On the  other hand, he has been, perhaps, too much struck with
 one variety of  these  tubercles, those, namely, which he has de-
 scribed under the name of miliary granulations.    These are, no
 doubt, very remarkable by their want of colour, transparency, dis-
tinct round or oval shape, smooth and shining surface, great hard- 
PHTHISIS PULMONALIS.
41
 ness  uniformity  of size, and infinite number spread through the
 whole lungs, (healthy in other respects,) or a great part of them,
 without their being ever found united or grouped together.  They
 look as if they had all been  produced on the  very same day, not
 one of them being more advanced than another.
    M. Bayle has however evidently been  deceived in considering
 these  granulations  as  different from  tubercles; still  more so in
 classing them with morbid cartilaginous bodies (cart, accidentels)
 If this opinion were correct, we should see them occasionally  con-
 verted into bone, which is never the case.   But, indeed, an atten-
 tive examination  shows them to  be  tubercles.  In the centre of
 those  least transparent  we can discover a yellow opaque point
 which is obviously the commencement of the passage to the se-!
 cond or mature stage.   M. Bayle himself cites  a strong example
 ot this (case 4).                                            r
    Besides, in some cases, we find the lungs completely filled  with
 very small, equal-sized tubercles, but opaque,  yellow, and occa-
 sionally in a well-marked state- of maturation.  M. Bayle "ives
 also an example of this kind,  (case 16), although  he pretends to
 distinguish this  variety  from that of  his miliary granulations,
 Ihe only  ditierence, in my opinion, between them,  is the differ-
 ence that exists between the green and ripe fruit.  Besides, these
 miliary granulations are never found but in  lungs  which  contain
 other  and larger  tubercles,  whose advanced  stage incontestiblv
 proves their character.                                       J
   The progress of tubercles in different  organs affords a sufficient
 number  of facts,  to prove, that in their first  and  earliest stage
 these  foreign bodies are always  diaphanous  or semitransparent'
 colourless, or at most slightly  greyish.   This  is often the  case
 with the tubercles observed on the surface of the pleura and peri-
 tonaeum.   On the contrary, these  have  sometimes an opaque yel-
 low spot in the centre, and, on other occasions, they are convert-
 ed into tuberculous matter more or less  soft.   All  these varieties
 are observed on  the  same membrane.  The same  varieties of
 miliary tubercles are found in  the bottom of the intestinal ulcers
 of consumptive  patients.  Lymphatic glands containing tubercles
 have often a  slight degree  of  semkransparencv  and pearl  colour
 in the  tissue surrounding these,—a proof and sign  of the ulterior
degeneration of the  whole gland.  Bayle has found the  spleen
filled with  small greyish  bodies, which  he himself considers  as
tubercles.
   Besides the effect of the various degrees  of development, other
 iccidental causes may affect the colour of tubercles.  Icterus rer^ 
12
DISEASES OF THE LUNGS.
ders them  yellow, especially at the surface, and this is chiefly in
the liver.   Gangrene in their vicinity, and also the black  pulmo-
nary matter, blackens them in a  greater  or  less degree.   More
especially those  found in  the  bronchial glands  are  often tinged
with a deep black, which  is seen gradually fading into the natural
colour of  the  tubercle.   Most miliary tubercles, whether semi-
transparent, or yellow and opaque, have a  small dark spot  in their
centre, which disappears as they  enlarge.   This condition  must
not be confounded with melanosis, as will be shown more particu-
larly hereafter.
   When  there  exists  a  great number of tubercles, even very
small ones, in the lungs, death will sometimes take place before
any of them have arrived  at the stage of maturation; and  conse-
quently before these can have formed any  ulcerous excavation.
   When,  on the contrary,  there is only a small number of tuber-
cles, we sometimes  find them all evacuated and hollow on  exami-
nation after death.   In the majority of cases, however,  the de-
velopment of tubercles is  evidently successive, so that, on  exami-
nation, we generally find these bodies in the  different  stages we
have described, viz  :  1. granular, grey  or colourless, and semi-
transparent ; 2.  grey, but larger, and yellow and opaque  in  the
centre ; 3. yellow and opaque throughout, but still hard ;  4'. soft^
especially  towards the centre ; and, lastly, cavities more  qr  less
completely empty.
                      SECTION SECOND.

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

  To many practical physicians, who are not anatomists, the pos-
sibility of a cure taking place after the formation of an ulcerous
excavation in the  lungs, may seem  quite admissible.  This opi-
nion, however, will, in all likelihood, appear quite absurd to those
who have paid much attention to morbid dissection.
  Previously to the knowledge of the true character and mode of
development of tubercles, and  while consumption  was considered
simply as  a consequence  of the  chronic inflammation  and slow
suppuration of the pulmonary tissue, medical men  did not question
(any more than the vulgar now do) the  possibility of curing this
disease by a suitable mode of treatment, especially if taken intime,, 
PHTHISIS PULMONALIS.                 43
and during the first stage of it.  It is now, however, the general
opinion of all those  who are  acquainted with the actual state of
our  knowledge respecting the  pathology of diseases, that the tu-
bercular affection, like  cancer, is  absolutely incurable, inasmuch
as nature's efforts towards effecting a cure are injurious, and those
of art are useless.   Bayle, in particular, advocates the incurability
of this  disease: he, however,  admits the possibility of its being
almost indefinitely prolonged.
  The observations contained in the treatise of M. Bayle, as well as
the remarks made in the preceding section, on the development of
tubercles, sufficiently prove the idea of the cure of consumption in
its early stage to be perfectly illusive.  Tubercles tend essentially
to increase in size and to become soft.  Nature and art may retard
or even arrest their progress, but neither can reverse it.   But while
I admit the incurability of consumption in the early stages, I am
convinced, from a great number of facts, that,  in some rare cases
the disease  is curable in the latter  stages, that is, after  the  sof-
tening of  the tubercles and the formation of an ulcerous excava-
tion.
   Occasionally, while examining  the lungs of subjects that  had
suffered from chronic  catarrh we find irregular caviues lined by a
semi-cartilaginous membrane, in all respects similar to that describ-
ed above, and these Cavities accord perfectly with the tuberculous
exulcerations, except that they are empty.  In carefully investi-
gating the history of such subjects, we find that they all  referred
the origin of their catarrh to a violent anterior disease which bore
the character of consumption, so strongly  as to  make their case at
the time, be considered desperate.
  On the other hand, in subjects dead of consumption, whose disease
had lasted very long, several years for instance, we very commonly
find similar excavations entirely lined by semi-cartilaginous mem-
brane, and free, or almost free, from tuberculous  matter. In the same
lung we shall also find excavations having the cartilaginous mem-
brane much softer and less complete, and  still containing a consi-
derable quantity of tuberculous matter;  while other excavations
are observed  almost filled with  the puriform tuberculous fluid,  and
with  scarcely any  of the cartilaginous lining   In conjunction
with all these we  almost always find tubercles in various degrees
of maturation, and even  in their  miliary  and semitransparent
stage.   This reunion  of tubercles  in all  theirvarious degrees of
development, considered in conjunction with the slow progress of
the disease, decidedly proves, in my opinion,  that the tubercles
have been developed at  different periods; and that the  oldest__ 
44
DISEASES OF THE LUNGS.
those, namely, which have given rise to the empty ulcerous cavities
lined by the cartilaginous membrane—have originated, in many
cases, several years before the others.
  The formation of this semi-cartilaginous membrane on the sur-
face of tuberculous excavations, must be considered, in my  opi-
nion, as a curative effort  of  nature.  When completely formed it
constitutes a sort of  internal cicatrix analogous to a fistula, and is,
in many cases, not more injurious to health than  this  species of
morbid affection   All the persons whose cases I  noticed  above
died of diseases not referrible to the pulmonary organs.   They had
all lived a greater  or less  number of years in  a very supportable
state of health, being merely subject to a chronic catarrh   Some
indeed had more or less of dyspnoea, but without any fever or ema-
ciation.
   I have  at present Under my care several patients affected with
chronic catarrh, and  who afford distinctly  the sign of pectorilo-
quism,* although they have in no other respect any symptom of con-
sumption.  I have met with several other cases, wherein this phe-
nomenon  was observable along  with a slight  habitual cough, very
little expectoration, and  scarcely  any  marked  alteration in  the
general health.  In a lady formerly a  patient  of  M  Bayle eight
years since, and whose case was decidedly consumption (as appears
from M. Bayle's notes  in her possession), the sign of pectoriloquism
is most distinct   This lady recovered beyond all expectation;  she
is now stout, and  the  only  symptom she has  at all referrible to
the lungs, is a slight  cough.   I  have  no doubt that the cartilagi-
nous excavations above described exist in this person's lungs.
   In proof and explanation  of what we have advanced  in this sec-
tion, I shall here give a brief notice of five cases that  have come
within my own observation.
   Case 1. A woman, aged 68, laboured under an  affection of the
chest for many years, chiefly marked by copious expectoration and
dyspnoea, and called by her  asthma.  Along with other morbid ap-
pearances, there were found two  large ulcers or  excavations in
the lungs, perfectly lined by the cartilaginous membrane as above
described.
   Case 2. A man aged 32, brought to the hospital for a maniacal
affection, died a few days after, comatose.   On examining the body
sufficient cause of death was detected in the brain, and the follow-

   * For an account of this particular sign, which the author considers quite
pathognomonic of that stage of Phthisis when the tubercles are evacuated.
see Paht Seconik—Trans. 
PHTHISIS PULMONALIS.
45
ing appearances were found in the lungs.   The left lung much less
than the right, and  containing  a few tubercles in the first stage.
The right lung containing  in like manner tubercles in different
stages, and also an  excavation large enough  to  contain  an  egg.
This was filled by a clot of blood, and  Was completely lined  by
the cartilaginous membrane above described.
   Case 3.  A  woman  aged 42, long subject  to  cough, difficult
breathing, and expectoration, died of an aggravation of the symp-
toms.   The left lung contained a few tubercles past  the first stage,
and a small excavation, of the size of a filbert, lined by a  soft
white membrane, and  filled by tuberculous matter, partly of the
consistence of cheese and partly puriform.  The right lung  con-
tained a cavity of the size  of a walnut completely lined by the
semi-cartilaginous membrane, communicating  with the air  cells
by one bronchial tube of  the  size of a  crow-quill, which  was
partly obstructed by a calcareous concretion  The lung contained
a few  more similar concretions, but was not in other parts much
diseased.
   Case 4.  A lady aged 48, was subject for several years to severe
attacks of pulmonary catarrh, which usually became chronic, and
reduced the patient considerably.   Latterly she  had  been much
better.   In July  1818, she seemed to have all the symptoms of in-
cipient tubercular phthisis.   In February 1819, a great  expecto-
ration supervened and continued a  month, after which time she
began gradually to  amend, and finally recovered completely.  Af--
ter the period of the expectoration the symptom of pectoriloquism
was observable, and still continues very distinct.   She  has  little
cough and less expectoration.
   From considering the foregoing observations, the shape of  the
pulmonary fistulas,  the smooth and polished surface of their lining
membrane, and the analogy of fistulae in other parts of the body,
we might naturally  be led to suppose that the formation of the semi-
cartilaginous membrane is the last effort of nature towards a  cure,
after the formation  of an  ulcerous excavation in the substance of
the lungs, and that it is impossible for the walls of a cavity lined
by such a membrane to unite and cicatrize.  The following case,
however, leads me to the contrary conclusion.
    Case 5.  A patient, admitted into the hospital for a diarrhoea,
and who was observed during the time he remained there to have
also a cough and expectoration, died suddenly of an apoplexy, the
cause of which was  found  in the brain.  Both  lungs  contained
tubercles, and in the left lobe was found a cavity sufficient to hold
 en almond in its shell, into which several bronchial tubes opened. 
46
DISEASES OF THE LUNGS.
 lined exactly as those already described by the semi-cartilaginous
 membrane.  In  the  other lobe there was found, on its superior
 part, a deep hollow on the external surface> which, on further ex-
 amination, was found to be connected with an internal cicatriza-
 tion.  From the centre of the depression a cartilaginous band, half
 a line in thickness, passed inwards, and, after the space of half an
 inch, divided into two portions so as to form a cavity or cyst capa-
 ble of containing an almond, and  then these  two  reunited and
 formed one band  as at the opposite extremity.  This cavity was
 halt filled by  tuberculous matter,  of a  yellowish white colour,
 opaque, friable, and much drier than usual.  (See fig. 2, plate II.)
   The foregoing condition ot parts appears to  me evidently pro-
 duced by the imperfect union of the membrane  lining two sides of
 an ulcerous excavation, and which has been rendered imperfect by
 the portion of tuberculous matter still remaining in it at the period
 of union.  This must be  regarded as a very rare occurrence.   It
 is the only one of the kind  I have met with.  It is, however,  not at
 all uncommon to find in different parts of the lungs, especially in
 the upper part  of the superior lobes (in which situation tubercles
 are well known to  be of most frequent occurrence), bands com-
 posed  of a condensed cellular substance, intermixed sometimes
 with fibrous, or fibro-cartilaginous portions, which by their white-
 ness form a striking contrast with the natural tissue  of the lungs.
 These bands have every resemblance to cicatrices in the pulmo-
 nary substance.   Sometimes, in place of these bands, we observe
 masses, of various size, of condensed cellular or  fibro-cartilaginous
 substance.  Commonly, the substance of the lungs in the vicinity
 of these  accidental productions is much more  impregnated with
 the black pulmonary matter than elsewhere; so much so, that, it
 would seem as if the formation of such foreign bodies were neces-
 sarily accompanied  by an  extraordinary secretion of  this peculiar
 matter, which ought not to be considered as a morbid production.
 The parts most deeply impregnated with this matter are commonly
 more flabby and less crepitans than natural, and have intermixed
with them fibro-cartilaginous bands.  It is not uncommon to find
 in such lungs concretions of a bony or earthy nature.
   I had often observed the above state of things without knowing
to what to attribute it, and without  attaching much importance to
the appearance; but after I was convinced of  the  possibility of
 cure in the case of  ulcerations of the lungs, I began  to fancy that
 nature might have more ways than one of accomplishing this end,
 and  that, in certain cases, the excavations, after the discharge of
their contents, by expectoration or absorption, might  cicatrize in 
PHTHISIS PULMONALE.
41
the same manner as solutions of continuity in other organs, with-
out the  previous  formation of the semi-cartilaginous membrane.
In consequence of this idea I examined these productions more
close!v, and came o the conclusion, that, in every case, they might
be  < onsidered  as  cicatrices, and that, in many "cases, they could
hardly be conceived to be any thing else.
   In all such cases of supposed cicatrization,  I found on the su-
perficies of the lung, at the point nearest to such cicatrice, a de-
pression of greater or Jess extent, with a hard and irregular  sur-
face, furrowed by linear  marks, which sometimes  exhibited an
irregular net-work or  embroidery, and sometimes resembled the
mouth of  a purse by their common union in one  centrical point.
In the same point there are usually found adhesions between the
pleura of the ribs and lungs.
   These depressions are found most frequently on the posterior or
exterior side of the upper lobes.   When they are  very deep, it
sometimes  happens that the anterior part of the lobe, drawn up-
wards and backwards by the apparent loss of substance and conse-
quent falling in of the part, overlaps the depressed portion like the
crest of a  helmet.   The  posterior portion of the lung has some-
times the same appearance, but  in a manner much less strongly
marked.  (See fig. 1 and  2, plate III.)
   Whatever resemblance these depressions may have to cicatrices,
I do not consider them as really such, but rather as analogous to
those depressions  met with in schirrous mammas,  which are, in
like manner, occasioned by the diseased action going on in the  sub-
stance within.  In the one case  the surface  of the  lungs, in the
other the skin,  is  retracted by the shrinking of the subjacent parts.
   In carefully examining such  lungs as showed similar depressions
on their surface,  I have invariably found, at  the  depth of half a
line, a line, or two lines at farthest, a cellular, fibrous or fibro-car-
tilaginous mass similar to those described above.  The pulmonary
tissue comprehended within this (depressed) space is almost always
flabby,  and not crepitous, even in cases  where there is no sign of
congestion  nor of impregnation with the black pulmonary matter.
Every where else, however, in  the vicinity of these productions,
the lung is generally quite sound.
  In tracing the bronchial tubes  near these masses I  have observ-
ed that  such as  held  a direction towards them were commonly
dilated.   In some cases 1  have  been  able  to  trace them, as  also
blood-vessels,  into the  fibro-cartilaginous mass, with which, al-
though obliterated, they formed  but one substance.    (See pi. II.
fig. 1, and  pi. V.  fig. 2.)  This fact seems to me to leave no doubt 
48
DISEASES OF THE LUNGS.
 of the nature of these productions, and of the possibility of cicatn
 zation in ulcers of the lungs.   It further proves, that a bronchial
 tube  may traverse a tubercle, and afterwards a tuberculous exca-
 vation, without being destroyed;—a case, however, as we have
 already observed, which is extremely rare.  Those wrinkled de-
 pressions, then, on the exterior  surface of the lungs, are not them-
 selves cicatrices,  but the  consequence of a true cicatrization in
 the interior of the lung.
   These cicatrizations, especially when  complete and composed
 of a  substance analogous  to other  natural tissues, produce  no
 symptoms whatever that can denote their existence.  I have only
 remarked in some cases,  when there was reason to believe their
 existence, that the  respiration  Was less distinctly audible  in the
 supposed diseased point.  In such  instances, also, where there is
 much of the  black  pulmonary  matter intermixed, and  still  more
 where there are calcareous concretions, there  generally  exists a
 small  degree of cough, and an expectoration of mucus which is
 very viscid, semitransparent and marked by dark dots.
   The two following cases afford remarkable instances of these
 pulmonary cicatrices.
   Case 6  A  man,  aged  65 years, came  into  hospital affected
 with slight pulmonary symptoms, chiefly marked by dyspnoea, to
 which he had been long subject, and which he considered as asth-
 ma.  At first he coughed but little, and had scarcely any expecto-
 ration.  After remaining in the  hospital two months, with no very
 marked pectoral symptoms, he was seized with peritonitis, &c. and
 died.   Besides some fluid  in the cavity of the pleura—very gene-
 ral cellular adhesions between  it and the lungs—^and the produc-
 tion of some albuminous  membranous concretions,  the  following
 evident cicatrization was found in  the left superior lobe.  In a
 point where this adhered to the pleura by a cellular tissue, there
 was an irregular depression, in the centre of which  lay a small
 ossification.   From this point could be traced into  the substance
 of the lung a band  of very white cellular tissue, very dense, yet
 scarcely amounting to the consistence of a membrane. This band
 was about an  inch long, six lines  broad,  and  three  or four thick.
 Its  white  colour formed a striking contrast with the natural pul-
 monary tissue.  Some bronchial tubes of the size of a crow-quill,
or larger, terminated, and became lost in this band.  An acciden-
tal circumstance prevented  me from examining this substance more
minutely
  Case 7.   A labourer, aged 62, had been affected five years with
an habitual cough, but was otherwise of a good constitution.  He 
PHTHISIS PULMONALIS.
49
Was suddenly attacked with peripneumony, which carried him off
on the fifth day, he having  been admitted into the hospital only
the day before.   On examination after death, the lungs, exclusive-
ly of the peculiar characters denoting recent pulmonic  inflamma-
tion (which will be particularly noticed in  another place), and of
some old adhesions, presented the following appearance. On the
top of the right lung there was a fibro-cartilaginous mass, three
lines in "hickness in the centre, which connected it with the pleu-
ra of the  ribs.   In the  same  lobe, included  in the pulmonary
tissue and  strongly  adhering to it by continuity of substance, there
Was found  a fibro-»artila'|inous mass  of a similar kind, of the
size of a walnut,  and of an  irregufar  conic  shape.   This mass
was of a brilliant white colour and opaque, and formed a striking
contrast with the surrounding pulmonary tissue,  which contained
an unusual quantity of black pulmonary matter.  The part of the
pulmonary substance interposed between it  and the superficial
mass about two  lines in thickness', was  quite black, and was quite
destitute of air,  although its texture was very perceptible.   This
fibro-cartilaginous mass, when cut into, presented all the charac-
ters of a pulmonary cicatrice. Several bronchial tubes terminated
and  were obliterated in  its subsJance.   Two, especially,  which
terminated in it in  forming a cul  de sac, were of the size  of a
goose-quill.  One of these, after forming the cul de sac of a dia-
meter of two lines, became all at once contracted to a  size scarce-
ly equal to that of a  crow-quill, on entering  the tumour,  into
which it could be traced  half an inch.   In this tract, however,
its cavity was entirely obliterated, and it resembled in colour and
texture the tumour, from  which it was  only distinguished  by the
direction of its fibres, or by a slight shade of colour which pointed
out both its coats and its obliterated canal.  (See plate II. fig. 1.)
   In the superior lobe of the left lung there  was a small  cavity
capable of containing a filbert, lined by a fine semitransparent
membrane, of  a  demi-cartilaginous consistence,  and  through
which the  black pulmonary matter could be distinguished.   This
excavation contained a  small  quantity of tuberculous matter,
friable, and of the  consistence  of soft  cheese.   The  pulmonary
tissue amid which it was placed was perfectly sound and crepitous.
Near the origin  of the bronchia was observed a single tubercle of
the size of a barley-corn, softened to  the consistence of soft cheese,
and surrounded by a dense membrane, greyish or  semitransparent,
of the nature of semi-cartilaginous bodies, or imperfect cartilages.
   The foregoing observations prove,  I think, that tubercles in the
lungs are not in every case a necessary and inevitable  cause  of
                               7 
50
DISEASES OF THE LUNGS.
death; and that a cure may take place in two different wayr, after
the formation  of an ulcerous  excavation:—first, by the cavity
becoming invested by a new membrane;  and  secondly, by  the
obliteration of the excavation by means  of  a cicatrix, more or less
complete, consisting of cellular, fibrous, or cartilaginous substance.
  The identity of the excavations observed in  the 1st, 2nd, 3rd,
5th, and 6th cases, leaves no question that they had one and  the
same  origin, namely, in the maturation and discharge of the tuber-
culous matter originally contained in them.  The first case may
be considered as affording an  example of a perfect cure, since  no
more  tubercles existed  in the lungs.  The same  may be said of
the 7th,—inasmuch as there was only one  very small  tubercle in
the lungs.   The subjects of the 2nd, 3rd, and 5th cases would, no
doubt, have  had  relapses  of their disease, since their lungs  all
contained tubercles more or less advanced,  and which, necessarily,
must  have been eventually developed.  This development,  how-
ever,  might  have been  remote;*since it has been truly shown  by
M. Bayle, that immature, and still more, miliary tubercles   con-
tinue  to exist for  a great many years without materially affecting
the general health
   Were it  in our power to ascertain the previous history of such
cases as exhibit these cartilaginous excavations and  cicatrizations
in the lungs after death, we should,  in  all probability, find that
the patients  had been  subject to a long  continued cough,  and
severe catarrh, or even  to  a  disease considered  at the  time  as
true consumption, and which had been  very  unexpectedly cured.
These morbid appearances, at least, sufficiently explain the fact
of the seemingly intermittent  character of certain  cases of con-
sumption, and the extraordinary cure of others.*
   These pulmonary fistulas and cicatrices  are  very common, as
any one will be convinced who practises morbid dissections in an
hospital for any length of time.  I have only mentioned  a few of
those  that I have met  with  lately; and, indeed, it is only lately
that  I have paid any  minute  attention to such appearances.   I
had,  however, frequently met with them long  before,  and  have,
indeed, partly described them in another place.f  They  are very
various in their appearance;  still  it would seem that it  is  espe-
cially by  the  production of  this extraneous cartilaginous  tissue
that  nature  attempts a cure of tuberculous excavations.  With

  * 1  am aware that Phthisis may be closely simulated by a common catarrh.
I shall notice a cn'se of this kind  hereafter, and M. Bayle details two in his
work, viz. cases 48 and 49
   t Diet, des Science. Med. Art.  Cart. Accident. 
PHTHISIS PULMONALIS.
51
 this end she seems occasionally to  throw out  a superabundance
 of it; as  the  exterior portion  of the  lung  is  sometimes  coated
 with it, as in  one of the cases already derailed.   On  other occa-
 sions the cartilaginous walls of the  cavity  are  observed of very
 unequal thickness^r-as  thick in  some places as half an inch or
 an inch,—as if the remedial powers of nature were undetermined
 whether to form a perfect cicatrix or only a fistula.  (See  plate
 HI. %• 2.)                           J            \     V
   The merely temporary cure of many phthisical cases is readily
 explained, as above remarked, by the cicatrization of a  softened
 tubercle, and  by the eventual softening of others  which   were
 only in their first stage  at  the  period  of the cicatrization of the
 first.  For example, we can easily fancy that the subject of case
 5th, detailed above, had he not been carried off bv another dis-
 ease, might, after the perfect cicatrization of the cavity in the
 right lung, have  enjoyed tolerable health for several  years  until
 the ultimate maturation of the miliary  tubercles.  The following
 is a brief  note of a case of this sort:—
   Case 8.  In 1814  M. Recamier  and' myself were consulted
 by a young lady who had every symptom of pulmonary consump-
 tion, such as frequent cough, purulent expectoration, much ema-
 eiation, hectic  fever and night sweats.  Several of the lymphatic
 glands of the neck were  swollen, and for a few days she bad
 been affected with very  severe  diarrhoea.  Astringents, sulpbur-
 baths, and ass's milk were  prescribed.   In the course of two
 months her strength, flesh, and  colour were  quite  restored,  the
 cervical glands were diminished by  one half, and,  in short,  she
 was in  a state of perfect health.  She passed  the winter  very
 well, but in April the cough and all the other phthisical symptoms
 returned, and she died in the end  of summer.
   Such  examples  of perfect, though  only  temporary cures of
 consumption are rare; but it is by no means unusual to find  persons
 affected with all the symptoms of  this disease surviving for many
years, alternately experiencing imperfect convalescences  and re-
lapses more or less severe.   It  is  such  cases M. Bayle  had
in view when he said consumption  may  continue  forty  years.
These imperfect cures may, I think,  be attributed to the  succes-
sive softening of several  tubercles, and  their  subsequent conver-
sion into fistula;;  whilst the more perfect, though still  temporary
cures, may depend on the formation  of a  cicatrix.   The  results
of these  two kinds of cure, as far as  I am able to judge from the
cases I have met with, seem  to  me   to be the  following :—the
cure  by  fistulas  usually leaves behind  it a chronic catarrh, more 
52
DISEASES OF THE LUNGS.
 or less severe,  and accompanied by an expectoration which is
 sometimes very copious; cicatrization, on the  contrary, produces
 no other invonvenience  than a dry cough, neither frequent nor se-
 vere.  Sometimes, indeed, there is  no cough,  especially  where
 the  texture  of such  cicatrices  clearly  resembles that of other
 natural tissues in the animal economy, especially the cellular  or
 fibro-cartilaginous.   When,   however,  the  substance   of  the
 cicatrice is less perfect,  and more remote from the healthy  tissues
 of the body, and  when  it is impregnated with  much of the black
 pulmonary matter, we find  an  habitual cough,  either  dry  or ac-
 companied by a mucous expectoration, and cachectic condition
 of the body.
  When we consider that the  formation of  tubercles in the lungs
 seems to be  the  consequence of a  general  diathesis;  that these
 are frequently found contemporaneously in  the  intestines,  where
 they  ultimately occasion ulceration  and colliquative  diarrhoea ;
 and  that, in some cases, also,  they exist in  the lymphatic glands,
 the prostate, the testicles, the..muscles, bones, &c; we  must be
 led to believe the most perfect cure  that can take  place  in con-
 sumption as  merely temporary.   Admitting,  however, the justness
 of this conclusion in those  extreme  cases of tubercular diathesis
 (which,  after all,  are  but rare when compared  with the  vast
 number of. consumptions), we  are still  entitled  to  hope for the
 cure of many cases of  phthisis, or at least,  for such a suspension
 of their symptoms as may  be  deemed  almost equal to  a cure,
since the individuals may enjoy  such a  state  of health,  as may
 enable them to fulfil all  the duties of civil life, for  several years,
 or until such time as a fresh development of tubercles, at present
 immature, produces a fresh and final seizure.
  It is further worthy of remark, that, although  in the majority
 of the subjects in which 1 have  observed these fistula;  and cica-
 trices, the lungs  contained  tubercles  in  different  stages of their
 progress,  and,  consequently,  a certain  though  perhaps  remote
 cause of a return of the disease, still  I  have  found the same
marks of a cure in subjects in  whom  there were no tubercles
whatever, neither in the lungs  nor in any other  organ.  In such
instances it may be supposed,  perhaps,  that  the  excavations  had
 been the product of simple inflammation of  the pulmonary  tissue,
 and not of tubercular degeneration.   Such a supposition is, how-
 ever, quite gratuitous    Those  accustomed to much morbid  dis-
section have almost daily  experience of the  formation of these
membranes  on the surface of tuberculous excavations ;  while
the   formation of pus,  or  true  abscess  of  the  substance  of the 
PHTHISIS PULMONALIS.
63
lungs, is so  extremely rare (as we shall  see  more  particularly
when treating of peripneumony)  as to be justly  esteemed one of
the most extraordinary  appearances  in  morbid  anatomy, and,
therefore, quite inadequate to account for an occurrence  so com-
mon as that of fistula; and cicatrizations of the lungs.
   These.considerations ought  to induce us still to entertain some
hope in  those cases of consumption wherein we have reason to
believe the  greater portion of the lungs remains still permeable to
the air.   Although we are, therefore, certain that a subject that is
pectoriloquous has an exulcerated cavity in the lungs, we are  not,
on this account, equally certain that this will prove fatal.
   We may  even be justified in believing that a case, wherein all
the ordinary symptoms of consumption exist together with pectori-
loquism, is more  favourable than one in which they exist without
this peculiar phenomenon; since, in the first case, we may attri-
bute the symptoms to the efforts of nature  in maturing and evacu-
ating the tuberculous matter,  and  may hope  for their  cessation
when this is effected, provided  the greater  portion of the lungs  is in
other respects healthy,  (as we can ascertain by the  stethoscope)-*
while, in the second case, we  must imagine that the tubercles are
very  numerous,  since they produce such  violent  general effects
previous to  the period of  their softening, and  that therefore  they
will, in  all  probability, occasion death before  the epoch of possi-
 ble  cure arrives.
   The two following cases, as well as the others already related,
 prove the curability of Phthisis.
   Case 9.  An English gentleman, aged 36, detained in  Paris as
 prisoner of war, in September 1813 had an attack of haemoptysis,
followed by a cough, at  first dry, but, in  the course  of a  few
weeks, accompanied by purulent sputa.  To these symptoms were
 added a well-marked hectic, considerable dyspnoea,  night sweats,
 emaciation and  great debility.  The  haemoptysis returned,  in a
slight degree, now and then, and in December he had diarrhoea.
In the beginning of January he was so much reduced that  both
M  Halle  and  Bayle agreed  with me in  opinion  that his death
might be daily  looked for.  On the 5th of January, during a se-
vere fit of coughing, and after bringing up some blood, he expec-
torated a solid mass, of  the size of a  filbert,  which, on  examina-
 tion, I found to be evidently a tubercle in  the second stage,  sur-
 rounded by a portion of the pulmonary tissue, such as  has been
 already described as impregnated with grey tubercular  matter in

   •  The. instrument for ascertaining the existence of pectoriloquism.  See
 Part II.  Tram. 
54               DISEASES OF THE LUNGS.

the first stage, often met with  around these  bodies when large.
Thi pa.Jt Remained in the same degree of extreme emaciation
and debility all January;  but in  the  beginning of February  the
perspirations and diarrhoea ceased  spontaneously, the expectoration
sensibly diminished, and the pulse,  which had been constantly as
high as 120, fell to  90.   In a few days  the appetite returned,  the
patient began to move about in his room, his emaciation  became
less, and, against the end of the month, his convalescence was
evident.   In  the  beginning of  April he was  perfectly recovered;
and his health has continued good ever since,  without even  the
least cough, and without his  being at all particularly guarded m
his climate or regimen.   In 1818 this patient again consulted me
for a different complaint, and I took the opportunity of examining
his chest  by  means of the stethoscope.   The only  thing  I  could
detect  was the comparative indistinctness of  respiration in  the
superior portion of the right lung.   There was  no pectonloquism.
From  these circumstances I am of opinion  that the  excavation
which  contained  the expectorated tubercle must have been cica-
trized; and as the total absence of cough, dyspnoea and expectora-
tion for  four  years, forbids  the  supposition  of the existence ot
others  in the  lungs, I think we have a  right  to  consider  this  pa-
tient as perfectlv  cured.
   I think there* can be no doubt that had this patient been  ex-
amined by the stethoscope after the  expectoration of the tubercle,
he  would have been found pectoriloquous, and the subsequent ces-
sation  of  this  phenomenon would have indicated the formation of
a cicatrice.   And I am convinced that  when the use  of  this in-
strument  shall have  become more general, the development  and
■subsequent cessation of t,ectoriloquism  will be  often detected, not
only in cases of decided phthisis, but also in  many cases of obsti-
nate cough,  which are usually rather  dreaded  as a cause of the
future development of  tubercles, than  as a  sign of their  actual
 presence, and which are found to get well after a longer or shorter
continuance.
    Case 10.  This case is  detailed in M. Bayle's treatise (see case
 54), and is that of a gentleman who, after having experienced all
the symptoms of consumption in  the greatest degree, perfectly re-
 covered by change of air  and living by  the sea-side.  As  both M.
 Bayle and myself  (for this was  my patient) then conceived the
 cure of phthisis impossible, we  considered the case as one of
 chronic catarrh, and it is so entitled  in M. Bayle's book.  Since
 then I have had  an opportunity of  satisfying myself, by. means of
 4he cylinder, that our patient had had  more  than a mere catarrh. 
PHTHISIS PULMONALIS.
55
His respiration is quite perfect throughout the whole chest, except
at the  top of the right lung, in which point it is totally wanting.
On  this account I am certain that this  portion of lung had been
the  seat of an ulcerous excavation, and that this had been replac-
ed by a complete and solid cicatrice.  The health of this gentleman
continues good, although he has often occasion to speak in public.
He  has sometimes a little dry cough, on the change of weather,
but  takes cold very seldom.
                       SECTION THIRD.
                            I     ■ (
   Of Vomicae, and the Expectoration of Tuberculous Matter.

  The morbid condition usually denominated Vomica, is one bet-
ter known in theory than it is common in practice: its phenomena
are readily explained by the cicatrization of the tuberculated cavi-
ties,  or the formation of fistula; as above described.   By the term
vomica, we commonly  understand a sudden and abundant  expec-
toration of purulent matter, supervening upon a disease which had
all the usual  symptoms of an  incipient  consumption.   In these
cases we sometimes find, after an expectoration  so copious  as
would almost, in the course of  twenty-four hours, fill one of the
cavities of the chest, the cough gradually lessen after a few days,
the sputa decrease in like proportion, and the patient gradually re-
cover a complete and durable state  of  health.  More commonly,
however, the amendment is merely temporary, and  the  return of
all the bad symptoms puts an end to the patient's life.
  Cases like these had  attracted the attention of medical men  in
the very infancy of the art.   Hippocrates treats  of them *at great
length in different parts of his writings.   He considered  vomica;
as true abscesses of the lungs, and, in  consequence, designated
those affected  with  them, empyical or suppurated; a  term  which
he extended to this  particular affection, in whatever organ it might
be seated,.but which has been  confined, by  modern  surgeons, to
purulent collections in the  cavity of the pleura.   He  seems to
have considered such  a disease as different from  phthisis.  He
imagined that the abscess  might be evacuated either by the bron-
chia  or into the cavity of the pleura.  The former termination ap-
peared to him fortunate, and he sometimes attempted to produce it 
56
DISEASES OF THE LUNGS.
  by the succussion of the patient's body: the  second termination
  he considered as the usual cause of empyema.
    These notions, very incorrect  in many respects, are  still held
  by many medical men unacquainted with morbid anatomy.  They
  are especially false in respect of the origin of the pus, since, as I
  have already observed, and as I shall more  fully prove hereafter,
  the formation of an abscess or of a collection  of pus in  the  Sub-
  stance of the lungs, as a consequence of inflammation, is an ex-
  tremely rare case;—at least a hundred times less frequent than a
  well marked  vomica, and a thousand  times  rarer than a case  of
  empyema.
    I consider vomicae, such as are met with in practice and as 1 have
 described, as  produced by the softening or solution of a tuberculous
 mass of great extent.  The copious expectoration, however, which
 usually continues for several  days after their  rupture, cannot be
 considered as entirely supplied by the  tuberculous contents of the
 excavation,.   A patient, who  had been affected for  several months
"with  a dry cough, dyspnoea, hectic fever, and other symptoms in-
 dicative of the existence of immature tubercles, during a violent
 fit of coughing suddenly expectorated a glass full of pus. For eight
 days he spit up, during every twenty-four hours, about three pounds
 of a similar fluid.  After this the expectoration diminished gradu-
 ally, and finally ceased  along  with the other symptoms, and the
 patient  was  disclwrged, at the end of a month,  perfectly cured.
 An expectoration so copious as this can  only be .explained by a con-
 tinuous secretion; and  in the particular case just  mentioned the
 matter was, doubtless, furnished  bj the walls of  a very extensive
 tuberculous excavation, and probably,  also, by  the  bronchia, irri-
 tated by the tuberculous matter.   It is also probable, that, in this
 instance, the termination of the expectoration was  owing to the
 cicatrization of the cavity.
   The case of a vomica, as usually characterized in practice, and
 which is justly considered as  of rare occurrence, differs merely in
 degree of intensity  from a condition which is very common,  and
 which may be frequently observed by  any one who takes the trou-
 ble to observe and  compare  the sputa of a number of phthisical
 patients at one time, as can be done in  the wards  of an hospital.
   The truth is, that phthisis, considered relatively to the expecto-
 ration, presents two very distinct stages during its progress. In the
 first, the cough is dry, hard, and fatiguing; or, if  there be expec-
 toration, the sputa are entirely supplied by the saliva, and mucus
 from the [bronchia] mouth and  throat.  The reunion  of these
 may form a copious  expectoration, which  will  be transparent. 
PHTHISIS PULMONALIS.                57
 colourless, liquid, ropy, and  somewhat frothy  at  top.   To  this
 there will be occasionally superadded a little of that grey, viscid,
 semitranspafent matter, often mixed with black specks, to which
 we  commonly give  the name of bronchial mucus.  When this
 takes place the expectoration is very scanty; otherwise, it is often
 abundant.  Both these kinds of expectoration indicate the  exist-
 ence of immature tubercles.
   In some cases, however, the expectoration is  extremely copious
 and ropy, but always nearly colourless and semitransparent.  This
 condition of the expectoration indicates, as has been truly remark-
 ed by M. Bayle,  the existence  of a great number of immature
 miliary tubercles;  but not  exclusively, as he imagined, that variety
 which he denominated granular.
   In the second stage the  sputa put on quite a different character.
 They then become opaque, of a pale yellow, and sometimes slightly
 greenish, with more  or less  of tenacity.  Sometimes  they per-
 fectly resemble those of a simple catarrh, and, on the other hand,
 they are occasionally loose and puriform.  In some cases we  can
 discover fragments of tuberculous  matter  imperfectly  dissolved.
 This last character may, perhaps, be deemed quite pathognomonic.
 It is not, however, so;  as portions of a sebaceous, concrete,  and
 friable matter, entirely  resembling these, are occasionally formed
 in the tonsils, and expectorated  by many  persons in a state of
 health.*
   The transition from the one stage  to the  other  is sometimes
 sudden and complete, that is to say, the transparent mucous sputa
 cease at  the instant the yellow and puriform begin  to make their
 appearance.   The accession of these  last  is sometimes accom-
 panied  by a slight  hemorrhage,  and a  temporary  relief almost
 always follows.  Instances of this kind are not  at all uncommon:
 they offer examples of vomica; in miniature.
   Very often the transition from the first to  the second stage is
 not so distinct as  this.   The  transparent  mucous  expectoration
 will frequently  continue along with  the  opaque  and  puriform
 sputa;  and in this case, if we merely  looked to  the  nature of
the discharge, we should be at a loss to decide whether  the new
sputa originated in the softening of  the tubercles, or were produc-
ed  by the  supervention of a pulmonary  catarrh  upon the  old
 cough of the patient.

  * There are, however, two characters by which these substances may be
distinguished:  the cheesy matter has usually a peculiar foetor, and when
heated on paper it greases it.  These characters are wanting in the tuber
culous matter.
                              8 
58
DISEASES OF THE LUNGS.
   These two  different conditions of the expectorated fluid are in
perfect accordance with  the  organic  affection which  constitutes
phthisis, since they indicate—first,  the crude state of the tuber-
cles;  and,  secondly,  the  evacuation  of these, by  the  bronchia,
when mature.  The  first species of sputa is merely  the  mucus
of the bronchia, secreted in greater quantity than  usual, on  ac-
count of the irritation excited by the  tubercles contained  in  the
pulmonary  tissue; the second species, on  the  contrary, consists
partly (especially in the beginning) of the  softened matter of the
tubercles, and partly  of a purulent or  puriform fluid secreted by
the lining  membrane of  the tubercular excavations, and by that
of the bronchial tubes themselves.  The truth of the  latter part
of this statement is proved by the fact that most consumptive  pa-
tients daily expectorate a  greater quantity of sputa, both in  weight
and volume, than the substance of all  the tubercles in their  lungs
would supply.
   The general symptoms of the disease are by no means so exactly
coincident, either with the nature of the expectorated  matter, or
with  the extent of disorganization in the lungs.   Hectic fever
and emaciation sometimes exist in a great degree  before the  ap-
pearance of the puriform  sputa, and sometimes even death  takes
place in  this early stage*   On the other hand, a  state of com-
parative  robustness and tolerable health shall continue long after
the occurrence of the opaque  expectoration, and  the discovery
of pectoriloquism.   Indeed,  I am led  to believe from many facts,
that,  in  the  majority of cases of consumption which terminate
favourably by the formation of fistulae or cicatrices, the patients
have  undergone the different processes of the development, solu-
tion, and evacuation of the tubercles, without any'suspicion of
being affected by a more  serious disease  than  a nervous  cough,
or, at most, a  suspicious  catarrh.
   There is not one  patient in ten that dies  consumptive  before
the complete  softening of a part of the  tubercles, and,  conse-
quently,  before the formation of one or more  excavations.   It is
still more uncommon for such excavations to take  place without
communicating  with the  bronchia; nay,  it sometimes happens
that these organic lesions take place long before  any  perceptible
change in the general health.   This fact is readily explained  by
a reference to the  morbid anatomy of the affected  organ.   The
simultaneous  existence,   in  the  lungs of almost  all  phthisical
subjects, of tubercles in   every stage,  from the miliary tubercle
* See Bayle's Cases 14 and 15. 
PERIPNEUMONY.
59
to the ulcerous excavation, must convince us that their  develop-
ment is successive, and that some may have  reached their last
stage at the very period  of  the formation of others.  And we
can readily understand how a  single tubercle  may  pass  through
all  the  stages  of its  progress without  materially  affecting  the
general health, while a  great  number of similar tubercles  may
prove highly deleterious and destructive.  We  have  an  instance
perfectly analogous to this  in  the case of scrophulous lymphatic
glands:  for example,  we  often observe  a  single cervical gland
to tumefy, and eventually to discharge  the  tuberculous  or scro-
phulous matter (the development of which had caused the morbid
affection), without the general  health being at  all affected; while
the very same disease, when it extends to many  similar glands,
gives rise to hectic fever, marasmus, and death.
   In concluding this  discussion I would observe, that the cure of
consumption, in cases where the lungs are not entirely disorganiz-
ed, seems to me to  present no character of impossibility, neither
in regard to  the nature of the disease, nor  the  nature of the  or-
gan affected.   In the first place, the tubercles  of the lungs differ
in no respect from those situated in the glands, and which, under
the name of scrophula, after being softened and evacuated,  are
often followed by a perfect cure.   Secondly, the destruction of a
portion of  the pulmonary tissue is not necessarily fatal in its na-
ture, since we know that wounds of this organ are frequently
cured,  notwithstanding the aggravation of the  case  produced by
the perforation  of the thorax and admission of  air into the cavity
of the  pleura.
                        CHAP.  II.

 OF PERIPNEUMONY, OR INFLAMMATION OF THE
                          LUNGS.

  Peripneumonv,  or Pneumonia,  is inflammation of the sub-
stance of the lungs.   Considered in an anatomical point of view,
this disease presents  three different varieties,  or  degrees, very
distinctly marked.
  In the first, the lung is of a livid or violet colour externally, is
much firmer internally, and  heavier than in its  healthy state.   It 
60
DISEASES OF THE LUNGS.
is still crepitous, but much  less so  than a sound lung, and,  oo
pressing it between the fingers, we perceive that it is injected  by
a liquid.   When cut into, it appears of a livid red, is quite  in-
jected by a frothy serous  fluid, more or less sanguinolent, which
flowsfrom it abundantly.  We can still, however, discover  very
clearly the.  natural alveolar and  spongy texture of  the  viscus.
This is the condition of lung entitled by M.  Bayle,  obstruction,
(engoument)!.
   In the second variety, the  lung has  entirely lost its  crepitous
feel under the finger, and has acquired a consistence and weight
altogether resembling  those of liver.  From  this circumstance,
modern anatomists have named this condition  of the  organ He-
patization or Carnification.   The  former of these  terms is suf-
ficiently correct; the last is very  improper, and would  be  more
applicable to a morbid  condition of the lungs  to be hereafter  de-
scribed.
   In this, the second degree  of inflammation, the lungs  are fre-
quently less  livid externally than in the first variety; but they  ex-
hibit in their interior a  red colour more or less  deep, which forms
a striking contrast with the spots of  black pulmonary  matter,  the
bronchial tubes, the blood-vessels and air-cells, all visible on  the
cut surface.   The  air-cells, especially, which  are so indistinct in
the natural condition, become very obvious.    Their membranous
walls seem  frequently exempted  from the general inflammation,
and their whiteness thus renders them very visible.
   If we cut into slices a lung so affected, there is scarcely any fluid
whatever flows from the incised  surfaces; but if we scrape  these
with the scalpel, we can force out a small portion of bloody serum,
which is thicker and less clear than that above described, and in
which  we can  often  distinguish a  matter still  thicker, opaque,
whitish and  puriform.   In examining  the  incised surfaces in  a
proper light, we find  the lung to have entirely lost the eellular
structure, and to have acquired  a  sort  of granulated appearance,
as if composed  of little red  grains,  of a roundish and somewhat
flattened shape.   This species of granulation  appears to me to be
the proper anatomical characteristic of inflammation of the pulmo-
 nary tissue, by which it can be best distinguished  from the tuber-
 cular, and from the various other kinds of induration  to which it
 is liable.
    When a lung is entirely hepatized it seems, at first sight,  to be
 larger than natural, but this seeming enlargement is merely caused
 by its not being able to collapse,  and its thus continuing  to fill the
 cavity of the pleura.   I have often measured the  dimensions of 
PERIPNEUMONY.
61
this cavity, in cases of pneumonia, both in the dead and living sub-
ject, and have never  found the slightest degree of enlargement in
the side affected; a circumstance, as we shall more  particularly see
hereafter, which establishes a great difference between this com-
plaint and pleurisy.
   It even appears that the lungs when inflamed are totally without
any power of impressing, with any force, the surrounding parts, as
I have seen,  on the surface  of a  completely hepatized lung, an
indentation, of a line in depth, produced by a patch of coagulable
lymph, extravasated on the  corresponding, point  of the pleura cos-
talis, and not of firmer consistence than the white of egg boiled.
   In the third variety or degree  of inflammation,  the pulmonary
tissue  has  the same  consistence  and granular texture  as we have
just described, but it is  of a  yellowish  pale or straw  colour,  and
discharges, from the cut  surfaces, in  considerable quantity,  an
opaque, yellowish, viscid matter, which is evidently purulent, but
with a heavy smell which is not nearly  so disagreeable as that of
pus in an open  wound.   This is, properly speaking,  suppuration
of the substance  of the lungs; for,  as we have already  shown,
what  are  usually considered as such,  viz. vomicae,  are  merely
softenings of the matter of tubercles.
   In several hundreds of cases of peripneumony, wherein I have
 examined the lungs after death, I have met with collections of pus
 in the inflamed organ not more than five or six times.   These ab
 scesses were very few in number, and inconsiderable in extent.
 They were  found in cases of the third variety, above described,
 and were  dispersed  here and there  throughout  the lung.   Their
 walls consisted of the pulmonary tissue, injected with pus, and in
 a sort of putrid condition,  which gradually disappeared in reced-
 ing from the abscess.  Once only have I met with an abscess of
 considerable extent.   In this case, the patient died on the twen-<
 tieth  day of his disease   The abscess was seated in  the  anterior
 and middle portion  of the lung;  it was long and flat, and would
 have contained three fingers.  Correctly speaking, it could hardly
 be said to have  any direct boundaries.   In proceeding from  the
 centre of the collection the pus became gradually converted into a
 sort of purulent detritus; a little  further on, the pulmonary tissue
 was more firm, but profoundly gorged with pus: at the distance of
 half  an inch the substance of the lung exhibited  merely the com-
 mon  characters if the third variety or  degree of inflammation. In
 this case, as in every other instance of purulent collections in the
 lungs, the peripneumonic affection occupied only one portion  of a
 single lung.   This  circumstance may  assist us  in accounting foi 
G2
DISEASES OF THE LUNGS.
  the infrequency of such appearances; since we can believe  that a
  partial peripneumony is usually removed by nature or art, while one
  involving the greater part of the viscus, will  prove fatal before it
  has reached the stage of the entire  destruction of any portion of
  the lung by abscess.
    From this  description we perceive the marked difference between
  such purulent depositions and the cavities formed by the  softening
  of the matter of tubercles.  This last, although  sometimes resem-
  bling pus in colour, commonly differs from it by containing tubercu-
  lous fragments of a friable  consistence. Besides, the compactness,
  the  exact  circumscription  of the  tuberculous  cavities, the soft
  false membrane which uniformly invests these, and the  semi-carti-
  laginous one  which occasionally succeeds it;—all suffice to denote
 a morbid state of parts very different from that noticed  above.
   The three varieties of inflammation above described, are very
  commonly conjoined in different ways.   Very  commonly  one lung
  is inflamed throughout in the third degree, while the other exhibits
 only some spots in the  first or second degree.   Sometimes the three
 varieties  exist in the same lung, dividing it  into different zones^
 which  are either very strikingly contrasted, or shaded into one
 another by insensible gradations.
   The transition from one degree to another is marked  by the de-
 velopment  of some spots  of greater  inflammation.    Thus, the
 transition from the first to the second is characterised by a red-co-
 loured tissue, containing much frothy and bloody serosity, and still
 somewhat crepitous on pressure, in the midst of which we observe
 some portions of a redder colour, much firmer, not crepitous, con-
 taining much  less serosity, and  presenting.granulated surfaces on
 incision.
  The transition from  the second to the third degree is marked by
 yellowish, irregular, uncircumscribed  spots, which pass  insensibly
 into  the red colour of  the second degree of inflammation.  This
 character of coulouring, added to the grey or black striae arising
 from the intermixture of the black pulmonary matter, exactly resem-
 bles some species of granite, consisting of red and yellow  felspar,
 grey quartz, and black mica.
  The'lower parts of the  lungs  are those  most commonly  affected
 in peripneumony; and  when the disease extends to the whole of
 them, it is in this part that it almost always commences.
  When  all the varieties of peripnemony exist in the same lung,
 the greatest degree generally is observed in the same inferior portion.
It is extremely rare to find the inflammation confined to the supe-
rior lobe; and  it  in nearly equally so to  find it seated in the centre 
PERIPNEUMONY.
63
of the lungs, while the surface throughout retains its crepitious cha-
racter.
   We never find the whole of both lungs inflamed in the third,
or even in the second  degree; but it is not uncommon to find one
whole lung, and half the other, entirely impermeable to the  air.
   In other- cases, on the contrary, death takes place before the
fourth part of the lungs is affected by the  inflammation; a fact
(among many others) which proves that death is often produced by
the exhaustion of the vital principle, rather than by the  intensity
or extent  of the local lesion.
   Peripneumony, even when it has reached the third stage, or that
of purulent deposition, may still admit of cure without disorganiza-
tion of the pulmonary tissue.   In such cases,  if the patient happens
to die during convalescence,  we find the hepatization  gone, and
only the hardness of the first stage of the disease remaining.  The
lungs are  slighly crepitous, do not always sink in water, and still
contain a  portion of purulent fluid.  The incised surfaces present
a dirty yellow or pale green colour, very different from that of the
healthy lung.   In a still farther advanced period of restoration the
same colour remains;  the lung  still continues more humid than
natural, but contains no perceptible portion of pus.
   Chronic  peripneumony, when  uncombined with tubercles or
other morbid growth, presents entirely the same anatomical charac-
ters as the acute; and it would be therefore extremely difficult, even
for  those  most  accustomed to  morbid  dissections,  to  form  any
probable  opinion of the duration  of the disease from the appear-
ances after death.
   The only symptom of peripneumony, that can with any propriety
be treated of in this place, is the nature of the expectoration.  And
of all the  symptoms of the disease, this is the only one that  can be
at all regarded as pathognomonic, since it is the only one that is
found exclusively  in it.  The sputa are white, slightly yellowish,
or greenish,  somewhat diaphanous, and intermixed with bubbles
of air which are retained by its extreme tenacity.   This tenacity
is so great that we may often reverse the vessel  containing the
sputa, and even retain it in this  position for a long Jkne, without
being able to detach them from its sides. 
%4
DISEASES OF THE LUNGS,
                          CHAP. Ill


             OF GANGRENE  OF THE LUNGS.

    Gangrene of the lungs is extremely rare.   It can  hardly be
  considered as one of the terminations of the inflammation of that
  viscus,  and still  less can  it be regarded as a consequence of the
  intensity of the inflammation.   In  truth, in such cases the inflam-
  matory character is very little conspicuous, either in the symptoms,
  or in the morbid condition of the injured organ.  I would, therefore,
 say that this disease is  allied to  those which are essentially or
 idiopathically  gangrenous; such, for instance, as the different va-
 rieties of  anthrax;  and that the  inflammation existing around the
 gangrened part, is rather the effect, than the cause of the mortifica-
 tion.
   There are two varieties of this  disease, which are both conspicu-
 ously  marked,  as  well  by their general symptoms,  as  by their
 anatomical character;—the uncircumscribed and the  circumscribed
 gangrene of the lungs.   The  first is one of the rarest of organic
 diseases.   I have only met with two cases in eighteen years; and
 I am not aware of more than five cases having been seen in all the
 hospitals of Paris during the  same period.  This variety has the
 following characters:—the pulmonary tissue  is more humid, and
 much more easily torn than natural, and has the same degree of
 density as in the first  variety of  peripneumony; its  colour varies
 frorn a dirty white or  slight  greenish, to a deep green or almost
 perfect black, intermixed, sometimes,  with  a brown or earthy
 yellow colour.   These different tints are mixed irregularly in dif-
 ferent parts of the lungs, and are, further, interspersed with portions
 of a livid red,  altogether resembling the  state of parts in the first
 degree of peripneumony.   Some points here and there are com-
 pletely softened down to a sort of liquid and putrid mass.   A dirty
 sanies, or greenish liquid, of  an  insufferably pjtrid  odour, flows
from the affected parts when cul into.   This affection occupies, at
least, the greater part of one of the lobes; sometimes k extends to
nearly  the whole lung; in no case is it at all circumscribed.   In
some places, the sound parts of the lung, or, at least, those  scarcely
altered from the healthy state, pass insensibly into the gangrened
portions; in other places,  the sound and  mortified  portions are 
GANGRENE.
6.5
separated by a band inflamed in the first degree, and, more rarely,
by one arrived at the state of hepatization.
   The progress of  this disease, even when of small extent, is ex-
tremely rapid.  From the very first the patient falls into a state of
complete prostration of strength and oppression; the pulse is small,
weak, and very quick; cough rather frequent than strong;  expec-
toration loose, the sputa of a very remarkable green colour, and
extremely  fetid like that of a mortified  limb.   The expectoration,
very copious at first, soon ceases through debility, and the  patient
dies suffocated by the accumulation of the sputa.
  The partial or circumscribed gangrene of the lungs differs from
the preceding species in occupying only a small part of the  viscus,
and in having no apparent tendency to extend itsrlf to the surround-
ing parts.  On this account its progress is often very slow; so much
so, indeed, as sometimes to give it some resemblance to consump-
tion:  and, in truth, it has been ranged by M. Bayle as a species of
this disease.
   Partial or circumscribed gangrene of the lungs may have its seat
in any part of the  organ.   It ought to  be distinguished in three
different states: 1st, recent mortification,  or gangrenous  escharj
2nd,  deliquescent  sphacelus; and 3rd, grangrenous excavation,
formed by the complete softening down, and discharge, of the gan-
grened portion.
   The gangrenous  eschars  are very irregular in form, and very
variable in size.   Their colour is greenish black ; their texture
more humid, more compact, and harder than   that of the healthy
lung; they are, in short, completely similar to the  sloughs produced
by  caustic, and exhale strongly the peculiar fetor of mortification.
The part of the lung immediately  surrounding them  exhibits, to a
little  distance, the first or second degree of inflammation.   Some-
times the eschar, during its disorganization, becomes detached, like
the sloi'.ah from caustic,  and forms a sort of button or core, of  a
darkish, greenish, or yellowish tint, somewhat filamentous in its
texture, and  softer and drier than  the recent eschar.  It remains
isolated in the centre of the excavation formed by the mortified
portion.
   More commonly the eschar becomes  softened throughout, with-
out forming any distinct core, and  is converted into a sort of putrid
jelly, of a dirty greenish grey, sometimes sanious, and horribly fetid.
This  matier soon escapes  into some of the neighbouring bronchia,
and is thus gradually discharged, leaving behind it a true ulcerous
cavity.
  The interior of these cavities then becomes the seat of a secon*
                              9 
66
DISEASES OF  THE LUNGS
dary inflammation, which seems to retain for a long time somewhat
of the gangrenous character: the surface becomes covered by an
exiraneous membrane, of a greyish colour, opaque and soft, which
seen rts  either a dirty pus of the same colour,  or a black sanies,
h n «ng  be grangrenous fetor.
   Fr< quendy, however, this new or false membrane does not exist,
the >f id and various-coloured pus or sanies being secreted imme-
diaiely by the walls of the ulcerous cavity.   These walls are com-
monly firm, of a brownish or greyish red, exhibiting, when cut into,
a granulated surface.   This state of parts (which is evidently a
species of chronic peripneumony, not tending to suppuration,) does
not commonly extend more than half an inch, or an inch from the
ulcer; occasionally, however, it occupies the  whole extent of the
lobe in "which it is seated.   On  other occasions the boundaries of
the excavation are soft and fungous, and easily desroyed by scrap-
ing with the scalpel.   Blood-vessels of a considerable size, quite
isolated and denuded, yet still sound, sometimes cross these cavi-
ties; at other times these vessels are quite destroyed, and pour from
their open mouths a sufficient hemorrhage to fill the whole cavity
with clots of blood.
   These  gangrenous excavations constitute  the ulcerous phthisis
of M. Bayle.  Although he does not distinctly state  their origin,
he appears to have suspected it.  (See his cases 25—30.)
   Sometimes the  eschar makes its way into the cavity of the pleu-
ra, and  gives rise to a species of pleurisy usually  accompanied by
the extrication of air in that cavity.  This seems in some cases to
arise from the process of putridity alone, but, in  others, it is evi-
dently assisted by the access of the  external air through the bron-
chia.
   The  symptoms of the partial  gangrene  of  the lungs are ex-
tremely various, and differ  much in different stages of the disease.
In the commencement  it is marked  by the  symptoms  of a slight
degree  of peripneumony, but  attended with  a prostration of
strength and degree of anxiety quite disproportioned  to the small
extent and moderate intensity of the local affection.  Later in  the
disease there  are sputa of a green or greenish colour, and of a
gangrenous fetor, and followed by expectoration of a purulent fluid
of a grey or greenish yellow colour.  In both these stages the pa
tient often experiences very severe pain in the chest, and sometimes
very copious hemorrhages from the lungs. The countenance assumes
a sallow or rather leaden hue. When the disease reaches the chronic
stage, there is constantly present a degree of hectic fever, sometimes
high, but commonly less intense than in  most consumptive cases: 
GANGRENE.                       67
the skin is hot, sometimes extremely so; the sputa and breath retain
something of the gangrenous  odour, being excessively fetid,  and
perceptible  at a  great distance.   In  this  state  the  patient often
wastes  with great rapidity, and his case may then be easily mista-
ken for true phthisis.  More commonly, however, death takes place
before emaciation has made great  progress, this complaint seeming
tQ have a greater tendency to produce cachexy than marasmus
   I shall here subjoin the heads of four cases of this  disease,—the
1st, showing the eschar still entire; the 2nd, in the state of a half-
detached core; the 3rd, in the state of  deliquescence; and the 4th,
exhibiting the rupture of  the matter into the pleura and bronchia at
the same time.
   Case 11.   A man, aged 40, was seized, after a fit of intoxica-
tion, with pain in his joints, with  fever and very violent delirium,
which  symptoms proved  fatal on the  13th day, without any other
sign of disease of the chest, but a slight difficulty of breathing, a few
days before  death.   There were found effusion in the ventricles of
the brain, and  the following appearances   in the thorax: the right
lung was adherent to the pleura anteriorly and on the diaphragm;
the right side of the chest  contained about a pint and half of a sero-
purulent fluid; the lung of the  same side, reduced  to nearly half
its natural size and containing little air, was of a natural character
throughout,  except at its inferior and posterior margin, where there
was a dark greenish spot of the size of a large bean (feve de marais)
exhaling the gangrenous fetor; it was soft, and very like the eschar
produced  by  caustic.  It entered about  six lines deep  into the
substance of the lungs, to which it adhered.   The pulmonary tissue,
to the distance of an inch around, was of the consistence of liver,
and exhibited,  when cut,  a red and granulated surface.
   Case 12.   A man, aged  53, after  being  ill  six  weeks, came
into hospital, affected with dyspnoea, frequent cough, with expec-
toration of very thick,  opaque, yellow sputa, possessing (as did,
also, still  more so, his breath,) the fetor of gangrene.   His debi-
lity had gradually augmented  from the commencement of the dis-
ease ;  he was sallow  and flaccid, but without any considerable
emaciation.   He died shortly after without any material alteration
of symptoms.   The  following were the appearances on dissection:
the left side of the chest contained  much air,  and also two or three
pints of a black turbid serosity,  both  of  which were extremely
fetid.   The lung was reduced to one-fifth  of its natural size, and
contained  in its upper  lobe an irregular cavity, capable of  hold-
ing a duck's egg, and filled with the same matter as was contained
in the cavity of the pleura.  The  internal  surface of this excava 
68
DISEASES OF THE LUNGfc
tion exhibited no trace of the purulent membranous-like covering
usually seen in ulcerous cavities of the lungs, but showed the pul-
monary tissue quite bare, blackened, soft, and easily torn.   The
main excavation communicated with several smaller ones, and, in
the centre of each, there was a detached putrid mass of some con-
sistence, evidently the remains  of the gangrenous  eschar.   The
superior lobe adhered to  the  pleura, and its substance was some-
what denser than natural.  In every other part the pulmonary tis-
sue was  blackish, soft, inelastic, and without any trace either  of
inflammation  or tubercles.   There  were other diseased appear-
ances  in the  chest, but  none that  seemed  essentially connected
with the particular disease in question.
   Case 13.   A man, aged 55, came into hospital  affected with
what was supposed to be  a local affection of the nares.  He had
no pectoral symptom whatever, but a slight  dry cough, which ap-
peared to depend on the local disease: only towards the period of
his death, the respiration became difficult, and he complained of a
sharp  pain in the region of the larynx.  The only diseased ap-
pearances, found on  dissection, were the following: the inferior
part of the left lung was slightly inflamed throughout, and contain-
ed, in its interior, a portion of the pulmonary tissue  quite reduced
to a thin putrid mass with the gangrenous fetor.   This tliseased
mass was perfectly continuous with the surrounding  tissue  of the
lung, which was merely red and engorged.   The putrid mass was
about the size of a large walnut, and completely filled its contain-
ing boundaries, so as to leave no sort of excavation, until after it
was artificially discharged.
   Case 14.   A labourer, aged  42, subject for six years to occa-
sional pains in the chest, &c. began  to have cough and  very fetid
expectoration in 1818, when he came into hospital.   This patient
died after  remaining  in the hospital for several  months affected
with violent  pain of the  chest, cough, and frequent  purulent ex-
pectoration, often in great quantities.   The following appearances
were found on dissection.   The left side of the thorax was less
than the right.  When  cut  into, a great quantity of  extremely
fetid gas escaped.  The lung adhered in many places to the pleura,
and both these exhibited extensive recent depositions of coagulable
lymph.   The lung  was  much compressed.   The cavity left by
this compression was partly filled by a yellowish, semitransparent
fluid, having  at its bottom a copious deposition of a puriform fluid,
resembling that effused on the pleura, but softer.   In the inferior
border of the lung, there was found a small  dark jagged opening,
of the size of a goose-quill, which was evidently contained in the 
HAEMOPTYSIS.
69
centre of a gangrenous eschar.  This opening led to a cavity the
size  of  a  large  walnut, about six lines deep in the lung.  The
walls of this cavi y were very irregular, and lined by ;> dirty white
membrane, covered ivith a puruloid fluid.  Several bronchial tubes
opened into it, and the whole was imbued with the strong gangre-
nous fetor.  The tissue of the lungs  was flaccid, fleshy, and con-
tained little blood; Us density was much greater, almost fiepatic,
to the extent of  half an inch around the excavation.   The bron-
chial tubes in the vicinity  were much dilated.
   Besides  the idiopathic  gangrene just described,  there  is one
other circumscribed variety  of  this affection of the lungs, that,
namely, which takes place in the  boundaries of  a tuberculous ex-
cavation.   This is an extremely rare case;—at least ten times
more rare than that we have  been giving an account of.   In this
case the walls of the tuberculous cavity slough to the depth of one
or two lines: this slough, when softened down, is gradually expec-
torated; but the walls of the excavation continue for a long time
thereafter to secrete a  greyish sanious pus possessing the  gangre;
nous fetor.
                        CHAP. IV.

   OF  HAEMOPTYSIS, or PULMONARY APOPLEXY,

  The disease which I designate by the name of Pulmonary Apo-
plexy, though very frequent, is yet very little known in respect of
its anatomical characters.  It is, however, well known by its prin-
cipal symptom, viz  haemoptysis, or hemorrhage from the lungs.
  The anofents attributed haemoptysis to a rupture of some  of the
pulmonary vessels, and this is still the opinion of the vulgar,  and
also of many practitioners.  M'»dern  anatomis's, however, have
long been aware that  this pretended cause* of  haemoptysis is alto-
gether false.   Two varieties of this  disease  may, indeed, arise
from such a cause; and  these are, 1st, when  an aneurism  bursts
into the bronchia or trachea, and 2ndly, when there is a rupture
of a blood-vessel in a tuberculous excavation',—an event which I
have already shown to be extremely uncommon.   These two spe-
cies of haemoptysis are followed by immediate, or almost  imme- 
TO
.   DISEASES OF THE  LUNGS
 diate death, and can by no means explain the phenomena of a dis-
 ease so common, and  often  so slight, as  haemoptysis.   Accord-
 ingly, haemoptysis is now very generally considered as depending
 on some functional derangement of the bronchial membrane, which
 causes it to exhale blood in place of its ordinary mucous secretion.
 \nd  this  opinion is unquestionably correct as far as  regards the
 slighter varieties of the disease,  such, for instance, as occur in
 pulmonary catarrh,  peripneumony, and in the earlier  stages of
 phthisis.
   Those  cases, however, of  violent and  extreme hemorrhage,
 which often resist all medical treatment, arise from a  very differ-
 ent and more  dangerous cause.  In these,  some part  of the pul-
 monary substance  has undergone  great changes, being indurated
 to a degree equal to the completes! hepatization.  The induration,
 however,  is very different from the inflammatory  affection of the
 lungs distinguished  by this term.   It  is always partial, and  never
 occupies  a considerable portion  of the lungs; its  more ordinary
 extent being  from one to four cubic  inches.   It  is always very
 exactly circumscribed, the induration  being as considerable at the
 very point of termination as in  the centre.   The pulmonary tissue
 around is  quite sound and crepitous, and has no appearance what-
 ever of that progressive induration found in the peripneumonic af-
 fection.   The substance of the lung is, indeed, often very pale
 around  the haemoptysical induration; sometimes,  however,  it is
 rose-coloured, or even red, as if tinged with  fresh blood; but, even
 in this case, the circumscription of the indurated part is equally
 distinct.
   The indurated portion is of  a very dark  red, exactly  like that
 of a clot of venous blood.   When cut into, the  surface of the in-
 cisions is  granulated as in a hepatized lung; but in  their other
 characters, these two  kinds of pulmonic induration are  entirely
 different.   In  the second  degree  of hepatization,  along with the
 red colour of the inflamed pulmonary  tissue, we can perceive dis-
tinctly the dark pulmonary spots,  the blood-vessels, and the fine
 cellular intersections,  all of which together give  to this morbid
 state the aspect of certain kinds of granite, as  has been already
 observed.   The same  thing is observable  in the  third stage  of
 peripneumony, and even when  the infiltration of pus has convert-
 ed the lungs into a yellowish mass.  In the induration  of haemop-
 tysis,  on the contrary,  the diseased part appears quite  homogene-
 ous, being altogether black, or of a very deep brown, and disclos-
 ing nothing of the natural texture of the part, except the bronchial 
HEMOPTYSIS.
71
fcubes and  the  larger blood-vessels.  The latter have even  lost
their natural colour, and are stained with blood.
  In  scraping  the incised surfaces of these  parts, we  detach a
small portion of very dark, half-congealed blood, but in a much
less  proportion than we can press out the bloody serum from a
hepatized lung.  The granulations on the incised surfaces have
also  appeared to me larger than in cases of hepatization.   Some-
times the centre of these  indurated masses is soft  and filled by a
clot of pure blood.
  This morbid affection is evidently produced by  an effusion of
blood into the parenchyma of the lungs, in other words, into the
air-cells.   From its  exact resemblance to the effusion that takes
place in the brain in apoplexy,  I  have thought the name  pulmo-
nary apoplexy very applicable to  it.   The lungs and brain, how-
ever, are not the only organs in-which a similar effusion  may take
place.  I have seen  such  take place instantaneously in the subcu-
taneous cellular substance, and I have met with them, during dis-
section, in almost every part of the body,—between the intestinal
tunics, among the muscular fibres of the heart, and under the cel-
lular coverings of the  pancreas and kidneys   In  a case  of fatal
apoplexy  I have found large effusions of blood in the  cellular
membrane of every  limb, of the trunk,  and in that  surrounding
most of the abdominal viscera.   Some examples have occurred of
sudden death from haemoptysis, wherein the substance of the lungs
was  found lacerated,  and containing clots of blood.   Corvisart
mentions one  extraordinary case of this kind, in which the extra-
vasation  had lacerated the  lung  and  filled the cavity  of  the
pleura.*
   The haemoplysical engorgement above  described, is only a les-
ser degree of the same affection^  in which the effused blood (still,
in some degree, under the influence of vital action,) coagulates in
the  air-cells in such a manner as to form an intimate union with
the  pulmonary tissue, very different from what would be produced
by the mere physical  coagulation of the  blood.   We sometimes
find two or three similar  indurations  in  the  same lung, and fre-
quently  both  lungs  are affected  at the same time.  They  take
place most commonly in the central parts of the lower  lobe, m
towards the middle and posterior part of the lungs.
   The hemorrhagic  induration ef the  lungs is as easily distin-
guishable from the congestions that take place after death, as from
the alteralions produced by peripneumony.   The sanguineous con-
 gestions of the dead body consist of an accumulation  of blood in-
* Nouvelle Methode, &c, 
12
DISEASES OF THE LUNGS
 termixed with serum, often spumous, which flows plentifully on an
 incision  of the  part, and  tinges the lungs of a livid  or  vinous
 colour.   Being the mere consequence of gravitation, the engorge-
 ment is  found  most considerable  in the  most depending parts
 of the lungs,  and  gradually lessens towards  the superior parts.
 Where most engorged, the  part still retains some crepitation, and
 the incised surfaces are never granulated, even when the conges-
 tion is so great  as to destroy the spongy character of the lung.
 By washing, we can, in every case, remove all the blood, and le-
 store the  lung to that sort of flaccidity  which it possesses  when
 compressed by a pleuritic effusion.   The engorgement of haemop-
 tysis, on the contrary,  is accurately  circumscribed,  very  dense,
 dark red or brown, granulated, and almost dry when incised, and
 grows pale by washing, but without losing any part of its consis-
 tence.
   Whatever may be the severity of this disease, resolution seems
 to take place  with  considerable facility, since we find a  great
 many cases of cure after severe haemoptysis.   I have not had op-
 portunities of tracing the progress  of this resolution by morbid
 dissection; but I think  it  must often be quite complete, since I
 have never been able to trace  any vestige of the induration in
 subjects  who  had  been affected with  severe hemorrhage at a
 period of some years anterior to their death.
   The above  condition of  parts exists  in every severe case of
 haemoptysis; but, when the symptoms are moderate, and especially
 when  the  hemorrhage is  slight, the only morbid  alteration of
 structure  may  be  a reddening  and thickening of  the  bronchial
 membrane, which, in this case, seems to  secrete, as it were, or at
 least to permit, the transudation of  the  blood.   The  quantity of
 blood spit up  is not of  itself a sufficient  indication  of the nature
 of the organic lesion of the lung;  The  haemoptysical  induration
 or engorgement may lae very extensive,  while  the  expectoration
of blood  is inconsiderable,—for instance, only a wine-glassful in
the 24 hours;—while a much larger quantity  than  this  may  be
discharged by the mere  change in the bronchial membrane.
  The hemorrhagic  induration of the lungs may  he,  and often
is, accompanied  by the simple bronchial extravasation,  as we al-
most always find  the mucous membrane of the bronchia highly
reddened and swollen, in those-cases where  the pulmonary en-
gorgement  exists in  any  extent.   When this is very  great and
takes place  very suddenly,  the patient may  be suffocated before
any expectoration of blood  has taken place.
  The two following cases exhibit the disease in different degrees r 
ILEMOPTfSIS.
73
the first, with a moderate local lesion, and slow course; the se-
cond, more severe and more  rapid.
   Case 15.   A woman, between 50 and 60  years of age, came
into hospital labouring under haemoptysis,  accompanied by great
prostration of strength and emaciation, great  dyspnoea, the gene-
ral anasarca.  No account of her previous state could be obtained.
She died in the course of a few weeks thereafter, continuing to
spit up blood to  the  last.  On examination  after death there
were found marks of inflammation in the pleura, and considerable
disease of the heart.   The state of the lungs shall only be here
noticed.   The left lung contained here and there in  its  subtance,
portions of a reddish brown colour, firm, granular when incised,
exactly circumscribed, and surrounded by  parts  perfectly  crepi-
tous.   These indurated portions  were not at all like  those of
peripneumony, but  seemed to be the  consequence of a peculiar
combination of the blood  (strongly coagulated  and dried) with
the pulmonary tissue.   In the inferior  lobe there was  a similar
mass, more than a cubic inch in extent, formed by three concen-
tric  layers, separated from  each  other  by  thinner layers of a
tissue still retaining its original soft and crepitous character,  but
only  much redder than natural.   The larger  layers (obviously
the product of effused blood) were  of a dark red, granular when
incised, very firm, fragile, and so dry that  it  was with difficulty
that even a small portion of clotted blood could be expressed from
them.   One of these layers was so soft in one point as to resem-
ble a clot of blood.   The portions of lung thus indurated yielded,
when  cut  into,  no humidity,  unless  when  pressed or  scraped;
while the other parts of the lungs were, more  than  ordinarily
imbued with a yellowish frothy serum, which escaped from them
when incised.  There were a few  tubercles. .In the right lung
there  was one morbid spot like  those  in the  Jeft.   The mucous
membrane of the bronchia was of a deep red colour, in  different
points, in both lungs.
   Case 16-  A  man, aged 45  years, who had  been affected for
six months with a disease of the heart (hypertrophia)  similar to
that alluded to in the  last case, accompanied with much dyspnoea
occasionally, and also partial cedema, came into  hospital, for the
third time, in January 1819,  affected  with an aggravation of the
same symptoms, viz.—great  dyspnoea,  pain of praecordia, cough,
diarrhoea, &c.  A fortnight after, subsequently to  an aggravation
of the dyspnoea, he discharged, almost without effort or cough, a
large quantity of red frothy blood:  he died four days after.   The
right lung, to the extent of three fourths of  its yolume superiorly, 
74              DISEASES  OF THE LUNGS.

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

   OF PULMONARY CATARRH,  OR BRONCHITIS.



                      SECTION FIRST.

               Of the Acute Pulmonary Catarrh.

  Pulmonary  Catarrh is unquestionably one  of the mosi
frequent of diseases, insomuch  that most  persons  are  affected
with it, in some degree or other, almost every year.  Notwith-
standing this frequency, it is perhaps less  understood than many
rarer diseases.   In most cases it occurs in  so slight  a  degree  as
scarcely to derange, in any respect, the  functions of the body, or
to prevent the individual  from following his usual  occupations;
occasionally, however, it is of sufficient  violence to endanger life. 
PULMONARY CATARRH.
75
  Pulmonary catarrh is inflammation of the mucous membrane of
the bronchia.   A  greater or less redness, and a  certain degree of
thickening of the membrane, are the only anatomical characters
of this affection; and  even these sometimes disappear after dea'h.
In the case of an old man who died of this disease, I found these
appearances much less distinct than in the body  of a woman who
had died the same day of fever, during the course of  which she
had coughed very little.
   This inflammation is attended, from the commencement, with a
secretion of mucus more abundant  than natural, and possessing
characters which vary in the  different stages of the  disease.   At
first it is thin, transparent, and somewhat acrid  or  saltish to the
taste; it becomes gradually thicker, more viscid, and less transpa-
rent;  and, towards the close of the disease,  it grows quite opaque,
and  assumes a whitish, yellow, or slightly  green colour.  In this
state  it  obstructs, more or less completely, the bronchial tubes,
especially those of a small calibre; and the impeded transmission
of air, in consequence of this, produces the  sound usually denomi-
nated the rattles.
   The  inflammation  which  constitutes pulmonary  catarrh  very
rarely occupies the whole bronchial membrane, even of one lung.
When the contrary is the case, the disease is very severe, and ac-
companied by a violent  fever.  Commonly, in  the  severest ca-
tarrhs, even when there are much fever and expectoration, there is
only inflammation of some portions of the membrane, either in
both lungs or only in one.  In slighter catarrh, unattended by any
perceptible  fever,  the  whole  seat  of the disease does  not extend
beyond a small part of a single lung.
  The only difference between this disease and croup, is, that, in
the latter, the  mucus  secreted is coagulated  so as to  resemble the
false  membranes  produced by the inflammation  of serous mem-
branes.  This variety of the pulmonary catarrh  is strongly mark-
ed, as well by its symptoms as by  its pathological  character: yet
there  are many other intermediate shades,  in  which  the chief
symptoms are only change of the voice, extreme  dyspnoea, and the
secretion of a mucus very tenacious and difficult of expectoration.
It is especially  in the catarrhal affections of children that we can
trace  all the gradations of this disease, from the mere pulmonary
catarrh  with an expectoration  quite liquid, to the severest croup,
in which the false membrane is of the  firmest  consistence, and
lines the bronchia to their extreme  ramifications.
  There is nothing peculiar or characteristic  in the cough attend-
ing acute catarrh.  In the commencement of the  disease it is hard, 
76
DISEASES  OF THE LUNGS'.
painful, and accompanied by much  irritation;  and the sputa arc
watery, transparent, slightly frothy,  and nearly colourless, and
seem to be entirely composed of an iutermixture of saliva and the
mucus of the mouth and throat.   Sometimes, especially when the
cough  is neither severe  nor frequent, the expectoration is  very
little, and consists for the most part of the grey,  glutinous, semi-
transparent  matter, intermixed with  dark  or  grey opaque spots,
which usually goes by the name of bronchial mucus.
   In this stage,  the expectorated  matter  is  very different from the
viscid, adherent, and united sputa of peripneumony, but differs in
no respect from  that which attends pleurisy or the early stage of
phthisis.  In  a  later stage of catarrh, this thin  and  transparent
fluid becomes intermixed, in small quantity, with sputa of a whit-
ish,  yellowish,  or  greenish colour, and  opaque.   Still  later, the
thin fluid disappears entirely, being replaced by  a copious forma-
tion of this opaque mucous expectoration, which, notwithstanding
its consistence, is commonly intermixed with bubbles of air.   This
kind of  sputa is also very distinguishable  from that of peripneu-
mony, especially in the first and middle stages of that disease; but
very frequently  there is no difference between it and the expecto-
ration in the last stage of peripneumony, or in a pleurisy which
terminates by resolution, or indeed from that of  the greater num-
ber of phthisical patients.
                       section second.

              Of the Chronic Pulmonary Catarrh.

  The chronic, like the acute catarrh, has a great variety of symp-
toms; they may all, however, be reduced under two principal spe-
cies, viz.—the humid and  the dry; the former being  attended by
copious expectoration, the  latter with scarcely any expectoration.
The humid species may be further divided into two varieties, viz:
mucous catarrh, or with opaque and yellow sputa; and  pituitous ca-
tarrh, or with transparent, colourless, ropy sputa, exactly  like the
white of egg diluted with water.
  The mucous catarrh  is often the habitual infirmity  of the aged.
I have seen  it, also, exist for twenty years in persons of middle
age; but this is very rare in adults.  Most commonly the mucous 
PULMONARY CATARRH.                77
chronic catarrh  has succeeded a severe  attack of the acute, the
rever whicn attended the latter having gone off, or, at least, be-
come very slight  and irregular, without any diminution of the
cough  or  expectoration.   After this change to the chronic state,
the sputa  continue copious, and retain nearly  the same character
as ,n the latter stage of the acute disease.  Sometimes, however
they become more opaque, slightly greyish, and more puriform'
and  are in every respect like  those of phthisis.   In this state the
expectoration  is in general easy, and  the cough  neither frequent
nor fatiguing.                                            ^
   Sometimes this  disease, after lasting several months, or even a
year or two, gradually disappears without leaving behind any trace
of it; at other  times, it changes into the dry species, to be noticed
directly; and occasionally, though rarely, it proves fatal, after hav-
ing exhibited all the symptoms of consumption, so strongly marked
as to render the real character of the disease unknown until after
death.
   When chronic catarrh has become habitual, and is attended by
much dyspnoea, it  constitutes  one of the diseases usually confound-
ed under the general name of  asthma.  In a nosological system,
founded, like that  of Sauvages, on the  character of the symptoms,
this  affection might be named Asthma a nimia respiratione.   This
is one of the least troublesome kinds of asthma; it is rarely marked
by any paroxysms, and remains usually in (he same degree of in-
tensity, unless when aggravated by an increase of the catarrhal
symptoms, or an attack of some other  disease of the chest.   This
variety of chronig catarrh is chiefly met with in old  persons and
in delicate and  nervous  habits.  When, in the former, the'pro-
gress of years, or  any other cause has  greatly  weakened the indi-
vidual, the power  of expectoration is  lost, and  the  rattle on the
lungs,  and finally  in the trachea, becomes very great,  and consti-
tutes the suffocating catarrh of practical  medicine.
   The pituitous catarrh is  usually attended by a much stronger
harder, and sharper  cough,  than  the foregoing species.   The
cough  comes in paroxysms, and is often followed by nausea, which
seems to facilitate  the expectoration of the pituitous matter.  There
is often not very much dyspnoea.  This variety of catarrh is com -
monly  met with among the aged,—in incipient consumption, and
also, in cases where the cicatrization of tuberculous  excavations
has been followed  by the formation of  cretaceous productions or
a great accumulation of the black matter, in the lungs.
   The dry chronic catarrh is that  which we shall describe  more
particularly under  Emphysema of the lungs.  It generally succeeds 
78
DISEASES OF THE LUNGS.
 to an acute catarrh, after the cessation of the expectoration of the
 latter stage, and is sometimes attended by  much irritation;  at
 other times it is very little felt.  Occasionally this variety of cough
 makes its appearance without being preceded by the acute catarrh
 In this case it is commonly called nervous; and too often,  consi-
 dering it as sympathetic, we search for its cause in other, and some-
 times distant, organs—as, for instance, the stomach, the liver, the
 kidneys, and even the uterus.
   I do not wish here to  deny the existence of sympathetic coughs,
 much less the reciprocal influence of affections of the lungs and
 liver, when these exist simultaneously; but I am certainly of  opi-
 nion that our imperfect knowledge of the anatomical  characters
 of the diseases of those  organs, has given a degree of importance
 to many  supposed sympathies which these little merited.
   The dry catarrh ceases sometimes spontaneously, but it readily
 becomes habitual, and the more so the less violent it had originally
 been; indeed it  is chiefly from the  infrequency and decreased vio-
 lence of  the cough, joined to the slight degree  of oppression, that
 we are led to suspect its continuance.  This slight oppression be-
 comes gradually  more considerable, and often augments in propor-
 tion to the decreasing frequency of the cough.  This is often so
 slight as to  be insensible to  the patient, and, indeed, may not at all
 recur for several days.   The expectoration consists of small por-
 tions of  greyish semitransparent  mucus, or, occasionally, a  few
very adhesive specks of  the yellow opaque sputa.
  After a time, symptoms of emphysema of the lungs  supervene
 to the preceeding.  Sometimes the cough ceases entirely during
the summer, and, in this case, the oppression on the chest becomes
less,—no doubt because the augmentation of the cutaneous  dis-
charge lessens the mucous  secretions of the  bronchia.   When' a
person  habitually subject  to the   dry  catarrh, has an  attack of
 acute catarrh, the oppression on the chest is generally at first aug-
mented;  but this lessens on the supervention of expectoration, and
indeed  becomes much less than before the attack of the recent dis-
ease.   This effect appears to me to  be accounted for by the
increased liquidity, and consequent easier  expectoration, of the
bronchial mucus during the prevalence of the  acute catarrh.
  Before terminating this chapter, it may be useful to make a few
observations on one symptom which many nosologists have  erect-
ed into a distinct disease—I mean Asthma.   This  word, which
properly signifies difficulty of breathing, has been as much misused,
 and has been made the cognomen  of as many different diseases
 as any word in  medicine.   It has been proved by Corvisart that 
DILATATION OF THE BRONCHIA.
79
a great part of the diseases usually so denominated, are, in fact,
diseases of the heart and large vessels; and every person accus-
tomed to morbid dissection is now aware that  the cases  denomi-
nated humid or humoral asthma, are  simply examples of chronic
catarrh.   The extended use of the stethoscope will, I doubt not,
further enable us to trace  many cases of this  disease now  consi-
dered as nervous, to particular organic lesions now little known.
Of this  number is emphysema of the lungs, as I shall show here-
after; an affection which I am more and more led to consider  as
constituting one of the most common species of asthma.
   I do not mean, however, to deny that there may be asthmas, or,
to speak more exactly, dyspnoeas, purely nervous, or unattended
by any organic lesion of the parts concerned in respiration.  In-
deed, we meet with cases  in practice, where there is neither ob-
struction to the air from organic disease, nor accumulated  sputa,
and where, nevertheless, the breathing is habitually difficult and
oppressed.
   Under the  same head of purely nervous,  may perhaps be ranged
the spasmodic asthma, when this is well characterised by an even-
ing paroxysm, and a morning remission, after  a slight expectora-
tion.  I must confess, however, that I have even doubts on this
case.   Characterised by the regularity of paroxysm mentioned,  it
is an  extremely rare disease;  and  when  irregular in  its recur-
rence, it differs in nothing from a  case  of errrphysema  of the
lungs.
                       CHAP.  VI

        OF  DILATATION OF  THE BRONCHIA.

  The organic lesion which I am now to notice,  seems to have
been hitherto entirely overlooked, both by the anatomist  and  the
practitioner.   This oversight is  easily accounted for by the  cir-
cumstance that,  as it generally occurs in  a small portion of a
bronchial tube, when observed, it has been mistaken for a larger
branch.   It can  only be defeated by tracing the individual bron-
chial tubes to their ultimate ramifications,—a thing which is rarely-
done in our examination of the  lungs.
  This species of dilatation is generally met with only in subjects
that  have died,  after being affected  by chronic catarrh.  It i= 
so
DISEASES OF THE LUNGS.
sometimes so considerable, that the bronchial ramifications, which
in their natural condition'would scarcely admit the point of  a very
fine probe, acquire the diameter of a goose-quill,  or  even of  the
finger.  These dilated portions terminate in culs-de-sac capable of
containing a hemp-seed, a cherry-stone, a filbert, or even an almond.
The mucous membrane  of these  is  commonly of  a red  or violet
colour,  and  is  evidently  thickened.   The cartilaginous  circles
seem to be converted into a fibrous  tissue, and are so closely united
with the mucous coat as not to be separable by dissection.
   This affection may exist in any part of  the lungs,  but is most
common in the superior lobe.  Ordinarily it exists in only a small
number of the ramifications of the  bronchia; sometimes, however,
it extends to all the branches of one of the lobes.   In this case,
the dilatation is always greater (not  relatively merely, but abso-
lutely) in  the smaller than in the larger ramifications, and  greater
in these latter than  in the trunks whence  they originate.  The
common trunks are rarely dilated,  in any perceptible degree, even
in the  cases where some of their  branches emulate them in dia-
meter. When the dilatation of the bronchia is so great as this,  the
intermediate substance of the lung  is flabby, void of air, evidently
compressed, and, in short, resembling, in every respect, the same
substance when compressed  towards  the spine, by  an effusion of
serous or purulent fluid into the cavity of the pleura.
   This affection of the bronchia is always  produced  by chronic
catarrh, or  by some other disease attended by long, violent, and
often repeated fits of coughing.   The hooping-cough, for this rea-
son, is the most frequent cause of all.
   When the dilatation is  confined to one  or  two  of the bronchia,
it produces no other inconvenience  but an habitual cough, not very
frequent nor severe, and a moderate degree of mucous expectora-
tion; but when a great number of the  bronchia are dilated, through
their whole  ramifications,  the  result is  a chronic catarrh which
lasts for life, and which, indeed, may sometimes shorten its dura-
tion, through means of the exhaustion produced by  the dyspnoea,
the severe and long continued fits of coughing, and, more espe-
cially, by  the abundance of the expectorated sputa, which are of a
greyish  yellow colour and altogether puriform.   Sometimes, how-
ever,  patients affected with all these  symptoms, and the degree of
infirmity the necessary consequence of these, live to an advanced
age.
   I shall conclude  this short account  of this rare organic-lesion,
by a brief detail of two cases  of it furnished me by M. Cayol.
   Case 17.  A child, three and half years old, had been affected 
DILATATION OF THE BRONCHIA.
81
with cough for three months, after an  attack of hooping-cough.
The cough came on in paroxysms after intervals of several hours,
and was followed by an abundant expectoration of a yellow puri-
form matter, excessively fetid, like  that from a carious bone.  It
was  sometimes intermixed with mucus.  It was evacuated not in
the usual manner of sputa, but rather in moulhfuls, which conti-
nued to flow for some time, from the child's mouth, after the fits of
coughing,  which  were violent and painful, and  attended by red-
ness of  the face.  In the intervals of the cough there was no pain,
and  ihe child  slept  well, and it  looked  fresh  and plump.   The
child gradually got worse, and died after a fortnight,  having pre-
viously  become feverish,  anasarcous, and affected with diarrhoea.
On examining the  lungs  after death, the only material  organic
alteration  found in them was in the inferior lobe  of the left  side,
the bronchial  ramifications  of which were found dilated in the
manner already detailed, and containing more or less of the same
purulent fluid  expectorated during the life of the child.   Upon
laying open these bronchial  tubes through their whole length, it
was found  that each of them, at the distance of about half an inch
after entering the substance of the lung, began to be dilated, and
progressively augmented in diameter until  it finally terminated in
a large  cul-de-sac, at the distance of  a  line or two from  the  sur-
face of the lung.   Towards their termination most of these tubes
would have admitted the little finger,  and  others would only have
received an ordinary sized quill.   During their course they gave
off several branches which ended in similar culs-de-sac, after run-
ning two inches or more.  The mucous membrane of  these dilated
tubes was,  throughout, of  a deep red or livid colour, thinner than
natural, but without any  breach of continuity, and was evidently
the secreting source of the purulent matter contained in it.
   Case 18. A woman, 62 years  of age, had  been affected, ever
since she was sixteen, with a disease of the chest, which exhibited
most of the usual symptoms  of consumption.   The  principal of
these  were—haemoptysis, very frequent,   and renewed   by the
slightest causes;  constant cough, with  expectoration of opaque,
yellow sputa,  having sometimes the character  of pus,  sometimes
of a puriform mucus; and respiration more  or less impeded. These
symptoms  varied much;  they bad  very marked  remissions,  but
scarcely ever any positive intermission:  they never prevented her
from following her  occupation of teaching the piano-forte.   Her
chest was  well formed, and she  had nothing of the  consumptive
configuration.   Without any material  aggravation of the  pectoral 
S2
DISEASES OF THE LUNGS
affection, this  woman  became  universally anasarcous, and  died
shortly after entering thehpspital.
   On examining the body after death, we could discover, in press-
ing the  body of the lungs,  which  were soft  and flabby, various
hardened portions of different sizes, especially  in the superior lobe-
Upon cutting into the lungs, these proved to be the hardened coats
of various of the  bronchial  tubes dilated in  the  manner  of the
former case.   Indeed  they agreed  in almost every respect  with
these-   The largest of  them would have contained the end of the
thumb;  some were empty, and others contained a  yellow purulent
matter like  that  expectorated by the patient.  They ramified in
the manner detailed  in the preceding case.    The  natural  tunics
of the dilated portions seemed all  converted into a single  one,
much harder and  more polished than the natural coats of the bron-
chia, and intimately connected with the tissue of the lungs.  There
was not  the slightest mark of ulceration in any part of the  inner
coat, so  that the pus  contained in these cavities  must have been
evidently secreted or exhaled by it.   The greater portion  of the
bronchial tubes in the superior lobe was in this condition, some of
them being dilated to a size seven or eight times greater than na-
tural. All the cavities taken together might probably occupy three
fourth parts of the lobe.  Some  of  them were divided merely by
very thin bands of the  pulmonary tissue, compressed into the  ap-
pearance of  a  membrane.   In some of the other lobes there were
a few bronchia similarly dilated, but in a lesser degree.   The
mucous  membrane of the trachea and larynx was sound.
                       CHAP.  VII.

          OF EMPHYSEMA  OF THE LUNGS

  The disease which I designate by this title is very little known,
and has not hitherto been correctly described by any author.   1 for
a long time  thought it very uncommon, because I had observed
only a few cases of it; but since I have made use of the stetho-
scope, I have verified its existence as  well  on the living as  the
dead subject, and am led to consider it as by no means infrequent.
I consider many cases of  asthma, usually deemed nervous, as  de- 
EMPHYSEMA.
83
pending on this cause.   The chief reason of this affection having
been so completely overlooked \s,  that it is in  some sort merely
the exaggeration of the natural tradition of the viscus.
   In order that we may have a clear idea of the disease  in ques-
tion, it may be useful to advert to the natural  organization of the
pulmonary tissue.  In examining,  in a good light,  the surface of
the healthy lung, we can  perceive, even  with the naked eye,
through the transparent pleura, which forms its covering, that the
parenchyma  of the  viscus  consists of an  aggregation  of small
vesicles, irregularly spheriod or ovoid, filled with air, and separat-
ed from each other by opaque white partitions.  .The^e- vesicles,
—which,  as seen on the surface of the lung, have the appearance
of small transparent points,-^-are not all of one  size.  The largest
are one third or one fourth part the size of a millet-seed.  These
are grouped  in  masses or lobules,  which  are  circumscribed  by
partitions  of condensed cellular substance, very thin, but 3 et thicker
and  more  opaque than  the  panitions which  separate  the  indi-
vidual  air-cells.   These larger partitions traverse the lungs in all
directions, and, consequently, in cutting each other at every pos-
sible angle, form, on the surface, figures of  very various  shapes—
lozenges, squares, triaugles, &c    It is along these  partitions  that
the black  pulmonary matter of which we have already spoken, is
most plentifully deposited.
   In emphysema of the lungs, the size of the vesicles is  much in-
creased, and  is less uniform.  The greater  number equal, or ex-
ceed the size of millet-seed, while some  attain the magnitude of
hemp-seed, cherry-stones, or even French beans (haricot). These
latter are  probably produced by  the  reunion of several of the air-
cells through  rupture  of the  intermediate partitions; sometimes,
however,  they appear to arise from the  simple enlargement of a
single vesicle.  The largest of these dilated cells are often in no
respect prominent on  the  surface of the lung; sometimes they form
a slight projection.   In the latter case the structure of  the lung
acquires a striking  resemblance to the  vesicular  lungs of the
Linnsean order of Reptilia.   Sometimes, though more rarely, we
observe on the surface of the lung single vesicles, distended to the
size of a cherry-stone or larger, quite prominent, exactly  globular,
and  apparently  pediculated.  I  say apparently pediculaied, be-
cause  on  cutting into them we find that there  is no  real  pedicle,
but merely a constriction at the point  where  the  cell begins to
rise beyond the surface of the lung.   The cavity of  these dilated
cells descends some  little way into the substance of the viscus,
and there  its walls do not collapse, when cut, as in the projecting 
84
DISEASES  OF THE LUNGS.
portion.  At the bottom of this inferior portion of the cavity, wti
find small openings by which the  Jilated cell communicates With
the adjoining ones, and with (be1 bronchia.   That these projecting
vesicles are produced by the dilatation of an air-cell,  and are not
owing to the extravasation of  air under the pleura,  is proved, as
well by the prolongation,  just mentioned, of their cavity into the
pulmonary substance, as by the circumstance that we cannot force
the contained air, by pressure with the finger, to leave  its place
and to pass under the contiguous pleura,—as would be  the case
if it were extravasated.
   As long  as the parts continue in the state above  described, the
disease consists merely in an excessive, permanent, and unnatural
distention of the air-cells, the air being still contained in its pro-
per cavities; but when  the distention,becomes still  more  consi-
derable, or takes place with greater rapidity, the  air-cells are rup-
tured in certain points, and the surrounding  cellular substance of
the lung becomes  distended by  extravasated  air,  exactly  in the
same manner as in emphysema of the subcutaneous adipose mem-
brane.   In this case  we find  on  the surface of the lung vesicles
of an irregular form, which can be made to change their  place by
pressure with the finger.   They vary in size from that of a hemp*
seed  to that of a walnut,  or even an egg.   Like  the simply dilat-
ed cells, these vesicles contain nothing but air, which makes its
escape on  their being punctured  with a pin.   Sometimes the air,
though truly extravasated  under the pleura, cannot be displaced by
pressure in the manner just mentioned.  This happens when the
extravasation is situated  at the point of reunion  of the  partitions
which divide the different groups of air-cells,  as above  mention-
ed.   In this case the projection has usually a triangular shape, and
is not very considerable.
   I have never found this extravasated air penetrate, to  any con-
siderable extent, into the  substance of these interlobular partitions,
nor into the  cellular substance which surrounds  the  larger blood-
vessels and bronchial trunks; but I have seen  the pulmonary sub-
stance in the interior of  the lung lacerated  by over-distention  of
the air-cells.  These lacerated portions contain air, and sometimes
also a small  quantity of blood, either coagulated or loose; and the
surrounding  air-cells, which form  the immediate walls of the ex-
cavation produced by the  rupture, are observed to be loose, flabby,
and without their natural globular  figure.
    The  bronchjal  tubes,  especially those of a small calibre, are
sometimes  very evidently dilated  in  those  portions  of  the lung
where the emphysema exists.  This is easily  proved by compar- 
                        EMPHYSEMA.                     86

ing the diseased and sound portions of the lungs.  It is a thing to
be expected; and  it is, indeed, singular that it is not  more com-
mon,  since the cause which dilates the air-cells must  act equally
on the bronchia: it is, notwithstanding, very rare.
   Emphysema may affect both  lungs at the  same time, one only,
or a part of one or of both.   In  the latter case,—and indeed in
any case, as long as there do not exist vesicles of considerable size
on the superficies of the lungs,—it is easy to overlook the disease
in the dead subject, and, as I have already said,  I am convinced
that this  has often been done, not only by myself but  by the best
practical anatomists.  For my own part I am  convinced, that if
we carefully examine the lungs of subjects who have long suffered
from  dyspnoea, from whatever cause, we shall almost  always find
more or  fewer of the air-cells dilated.    In lungs studded with tu-
bercles, which  presented no other symptom of emphysema. I have
sometimes  found two or three of the cells dilated  to the size of a
hemp-seed.
   When the disease exists in a high degree, and occupies the whole
of one or both lungs, one cannot help being struck with the ap-
pearance of the parts.   The lungs seem as if confined  in their na-
tural cavity, and, when exposed, instead of collapsing as usual, they
rise in some degree and project beyond the borders of the thorax.
If we examine them in this state they feel firmer than natural, and
it is more  than usually difficult to  flatten them.   The crepitation
they afford  on  pressure, or on being cut into, is less, and of a kind
somewhat different; it is mere like  the sound produced  by the slow
escape of air from a pair of bellows; and the air makes its escape
from the- cells  much quicker than in a  healthy state of the organ.
When we detach the  Jung, the crepitation is found to  be still less
perceptible, and the sensation conveyed by  pressing the parts is
very like that  produced by handling a pillow of down.  On plac-
ing an emphysematous lung into a vessel of water it  sinks  much
less  than a healthy lung; sometimes it floats on the surface with
scarcely  any obvious immersion.   The pulmonary tissue is drier
in a lung affected with emphysema, than in  a healthy  one; and it
is unusual to find,  even towards the root of the lungs, any trace of
the common serous or sanguineous engorgements usually found
after  death.   The contrary,  however, is sometimes the  case.
When a  single lung is affected, it becomes much more  voluminous
than  that of the other side, so much so, indeed, as sometimes to
press on one side the heart and mediastinum, and to cause an evi-
dent enlargement of the bony compages of that side of the chest.
   From  these observations it results, that Emphysema of the lungs 
6b
DISEASES OF THE LUNGS.
consists essentially in the dilatation of the air-cells, and (hat the.
extravasation of the air on the surface  of the lungs, constituting
the larger and more prominent vesicles, is a posterior affection,
and not necessarily connected with the disease in question.   The
latter species of lesion  is, moreover, one  of slight consequence
compared with the dilatation of the cells, as we can hope for its
removal  by absorption, as in other similar cases;  whilst  we can
hardly conceive in what manner either nature or art can  remedy
the other morbid derangement.
   The disease, the morbid anatomy of which has just been  de-
scribed, appears to me, as I have already observed, to have been
hitherto unknown   No general description of it certainly exisis;
although facts, that evidently can be only referred  to it, are  to be
found in several authors.  Bonetus and Morgagni give several ex-
amples of the lungs being found  very  voluminous and distended
with air.  Van Swieten and Stork have some cases wherein ve-
sicles of air were found under the  pleura; and Floyer noticed the
same thing in a broken-winded mare.  The author of the article
Emphyseme, in  the  Diet, des Sciences  Med.  relates a case  pre-
cisely similar to  these last mentioned, which  had been communi-
cated  to him by  M. Majendie;  but none of these various  authors
appears to have been acquainted with the real character of the af-
fection, viz.—dilatation of the bronchial cells.  All of them  seem
to have thought, with  the last mentioned  writer,  who expresses
his opinion  in a positive manner, that the derangement in ques-
tion consisted  in  the infiltration of the cellular  substance of the
lung with air.  Ruysch  and Valsalva are the  only authors, as far
as I know, who have observed, in  individual cases, the dilatation
of the cells.   The case  noticed by the latter is an example of par-
tial emphysema of the lungs complicated with empyema.   It has
been noticed by Morgagni, under  its latter character, who  does
not appear to have understood the  nature of the former change of
structure.   This, however, he has  described in a manner to  leave
no doubt of its true nature.   " Sinistri  pulmonis  lobus  superior
...... qua claviculam spectabat, vesiculas  ex quibus constat mirum
in moduni auctas  habebat;  ut nonnullae avellange raagnitudinem
aequarent; caeterae  multo minores erant.   Quaedam  globuli figura,
reliquae oblonga et ovali: omnes plenae erant  aeris.... una insuper
minima quaedam foraminula per interibrem faciem hiantia osten-
dit."*
   The case noticed by  Ruysch is  also one of partial emphysema

       * De Sed. et Caus. Morb., lib. ii. epist, 22, nos. 12 et 13. 
EMPHYSEMA.
8^
of the lungs:   " In aliqua autem pulmonis parte inveni vesicula-
rum pellucidarum acervum, ab aere expansarum et ita obstructa-
rum ut  levi  compressione eas ab aere  evacuare  haud  potuerim.
Impulsum  per asperam arteriam flatum nullum commercium cum
hisce expansis vesiculis amplius habere propter tarum obstructio-
nem expertus sum.   Post, aere per asperam arteriam  vehementer
adacto disrumpebantur nonnullas ex his vesiculis."*   This author
has, perhaps, a second case of the same kind (obs. 20), but  it is
too imperfectly described to justify any  deductions from it.
   Dr. Baillie, author of the Morbid Anatomy, has correctly ob-
served the three principal  circumstances  which  constitute  em-
physema of the lungs, namely—the great size of these organs,-—
the dilatation of the cells,—and the vesicles  formed by the extra-
vasation of air under the pleura;  but he does not appear to have
been acquainted with the mutual dependance  of these three states,
and describes  them  as three different affections, as is  evident
from the following passages,  which contain  all that he  says on
this subject.
   " Lungs distended  with air   In opening  into the chest, it  is
not unusual to find that the  lungs do not collapse,  but  that they
fill up the  cavity completely  on  each  side of the heart.   When
examined, their cells appear full of air, so  that a prodigious num-
ber of small white vesicles are seen upon the surface  of the lungs
immediately under the pleura.   The branches of the trachea are
often at the same time  a good, deal filled with the mucous fluid.
This fluid had probably  prevented the ready egress of  the  air,
so that  it had  gradually distended the air-cells of  the lungs,  and
had prevented the lungs from  collapsing."
   " Air Cells  of ihe  Lungs enlarged.  The lungs  are sometimes,
although I believe very rarely, formed into pretty  large  cells,  so
as to resemble somewhat  the  lungs  of an  amphibious  animal.
Of this I  have now  seen  three  instances.   The  enlargement  of
the cells cannot well be supposed to arise from  any other cause.
than the air  being not allowed the common  free egress from the
lungs,  and therefore accumulating in them.   It is not improba-
ble also, that this accumulation may sometimes  break down  two
or three contiguous cells into  one, and  thereby  form a  cell of a
very large size."
   " Air   Vesicles attached  to the  edge of the  lungs.  Vesicles
containing air have occasionally been seen attached to the edge
of the  lungs.   They do  not communicate, however, with the
* Buish, Obs. anat. centur., obs. xix\ 
ss
DISEASES OF THE LUNGS.
 structure of this organ,  but are complete  in themselves.   Upon
 the first view, it might be thought probable that they were  merely
 some of the air-cells  enlarged; but as they do not communicate
 with any of the air-cells, this opinion  is not well founded.   It is
 most likely that they are a morbid structure, formed in the same
 manner as the air vesicles attached to the intestines and mesentery
 of  some quadrupeds, and that the very minute blood-vessels which
 ramify upon the vesicles, have the power of secreting the air."*
   These observations I wish to confine  to  the  emphysema from
 internal causes, without  at all including the disease  mentioned
 by  surgical writers under this  name, produced by the introduction
 of  foreign bodies into the trachea, and  which  disease they de-
 scribe as consisting in an extravasation of air into the cellular sub-
 stance interposed between the air-cells.   It is  indeed  true  that
 such an accident, as well as violent exertions of the lungs, as  in
 childbirth, &c. can  and  do sometimes  produce  emphysema of the
 neck, chest, &c; but such an affection can only arise from rup-
 ture of the bronchial tubes  or air-cells: and I  am disposed  to
 believe that in no such  case is there any actual penetration, by
 the extravasated air, of the interlobular cellular substance  of the
 lungs themselves.
  The following cases afford examples of most of the facts noticed
 in this chapter.
  Case  19.   A woman, aged 50,  came  into  hospital  affected
 with great dyspnoea and cough, which  were said  to have  existed
 three weeks.  She  died  the same  night.  The right  auricle of
 the  heart was found much enlarged and distended  with  blood:
 and a great part of the right  lung,  and almost  all  the  inferior
 lobe of the left, were affected with emphysema, such as describ-
 ed in the preceding pages.                               y
  Case 20.  A woman had been subject to frequent and  severe
 catarrhal affections from  infancy, one  of which, in  her  twenty-
 eighth year, was  followed  by  nocturnal paroxysms of dyspnoea,
 which, together with cough, continued and became more frequent,
so as to  attack her in  the day-time.  When admitted into  the
hospital, in her forty-first year,  she laboured under an aggravation
 of the same symptoms, to which had  been recently superadded
frequent   palpitations  and  very  general   anasarca.   She died
shortly after her entrance.   The  whole of the  right  lung was
 emphysematous, and exhibited  on its surface vesicles full of  air,
 of the size of a small pigeon's egg   The left lung was partially
* Morbid Anat. Chap. Ill, 
EMPHYSEMA.
89
affected in  the same  manner.   There was hypertrophia  of the
heart.
  Case 21.   A man had been affected from infancy with  an ha-
bitual cough,  mucous  expectoration  and dyspnoea, which were
always so much augmented in winier as to confine him, for several
days, to bed.  In his thirty-seventh year, on the supervention  of
anasarca of the abdomen and lower extremities,  he came into
hospital.  At  this  time there was much dyspnoea, willi livid lips,
cough, very  severe and sonorous, accompanied  by copious  expec-
toration of colourless, ropy  and  frothy  sputa.  Percussion of the
chest produced a distinct sound, but the murmur of respiration
(see Part II.)  was  almost extinct over the whole  chest.   These
symptoms continued with much  variation of intensity, and  after
leaving the hospital twice, he returned  and  died in it the samg
year.
  The whole  of both lungs  were found  emphysematous,  as de-
scribed in the present chapter, and there were vesicles of extra-
vasated air  under  the  pleura.   There was no other disease  of
these organs, nor of any other, except the heart, which was en-
larged to twice its natural size.
  Case 22.   A man, of  delicate health in  childhood,  and affect-
ed with spinal curvature, in  his twenty-eighth year  became  sub-
ject to  slight  cough and habitual dyspnoea.   Two years  after-
wards  he caught  a severe  cold, with  much  aggravation of his
former symptoms,  and came  into hospital  in  January.   At this
time  there  was much dyspnoea  and severe fits of cough,  with'
mucous  expectoration; inability to lie in the horizontal posture,
and lividity of cheeks, lips and nails.    On percussion the chest
was sonorous, but  the respiratory murmur was not  perceptible  in
ihe greater part of it.  This man died in two days.   The whole
of the left lung was affeccd with emphysema, but was in other re-
spects  quite healthy.  The bronchial tubes  appeared to  be dilat-
ed; they were very red internally and filled  with a white ropy mu-
cus.  The upper and middle lobes of the right lung were in the
same emphysematous condition; but  in the  inferior lobe a  portion
of the tissue was  in the state characteristic of inflammation,  as
described in  the  chapter on peripneumony.  One portion was
hepatized.
  Case 23.    A woman,  aged 52, had  been affected for the last
eighteen years with dyspnoea, habitual cough, attended with little
expectoration, but often so severe as  to prevent sleep.   She had
never been prevented from following her occupation until the pe-
riod of her entry into hospital.   At this time there was consider- 
90
DISEASES OF THE LUNGS
able emaciation, complete incapacity to lie in the horizontal  pos
ture, respiration short and difficult, very frequent and severe cough,
of a convulsive character like that of the hooping-cough, and mu-
cous expectoration, the pulse quick, and skin of the natural tem-
perature.   The chest sounded well on percussion, but  respiration
was inaudible in  the greater  part of it: pectoriloquism was very
distinct above the right  clavicle.   This woman  died  three  days
after her admission.
  Both lungs were  found adhering strongly to  the  ribs  by  old
attachments.   The whole of the  left lung was  emphysematous,
the  air-cells in many places being very  prominent on the  surface
and large.  In several  places  on  the  surface of the lungs  there
were four or five marks of  an irregular  oval form, and of  the size
of an almond.  These marks  corresponded to excavations situat-
ed two  or three lines deep  in  the  lung, which  were  produced by
laceration of its substance.   These cavities,—of which the largest
might have contained a  middling-sized walnut, and the smallest a
filbert,—were full of air, and collapsed on being cut into.   The
infernal surface of two of these was  tinged with blood, and one
of them  contained  a small  clot of blood, one-fourth of  its own
size.   The walls of the others were of the natural colour of  the
lung, and  presented a layer of ruptured and compressed  cells to
the  depth  of a line and half.   Beyond this depih, on all sides, the
cells were distended beyond the natural size.   It is to be remark-
ed that the ruptured  portions did not  exist in any place at a greater
depth under the surface than an inch, and that, below this  the em-
physematous dilatation of the cells was not very distinguishable. It
was equally evident  that the cells  in the vicinity of these  lacera-
tions were neither larger nor more numerous  than elsewhere, and
that there  was no infiltration or extravasation of air into the inter-
alveolar tissue.   The right  lung exhibited, but in a lesser degree,
the  same dilatation of the cells, but no rupture of substance.  In
the  upper  and posterior part of this lung, however, there was found
an excavation of an  oval shape, about two inehes in length, fifteen
lines broad in its centre, and two lines deep.  The inner  surface
of this cavity was smooth and polished, though somewhat irregular;
it was white, but interspersed  with red  specks  arising from nu-
merous small vessels.  It contained some small  fragments of an
opaque, very  dry, semi-friable matter, of a pale  ochre yellow
colour, and attached to the walls of the cyst.  Three bronchial tubes,
of the size of a goose-quill, terminated with open mouths in this
cavity.  Their coats were continuous with its walls, and their com-
munication with their trunks was quite free. In detaching the lungs 
EMPHYSEMA.                       9i
 from the pleura costal is, this cyst was ruptured, so that one portion
 remained adheren; to the side.  It was of very unequal thickness, the
 part just mentioned being about two lines, while that imbedded in the
 lung was from three to seven  or eight  lines thick.   Its substance
 was of a while brilliant hue, slightly semitransparent, and  of a
 texture entirely similar to that of the intervertebral cartilages, only,
 perhaps, with a superior degree of density.  It was entirely empty.
 At the loWer and middle part  of  this cyst, where its  walls were
 thickened, it  gave  off, in  different directions, four or five bands
 (of an irregular thickness, and an inch in  length), of'the same
 cartilaginous structure.  The pulmonary substance interposed be-
 tween these bands  (to which, as  well  as to the  cyst, it was inti-
 mately adherent,)  was  flaccid,  compressed, and   of a greyish
 colour, but, in other respects, quite sound    In  different parts  of
 the same lung there were a few  small rounded  cysts, of  the size
 of hemp-seed or cherry-stones, containing a dry cretaceous fauy
 matter, which seemed intemediate between chalk and the maUer
 of tubercles.   These cysts were of an  equable thickness, of a line
 or a line and half, greyish, semitransparent, and of a semi-canila-
 ginous texture.   The heart was slightly diseased^ the other viscera
 were sound.
   The four cases, of which I have now given a brief outline, ex-
 hibit emphysema of the lungs in  its different degrees.  The last
 ease gives, further,  an example of a cure of what is usually call-
 ed an ulcer of the lungs, (see Chap i.)   It even exhibits both the
 modes in which this cure can be effected, viz: by cicatrization
 and fistula; as  we must regard the great thickness  of some  part
of the cyst, and the cartilaginous  bands connected  with it, as the
 consequence of that superabundance of the  cartilaginous forma-
 tion which we have seen occasionally  take place in such cases.
   It may be questioned what was the nature of the  matter origi-
 nally contained in this cavity, and of which I have noticed a few
 dried fragments as still remaining. Most probably it was a mix'ure
 of chalky and  tuberculous  matter.  Whatever it may have been,
 I am disposed to consider it as being dead matter.  In explanation
 of this term I may observe, that I agree with M  Bayle, in believ-
 ing  that such extraneous productions  as tubercles,  cancers,  &c.
 do certainly possess vitality, but   with a duration and  laws  dif-
ferent from those of the natural tissues of the animal economy.
   In their origin  these productions are of a firm consistence; they
are nourished  by blood-vesseJs, or, at least, by  lymphatics.  The
rapidity of their growth, as, likewise, the extent of it, is quite in-
definite.   When  this is accomplished, the tumour may-remain sta- 
92
DISEASES OF THE LUNGS.
tionary for a greater or less time, retaining its original organization;
or it may at once pass into a second state, that, viz.  of softening,
which must terminate in its destruction.  This process, also, is a
vital process, entirely independent of chemical action; and, on this
account, it  reacts on the living system, producing on  it an impres-
sion more or less deleterious;—for example, fever, emaciation, and
general  disorder of functions*   But should any part of this sub-
stance, in any stage of its solution or softening, be detached from
the rest, it  then ceases to  advance in  its  progressive decay, be-
coming an  inert, or dead substance, and capable of acting on the
System merely as a foreign body.   Case 5, p. 45, affords  a  stilf
more striking example of what I mean.
                    CHAPTER VIII.


   OF  (EDEMA, OR ANASARCA, OF THE LUNGS.


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

  * Tide Diet, des Scienc. Med. Art. Anat. Pathol.
  fHippoc. de Intern. Affect.—Carol.  Piso, de Morb. a serosa Colluvie.—
 De Haen, Ratio Med. torn. ii. De Hydrope Pectoris.
  t Comment, de Bonon, sc. inst. torn. i.
  § Observat. Anatom.—Perpignan, 1753. 
                           CEDEMA.                        y^

it comes on, most commonly, with other dropsical affections, in
cachectic subjects, towards the  fatal termination of long  conti-
nued  fevers, or organic affections,  especially those' of the  heart.
Peripneumony  that has terminated by resolution, appears  also to
leave a great predisposition to it; and the most extensive and se-
vere cases that I have met withv occurred during  a temporary
convalescence from severe attacks of this  disease.   Chronic ca-
tarrh, likewise, predisposes to it; and in such cases it often  proves
fatal by suffocation.
  Although this disease commonly is merely consequent on other
affections, and often takes place merely a few hours  before death,
nevertheless, in some cases, it has certainly lasted several weeks,
and even months; and, in  a few of these, it even seems to have
been  idiopathic.  The suffocative orthopncea,  which sometimes
carries off children after attacks of measles, is probably idiopa-
thic  anasarca  of the  lungs.  I have not hitherto been able to
verify  this conjecture  by dissection; but, when  we  consider  the
dropsical tendency of such cases, and the frequent complication of
measles  with peripneumony, it would seem to be well founded.
  The following are the anatomical characters of this disease
When it occupies the whole lungs,  and has been of some duration,
the pulmonary tissue has entirely lost the slight rose  tint which is  '
natural to  it, and is now  of a pale  grey colour; it is denser and
heavier than in its sound state, and does not collapse on opening
the chest.   It is, however, still  nearly as crepitous as before.  It
retains the impression of the finger more tenaciously  than a sound
lung.   Its vessels seem  to  contain  less blood  than  usual,  and,
when cut into, there flows from  it an abundance of serum,  which
is either colourless  or very slightly tawny, transparent, and just
perceptibly spumous.
  The characters last  mentioned would suffice  to distinguish this
disease from the first degree of peripneumony, (in which the serum
effused  into the inflamed lung is strongly tinged  with blood, and
very frothy,) even  if  the characteristic redness  of  inflammation
did not establish a very marked distinction  between  the two dis
eases.   However, it is by no  means uncommon  to find,  in ana
sarcous lungs, some spots  inflamed (as in peripneumony) in  the
first, and even second degree,—the inflammatory affection gradu-
ally shading into  the merely oedematous condition of the surround*
ing parts.   Facts of this kind point to the  great affinity  (which
will  be  noticed more  particularly  hereafter) between  inflamma-
tion and  the dropsical  diathesis.
  Whatever may be the intensity  of the oedema,  it  produces no 
94
DISEASES OF THE LUNGS.
 change  in the integrity of the alveolar  structure of the orgaii
 This fact is not, however, quite obvious until we cut into the dis-
 eased lung, owing to  the fluid contained in  the  cellular  tissue.
 When oedema of  the lungs has been of long standing  and univer-
 sal, we do not commonly perceive  the sanguineous congestion  of
 the posterior  parts of the lungs, as in ordinary cases.   The ana-
 sarcous affection,  which takes place merely a short  time  before
 death, is partial, and commonly occupies the posterior parts of the
 lungs, like the congestion  just mentioned, with which it is often
 combined.
   We  must  not  confound with  the  true pulmonary anasarca a
 species of infiltration which often takes place  in phthisis,  in the
 intervals of the tuberculous masses.  This latter, which is always
 partial, and of small extent, is formed of a half liquid,  gelatinous
 looking matter, which is semitransparent, greyish, or slightly san-
 guinolent.   Its  presence  completely hides the air-cells, and the
 parts so affected have quite lost their crepitous character.   When
 pressed they give out a very small quantity of serum, which is not
 at all frothy.   I have already given it as my opinion (p.  57) that
 this matter is  the same as that composing tubercles  in their first or
 semitransparent stage, only it has here a less degree  of consistence.
 This opinion rests  principally on the circumstance of there being
 frequently  found, in the thicker parts of this species of infiltration,
 a  great many small points, which are yellow and opaque, and
 obviously consisting of true tuberculous matter.
   The first of the following cases exhibits cedema of the  lungs in
 its  simple state; the second, with the complication above mention-
 ed; and the third is  an example of it supervening to a severe pe-
 ripneumony before its complete resolution.
   Case 2-1. A woman, aged 47, subject to irregular menstruation
 for a twelvemonth, was suddenly seized with a severe  pain in the
 left side, attended  by dyspnoea  and cough.   She came into hos-
 pital a fortnight thereafter,  affected with cedema of the  superior
 extremities, particularly the left,—dyspncea  and  cough (not very
 frequent),  with expectoration of white viscid sputa,  intermixed
 with much saliva.  These  symptoms got better during  the first
month; but during the second the anasarca greatly increased, and
extended over the whole body,  except the face.   She had  some-
times pain  in  the  chest,  and  sometimes in  the  abdomen.   The
pulsation of the heart was irregular, and the pulse very indistinct;
—the patient took  little sleep, coughed a little, and expectorated
blackish  sputa.  During all this time  the respiration was pretty
 distinctly audible throughout the chest, but accompanied by that 
4EDEMA.
95
particular noise  which  I  call the crepitous rattle. (See Part II.)
This person died three months after her entry into the hospital.
  On examining the  body,  the  cavities  of the pleura contained
somewhat less than a pint of a limpid  serum;  (he  lungs  adhered
nearly through their  whole  extent by  long cellular attachments,
and their substance was throughout  little crepitous, and  injected
by a frothy and nearly colourless serum, which gave the lungs a
sort of transparency,  and flowed  copiously from them when cut
into.   In other respects the pulmonary  tissue was sound, of a pale
rose-colour, free from tubercles, and exhibiting no trace of peripneu-
mony, nor even of sanguineous congestion.   There  was  found
water in  the cavities  of the pericardium and  peritoneum.   The
head was not examined.
  Case 25. A woman  who had been  affected (according to her
own account) with asthma and habitual cough, attended by  a
slight expectoration, ever since she was nine years old, came into
hospital in  her forty-fifth  year, on account of  an  aggravation of
her dyspnoea and a local pain of the  leg.  At this time the respi-
ration was  short, difficult, and interrupted by fits of coughing, fol-
lowed by yellow mucous expectoration; the skin was rather cold,
the  action  of the  heart regular, and the pulse a little  frequent.
The chest sounded rather indistinctly in some places, and the res-
piration was very imperfectly heard throughout its whole extent,
and was occasionally attended with a peculiar rattle.   During the
succeeding month the oedema of the lower extremities, which was
very slight on her entrance, increased; and  she had  comatose
symptoms,  which  seemed to threaten apoplexy.  This continued
more  or less; the anasarca became  general, and, together with a
severe attack of diarrhoea, exhausted the patient, who died about
six  weeks after her entry.
  There was a good deal of water in the head.  The  right lung
exactly filled the cavity of the chest and  remained uncollapsed;  it
adhered throughout to the pleura by well organized cellular laminae,
which were in some  places infiltrated  with a  yellowish  serosity.
On  the anterior surface of the lung  several of the  air-cells were
dilated to the size of a hemp-seed.  The lung seemed pretty firm;
on compression it was found to retain the impression of the finger,
and, when  cut into, allowed  a large quantity of a clear and ven
frothy serum to escape.   In  the  upper  part of the lung there were
some points of small extent,  here and there, which were somewhat
red, compact and not alveolar, and which exhibited the granulated
surface when incised.   The  remaindei  of the viscus had tire natu
sal aspect,  and was still sufficiently crepitous,but heavy; it did no* 
96
DISEASES OF THE UiNGS.
yield, like the sound organ, to pressure, being injected throughout
with a large quantity of an almost colourless serum, which could
be squeezed from it like water from a sponge.   The left lung ad-
hered, in like manner,  to the pleura, and, with the exception of the
peripneumonic appearances, exhibited  the same morbid condition
as the right.  There was,  furlher, on the superior part, a patch of
fibro-cartilaginous  membrane, two or three lines thick, which, in
this place, formed the medium of adhesion between the lungs and
pleura of the ribs, to both of which it was intimately united.  In
the interior of this lobe there was a  vast tuberculous excavation,
capable of containing a middle-sized apple  (reinette), and  which
contained merely a small  quantity of a very liquid mucosity.  It
was lined throughout with a  polished diaphanous membrane, of a
consistence between  that of the mucous membranes and cartilage.
This cavity  was traversed, in different directions, by very white,
small, rounded columns, which proved, on close examination, to be
obliterated blood-vessels, and which, although continuous with the
lining membrane of the excavation, were sufficiently distinguished
from it by their  shining whiteness and their opacity.  The trunks
of these obliterated vessels terminated in culs-de-sac,  either a few
lines within or without the excavation.   In the obliterated portions
the original cavity  of the vessel  was still  distinguishable  by  a
longitudinal band of greater transparency.   Five or six bronchial
tubes opened into this cavity, in the manner described in the chap-
ter on Phthisis.  (See plate I. fig. 1.)   The pulmonary tissue in the
inferior part of this excavation was crepitous, though injected with
serum; in every other part of the boundaries of the cavity, it form-
ed a layer, two or three lines in thickness, which was flaccid, and
of a very deep black colour,  owing to the accumulation of black
pulmonary   matter.   There  were no tubercles in  either  lung.
There was  some water in  the pericardium and peritoneum.
   The above  case is remarkable from the circumstance of the
tuberculous cavity being traversed by blood-vessels, a thing which
I have already stated (page 34)  to be of a very rare  occurrence.
This case further offers a  new proof of the possibility of  cure of
tuberculous excavations.   From the patient's history it would seem
that this  vast pulmonary fistula had  existed  ever since her  ninth
year.
   Case 26.  A woman, aged 40, had been always from her child-
hood of delicate health, and habitually snhject to great difficulty of
breathing and palpitation of the heart.  This state was aggravated,
in her twenty-seventh year, by the supervention of general dropsy,
ef which, however, she was cured by diuretics; from this time her 
IEDEMA.
97
irealth continued still  to decline.   In the beginning of January,
after having sat up with  a sick person for several nights, her res-
piration became extremely difficult, especially on motion, she lost
her sleep  and appetite, and  she had  a slight cough  with  mucous
expectoration.  In this state  she came into  hospital, with oedema
of the lower limbs, livid  lips, extreme  oppression, frequent palpi-
tation, and starlings during sleep.  The anasarca increased during
the whole of this  and  two  following months; she complained of a
severe impediment in the region of the diaphragm, and of  a  pain
between the scapulae.   She died in the beginning of  June.
   The  brain  was found natural, but with a  small  quantity  of
serum in the ventricles.  There was about half a pint of serum  in
each side  of  the chest, and some  cellular  adhesions on the right.
The upper part of the right  lung was sound, only injected with a,
colourless serum.   The middle and inferior lobes were more com-
pact, and discharged, when cut into, a great quantity of transparent
colourless  serum,  intermixed with a  thicker, yellowish, puriform
fluid.  These lobes were, nevertheless, crepftous, with the excep-
tion of a few spots, of small extent, here and  there, which had  a
density  equal to  that  of liver, a  yellow and  somewhat  reddish
colour, and a granulated surface on incision.   The left lung was
in the same state, only without  the more solid portions.  Both
lungs had the yellowish-grey colour, like that of this  viscus when
infiltrated with pus after an  attack of peripneumony, only paler.
Indeed, it appeared evident that, in this case, a peripneumony of
the inferior portion of both lungs  had ended in  suppuration,  and
that the greater part of the  pus had been absorbed, the final resto-
ration of the part failing through the debility of the  system.   The
pericardium contained two ounces of serum.  The heart was large,
its substance soft and easily torn,  and its cavities very voluminous.
   It may  be proper, in this place, to take some notice of that  con-
dition of the lungs so often mentioned  in this work, and which, if
not well understood, may frequently be  mistaken as  a cause and
sign of disease; I allude to the engorgement—(serous, sanguinolent,
or sanguineous,)—met with towards the root and posterior parts of
the lungs  in almost every subject.  Bichat first distinctly called
the attention of anatomists to this appearance.
   This congestion  is very variable as to its  appearance and degree.
Exteriorly, in the engorged parts, the lung possesses a violet colour,
more or less deep; interiorly, it is more dense and less crepitous
than in  other parts, and is gorged with a greater or  less quantity
of blood.   Sometimes this blood appears in a state of semi-coagu-
lation, and is with  difficulty completely expressed from the part;  it
                              13 
93               DISEASES OF THE LUNGS.
is, however, by no means so intimately combined with the pulmo-
nary tissue,  as  in the haemoptysical congestion formerly described.
  The state of this congestion just described, is such  as we meet
with  in  plethoric subjects,  whose large  vessels  and  capillary
system contain much blood,  especially  in  such as  have died of
acute fevers or scorbutic affections.   In cases of exhaustion,  on
the contrary, particularly in those who have died of marasmus con-
sequent on cancerous affections, the congestion shows itself merely
by  reddish  colour of the parts, without any  diminution of their
crepitous  character, and without  any discharge of  fluid on their
being cut into.
  In dropsical subjects, on the other hand, these parts, in place of
blood, contain a very frothy serum, more  or less sanguinolent, and
sometimes hardly  yellowish.  In this  case, the congestion some-
times greatly resembles the  first  degree of  peripneumony,. or
cedema of the lungs; and the only means whereby we can distin-
guish them is afforded by the fact—that  the latter affections exist
indifferently in any part of the lung, without regard to  the laws of
gravitation,  while the engorgement of the dead body, in obedience
to these laws, is always most  considerable in the most dependent
parts.
  Bichat  considered the  pulmonic engorgement of the  dead body,
like the marks and bluish stains met with on the back and poste-
rior parts  of the limbs of almost  all subjects,—as caused  by the
custom of placing dead persons on their backs.  This is doubtless
the  case; yet I am of opinion  that the  same posture  before death,
especially in cases of great  prostration of strength, may give rise
to the accumulation even while life still remains—at  least some
hours before death.  The few attempts I have made to ascertain
the  correctness of  this opinion, by  means of the stethoscope,  be-
fore death, tend to confirm it; if correct in reality,  it would  ac-
count for the rattle and the oppression  of breathing  observable in
most dying  persons,  even in those whose respiratory  organs had
remained  quite unaffected through the whole course of their dis-
ease.
/ 
ACCIDENTAL PRODUCTIONS.              99
                       CHAP.  VIII.

OF EXTRANEOUS, OR ACCIDENTAL  PRODUCTIONS
                    OF THE LUNGS.
                       SECTION FIRST.

       Of accidental productions  of ihe Lungs in general.

  Various species of cancer, of cysts  containing fluids of dif-
ferent kinds, hydatids,  cartilaginous, bony or cretaceous tumours,
are occasionally  developed in the lungs.   At present I shall only
take notice of such as I have had occasion to study thoroughly, or
which  have been  particularly noticed by others.  These produc-
tions are: 1st,  cysts, properly so called; 2nd, cysts containing hy-
datids; 3rd, fibrous, cartilaginous,  bony, or osteo-cretaceous tu-
mours; 4th, tubercles; 5th,  the  species of cancer  which I have
named Encephaloid or brain-like tumour; and 6th, and last,  the
species of cancer which I have denominated Melanosis.
  The effect of these various productions on the surrounding tissue
of the  lungs, is much less than might be expected.   In cases of
tubercles, for instance,  (and the same thing applies to  all kinds of
accidental productions found in  this organ)  the substance of  the
lungs,  in the intervals of these,  continues equally crepitous as in
the sound viscus, and exhibits no trace of the compression which
such tumours  might be supposed to produce.  This is the  more
remarkable, as, in many cases, the united volume of the tubercles
is more than equal to the fourth part of the lung itself, while their
weight is one  or two pounds: and the circumstance  is the more
striking when we consider, that a few ounces of effused serum al-
ways produces upon some portion of the lung a degree of compres-
sion sufficient to render it impermeable to the inspired air, and to
produce in it a particular flaccidity, which will be noticed more
fully when we come to treat of pleurisy.   Sometimes, indeed, we
find in  the vicinity of one species of tumours (tubercles) the pul-
monary tissue impermeable  to air, but this obstruction is the pro- 
100
DISEASES OP THE LUNGS.
duct either of  the tubercular  impregnation (noticed in Chap. I.
Sect. 1.), or of the serous infiltration  which sometimes takes the
place of this, or finally, of true inflammation of the part: in no case,
does 'he change of structure resemble the flaccidity produced by
compression.   This flaccidity, however, is frequently observed in
the vicinity of pulmonary cicatrices, particularly of those which
are hard,  cartilaginous,  and of an  irregular form.   I have found
tumours of the size of the fist, around which the substance of the
lung was quite crepitous, and without  any mark of compression.
                       SECTION SECOND.

                    Of Cysts in the Lungs.

  Br the term Cyst I understand, with the greater number of mo-
dern anatomists, a species of shut sac, commonly rounded, some-
times, however, irregular and anfractuous, and containing a liquid,
or, at least, soft matter secreted by the membrane which forms
the sac.
  There is, indeed, another Species of cyst,—namely, that which
contains substances of a more splid kind, and which are in their
nature different from the ordinary products of the animal economy,
and to which productions  the cysts, now alluded to, merely serve
as an envelope:  examples of this species are  furnished by tuber-
cles, and the different kinds of cancer.   In the present section it
is my intention to speak only of the former species of cysts.  These
are always formed of a natural tissue, that is to say—of a tissue
similar to some of those which exist naturally in the healthysub-
ject.  Most commonly they resemble, in every respect, the serous
membranes, for instance the pleura and peritoneum—as has been
observed by Bichat; sometimes, however, they are more allied  to
the mucous membranes, as those  of the bladder and intestines.
Very generally a layer of a fibrous substance, or of condensed  cel-
lular tissue, more or less thick and usually incomplete, surrounds
these cysts and unites them to the neighbouring parts.
   Sometimes we find cysts entirely formed of these two last men-
tioned (issues, except that, in  this case, there is commonly super-
added cartilaginous substance, and  also bony plates of greater  o; 
CYSTS.
101
less extent.   Tlie internal surface of these compound cysts has
never the smooth polished aspect of the serous or mucous varieties,
but is, on the contrary,  unequal, rugged, and frequently  studded
here and there by a half concrete, albuminous or fibrous matter,
which is intimately united with  the cyst itself, and passes insensi-
bly into its peculiar structure.
   Of all morbid growths, encysted tumours are most rare in the
human  lungs.   Morgagni gives only one example of the sort.  It
is, however, by no means uncommon to  find them in the lungs of
certain animals, particularly of the ox and sheep.  These are com-
monly of the  serous kind, consist of a very fine membrane,  and
contain a thin and very clear fluid.  In the human subject I  have
only met with three or four examples of cysts, and they were  all
of the kind  described in the former  part of  this section.   The
largest I have met with was capable of containing  an apple, and
was seated  in the inferior  lobe  of  the right side.  This cyst was
very irregular in  its shape, and varied in thickness from two to
four lines.    It was covered  internally with an  albuminous or fi-
brinous substance of a yellowish white colour, very  similar in ap-
pearance to the  middle coat  of an artery.  This substance had an.
irregular surface, and seemed in some points as if falling into de-
cay (detritus).   Externally  the cyst was-completely fibrous, and
resembled tendon in appearance.  In some spots it had the cha-
 racter of cartilage, and, moreover, contained several plates or spi-
 culae of bone.  These were  of different lengths, and some  were
 placed parallel with the  sides of the sac, and some perpendicular to
 it, so  as to project on  one side into  the cyst, and, on  the other,
 into the surrounding pulmonary tissue.   In  their latter direction
 they.were, however, separated from  the true  tissue of the  lung,
 by a thick layer of a fibrous character, which adhered very firmly
 both to  the ossified point and to the substance of the lung, so as to
 be not at all separable  from the  latter, although the  line of  de-
 marcation between the two was very distinctly marked.   The en-
 velope or sheath which  surrounded these spiculse, both in the pul-
 monary tissue and  in the coats of the cyst, forsook  them on their
 passing into the cavity of the latter, so that they projected into it
 quite bare.   This cyst  contained a yellowish puriform fluid. 
102
DISEASES OF THE LUNOV
SECTION THIRD.
                   Of Hydatids in the Lungs.


   The only species of Hydatids which I have found in the lungs
 belongs to the genus to which I have given the name of Acephalo-
 cystes.*   These  animalcules, for a  long  time  confounded  with
 cysts, or encysted tumours properly so called, coiisist of a simple
 vesicle of an ovoid or spheriod shape,  and of very variable size,
 soft,  and of a  consistence and  appearance analogous to that of
 white of egg half boiled.  Their coats are diaphanous or semi-
 transparent, colourless, or of a milky colour, varying sometimes
 towards reddish, yellowish, greenish, or greyish.  The fluid con-
 tained  in these vesicles is usually serous  and limpid, sometimes
 turbid, and tinged with a yellowish or sanguine hue.   Sometimes
.a large vesicle includes several smaller  ones; at other times, still
 smaller ones are  found adherent to the internal or external surface
 of their parent,  from which they only. appear to~be separated
 when they have attained a certain size.
   Hydatids present no distinguishable organ, and offer the simplest
 example of an animal  that can  be imagined.  This extreme sim-
 plicity of conformation has induced some writers to call in question
 their  animalcular character.  In this  place I shall merely observe
 that M. Percy has seen this species of hydatids move in  a  very
 distinct  manner, and  I have  myself observed  all  the stages of
 their  reproduction.  This takes place, as in certain polypi, by a
 process somewhat like budding. Small buds form in the thickness
 of the coats of the animalcule, which project either exteriorly or
 interiorly, grow hollow, assume the rounded form as they enlarge,
 and finally detatch  themselves from their parent.
   Hydatids are always inclosed in a cyst which completely sepa-
 rates  them from the surrounding parts. These cysts  are commonly
 of a fibrous nature, but frequently there are found in  them portions
 of a cartilaginous or  bony character.   Their internal surface is
 rarely smooth;  frequently it is so  unequal as to have the appear-
 ance  of being torn.  Sometimes it i3 lined by an opaque albumi-
 nous matter, semi-concrete, and partially reduced to delrituSj and

           * Bulletin de Faculty de Medecine, No. 10—180* 
HYDATIDS.                      103
Qf a yellow ochrey or tawny colour.  When there are several hy-
datids in one cyst, this further contains a fluid in which they float,
which is sometimes limpid,  sometimes turbid, yellowish  or  san«-
guinolent.   When the cyst contains only one hydatid, this some-
times fills it completely, and lines, as it were, its internal parietes.
   This  species  of hydatids may originate in almost every organ
in the body.  They have been often met with in the lungs;  at
least, all  the cases  of hydatids recorded as being found in this
viscus, appear to me to belong to this species.  The most  remark-
able are those published by Johnson,* Collet,f Malloet,| Baumes,§
and  Geoffroy.||   I shall here give an abridgment of the  case  of
M. Geoffroy.
   Case 27.  A young man had an attack of peripneumony when
18 years  of age,  which was perfectly cuted,  and he remained
well two years; he then caught a violent cold, which was attended
by acute pain in the left side preventing him  lying on  it.  He
never got q«ite well  of this  last symptom.  He was afterwards
attacked with jaundice ,which lasted three  months,  and  he also
passed some portions of taenia.   The cough and pain of side re-
turned after this, very violently, and, upon their cessation, he dis-
covered a small moveable tumour situated in the right hypo-
chondre.  This tumour increased and  extended towards  the um-
bilicus, being  attended by colic  and  headach.   Ihe  pulsation
of the heart was very strong in the epigastric region.  The princi-
pal symptoms at  the end of three  years were constant dyspnoea,
which increased to a feeling of suffocation  on  going up stairs;—
frequent faintings;—occasional cough  and spitting of blood, and
constant tremblings.   After a year  and half, these symptoms in-
creased, and the fits of suffocation became  more violent.   In one
of these he suddenly expired.
   On examination after death, a large hydatid was found partly
contained in the  liver, and  partly projecting into the abdomen.
Its coats were thin, yet fibrous.   It contained a fluid of a  brown
colour,  and a great number of smaller hydatids, most of them of
the size of peas, one or two as large as the yolk of an egg.  The
lower end of the sac  adhered to the small curvature of the stomach.
In the chest there was found on each side an enormous hydatid
containing five pints  of fluid.  They adhered to the ribs and the
mediastinum, and by their increase had compressed the lungs into

        * Philos. Trans. Abridg.
        | Comment, de reb. in. scient. nat. vol. xiv.
        t Mem. de l'Acad. des Scienc. an. 1782.
        § Annales de Montpel. torn. i.
        II Bulletin de l'Ecol.de Med. an. 1805*. 
104
DISEASES OF THE LUNGS.
 a thin leaf on the  anterior part of the cavity.   The heart was
 completely thrust out of the thorax into  the epigastrium.   Each
 hydatid was eleven inches long, and contained five  pints  and a
 half of a  perfectly limpid fluid.  It is  difficult to learn, from the
 description of these hydatids, whether they originated in the sub-
 stance of the lungs, or  merely beneath the pleura pulmonalis or
 costalis.   I think it, however, most probable, that they originated
 in the substance of the  lungs.  M. Cayol  has since presented a
 case very similar  to  the above, which has not yet been  made
 public.
   In the Journal deMe.decine for 1801, there is the case of a man
 who expectorated for several months, rounded pellicles which were
 evidently the remains of dydatids, and  some seemed to be  these
 merely flattened.   I have since seen  two similar cases,  both of
 which, as well as that recorded in the Journ. de Med. were cured.
 On this account the actual  seat of these bodies could not be de-
 termined, but there  can be little doubt of its having been  the
 lungs.
  A young woman consulted me being affected with severe  dysp-
 noea, cough,  abundant expectoration and emaciation:  in short, all
 the ordinary symptoms  of phthisis pulmonalis.   One day, after
 acute  pain of the epigastrium,  she evacuated by stool  a consider-
 able quantiij^of hydatids, of a  size from that of a  filbert to a
 pigeon's egg.  From this very  day the hectic fever, the catarrhal
 symptoms,  and dyspnoea ceased, and shortly after the  patient re-
 gained her  flesh and strength.   May we believe  in this case, that
 a cyst situated in the left lung made a passage into the stomach or
colon through the diaphragm?
                       SECTION FOURTH.


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

  These various productions are frequently met with in the
lungs,  and  they  have,  indeed, been  noticed by  almost every
pathological anatomist since the sixteenth century.
  Besides the cartilaginous productions already described  in  a 
OSSEOUS CONCRETIONS, ETC.             105
 former chapter, we sometimes find in the lungs cartilaginous cysts
 inclosing bony or chalky concretions, of the kind immediately  to
 be described; and  also  cartilages of no  regular shape or size,
 containing here  and there points of incipient ossification.   The
 bone which  is formed in these  cartilaginous  bodies,  or,  without
 their previous piesence, in the substance of the lung, is never of
 a perfect kind; or, at least, I have never met  with any accidental
 production of this kind  in  the lungs which had either the fibrous
 texture or solidity of the middle of the long bones, or the spongy
 character of the ends of the same   bones   It appears,  that,  in
 their formation,  a greater quantity of calcareous  phosphate, and
 a much less proportion of gelatine is employed, than in true  bone:
 hence these  bodies  resemble more a piece of stone than bone,—
 a character  which  accounts for the epithets  calculous and  to-
 phaceous given to them by authors.   In  some  cases  they do not
 contain  a particle  of  gelatine; and, in this case, the calcareous
 phosphate resembles moistened chalk.
   I shall notice  these different varieties  under the name of im-
 perfect ossifications and chalky concretions.
   The  imperfect ossifications are encysted, or  not encysted.  The
 former are very rare in the lungs.  They are of a rounded  form,
 of  a size from that of a  hemp-seed  to that of a  hazel-nut, and
 are inclosed in a cartilaginous cyst, of a line or line and  half  in
 thickness, which adheres closely the  them.
   The  non-encysted ossifications are of a  very irregular shape.
 Their surface is rugged  and rough.  Interiorly  they are white,
 opaque, very similar to calculous productions, and  readily reduced'
 to powder by  being bruised.   On the other hand, their  external
 parts are somewhat yellowish, slightly diaphanous, more difficult-
 ly pulverizable, and, in  short, in a more perfect state of ossifica-
 tion.
   These ossifications are  found sometimes  included in,  and  inti-
 mately adherent  to the pulmonary tissue; at other times they are
 observed in  the  centre  of a  cartilaginous  production;  and fre-
 quently in  the body of a tubercle, especially  those of the bron-
 chial glands.    In the latter  case, when the tubercle softens, the
 bony  concretion  may be found loose in the cavity,  or  may be
expectorated, if it is not of too great  a size to pass through the
bronchia.
  The  chalky  concretions are  found  in  two states,—one re-
sembling chalk slightly moistened, the other like chalk complete-
ly softened in  water.   In the last state they are always encysted;
in the first, they  may,  or may not be, although  they are  most
                               14
> 
106
DISEASES OF THE LUNGS.
commonly so.   When crushed between the finger and thumb, they
are sometimes reduced to an  impalpable  powder,  but  frequently
they give the feeling as if grains of sand were  intermixed with
the soft chalk.   These grains are small ossified points.
   The cysts enclosing these cretaceous productions are commonly
cartilaginous.   They are rounded, or without any  regular  figure.
I  have seen one in the form of a pyramid  with four unequal
sides.   The rounded cysts are sometimes bony, but of  an  imper-
fect ossification, and resembling in all respects,  the  semitranspa-
rent external crust of  the osseo-calcareous  concretions  described
above.  I have sometimes found concretions of this sort composed
of several  bony or cartilaginous cysts, one included within  the
other, and  each separated by a  layer of soft  cretaceous  matter,
It is much more common to find  this half fluid chalky  matter  in
the centre of a tubercle, particularly in tubercles of the bronchial
glands.  In this case, although the matter  is equally soft  as  the
substance of the tubercle  itself, still it is  easily distinguished
from it, by its greater opacity, and  by its whiteness, which forms
a considerable contrast with the  pale yellow colour of the  tuber-
culous matter.   When allowed to dry, this cretaceous matter be-
comes white, and acquires a degree of cohesion which prevents
it being pulverised by the mere pressure  of the finger.
   The bony or cretaceous concretions of the lungs are commonly
very small;  I  have never  seen them larger  than  an almond.
Neither have I ever seen the complete conversion of a portion  of
lung into a substance of this sort, but sometimes I have observed
the pulmonary  tissue around  an  imperfect  cicatrization as if in-
jected, or  impregnated with  a small  quantity of  disseminated
chalky matter.
   Very singular opinions as  to the  cause and origin of these cal-
careous productions are to be found in the writings  of most patho-
logists.  Cullen, with many  others,  regards them  as  a frequent
cause of asthma, and thinks that they may be occasioned  by  the
powdery substances diffused  through the  air breathed by different
kinds of artisans—such, for instance, as starch-makers, lapidaries,
lime-burners, &c   The chemical  nature  of the  concretions,  so
much better known than formerly, renders  this  opinion quite un-
tenable at the present day.   I do not mean to deny that the ha-
bitual respiration of a powdery atmosphere may cause  a tempora-
ry dyspnoeaf and even  be  the  source of a formal disease of the
lungs;  but as a proof that too much stress  has  been laid on this
circumstance as a cause of pulmonary disease,  we have only  to
 examine the  expectoration of a person who has  passed  the  night 
OSSEOUS CONCRETIONS, ETC.            107
 in an apartment the air of which  has been  rendered  turbid by
 the smoke of a lamp, or of a carrier who  has been all day on a
 road enveloped in clouds of dust:—in either case,  we  shall find
 that, in the  course of four-and-twenty  hours,  the  whole of the
 extraneous matter  has been  expelled along  with  the  bronchial
 mucus.   Besides,  if such  substances could  be retained  in  the
 lungs, they would be retained in the bronchia, and  we should, in
 such a case, find there an accumulation of such matters, differing
 in their nature  according to the particular  kind of  occupation of
 the individual.   Now, I believe, nothing of this kind  has  ever
 been discovered on dissection; at least, I can  assert that  I have
 never met with any thing of the sort, though I have  examined
 the lungs  of a great number of persons who had passed their
 lives in  workshops  of which  the atmosphere  was  constantly
 charged with calcareous or  other kinds of dust.
   Furthermore, I do not  intend  denying that the existence of a
 great number of bony concretions in the lungs may  be productive
 of habitual dyspnoea, more or less severe; but  I can assert that I
 have met with such concretions^ and in great quantity, in the lungs
 of persons who had never experienced any affection  of the  respi-
 ration; and  1  am convinced,  as well by my own dissections, as
 by those given by other observers, that those concretions have never
 been found  sufficiently voluminous,  numerous,  or congregated, to
 justify our  attributing to them  any case of dyspnoea sufficiently
 intense to  be reckoned by any  practitioner  under the  head of
 asthma.
   The opinions of  M. Bayle respecting the effect of these concre-
 tions are very singular, quite unsupported by either  reasoning or
 analogy, and, indeed, rather  invalidated than  confirmed by the
 facts he has himself adduced.  He considers them as one cause of
 Phthisis, and gives the following statement of the symptoms produc-
 ed by them: " The greater part of subjects (he says) affected with
 this disease, expectorate small calcareous fragments, of a greyish or
 whitish colour, often in great number, and they have a dry cough
 for a long period."
   It is remarkable that M Bayle mentions neither expectoration,
 dyspnoea, wasting, nor hectic fever,  as symptoms of the complaint,
 and it is therefore singular how he  has been led to reckon it as a
species of consumption.  The two examples adduced by him are
very little to  the purpose.   The  first (case  33) is the case  of a
man affected for nine months with a slimy  expectoration, inter-
 mixed with  puriform  sputa, and occasionally with small chalky
 fragments.   Hectic fever supervened and carried him off  in six 
108
DISEASES OF THE LUNGS.
weeks.   A great number  of small  cretaceous  concretions, some
soft, some hard, some encysted, some not encysted, were found in
the'lungs.   The  substance of the  lungs was slightly indurated
around these concretions, but, in other respects, healthy.   In  this
instance it is evident that the consumption and death were  pro-
duced by a chronic catarrh:  and I see no  reason to  attribute the
result to the concretions, since we often find  them equally numer-
ous without any such consequence    The second  example (case
34) is that of  a man who died  of fever  complicated by pleuro-
peripneumony.   He had experienced for twelve months dyspnoea,
frequent cough, and consequent  mucous  expectoration, but  very
little emaciation.   In this  as well as the former case, we find no-
thing characteristic of true consumption.
   In examining  the  cases of pulmonary concretions of this kind,
contained in the writings of Morgagni, Bonetus, and various other
authors, it is easy to perceive that, in most of them, the existence
of these was productive of no severe symptom, and that even the
dry cough, or  cough with  ropy expectoration,—symptoms most
nearly allied to consumption,—wa« by no means a constant attend-
ant on such a condition  of parts.  My own   dissections afford  a
similar result.   I have often found concretions of this kind in per-
sons who had no disorder of the respiration.   Others had a  dry
cough, or cough with expectoration  of different kinds, and with or
without dyspnoea; but  there was  in almost all these, some other
morbid alteration  of the pulmonary tissue, to which the symptoms
might be attributed with as much (or more) justice as to the con-
cretions.
   In particular it is very common  to  find coexisting with these
concretions, traces of cicatrizations in the lungs, of the kind  de-
scribed in a former chapter; and, at the same time, to observe the
pulmonary tissue  flaccid,  hard, and  impregnated with  a great
quantity of black  pulmonary  matter around the concretions, and
the interstices  that separate them from the cellular, fibrous, or car-
tilaginous cicatrices alluded  to, (see page 47).
   From these facts I am led to believe, that, in most cases, these
concretions are consequent on tuberculous affections that have been
cured, and are the product of the curative efforts of nature, which
appear to have elaborated  a superabundance of the calcareous
phosphate, which  is necessary to the formation of the cartilagi-
nous bodies which  constitute, for  the most  part, the fistulae and
cicatrices that are found in such cases in the lungs.   Several of
the cases related (3 and  6) countenance this  opinion, and others to
the same purpose  will be given afterwards. 
MELANOSIS.                      109
  I by no means, however, wish to assert that concretiens of this
kind may not take place in the lungs primarily, and independently
of the  previous existence of tubercles; but I look upon such cases
as very rare; and, when they do occur, I am assured that they give
rise to  little or no disorder of the system.
                       SECTION FIFTH.

                  Of Melanosis of the Lungs.

  The older surgeons, and, after them, the  modern  anatomists,
have confounded, under the name of Scirrhus,  Cancer, or Carci-
noma,  different morbid growths which have no common character  v
but that of their being unlike any of the natural or healthy tissues of
the  body,—their originating in an indurated state,—and their subse-
quent softening and self-destruction.   This confusion has proved a
great bar to the progress of morbid anatomy.   Convinced of this, I
have paid particular attention to the discrimination of these various
productions, and  have succeeded in pointing, out several  very
distinct species.   That which I am now to notice, and which I de-
scribed many years ago (1806) in an unpublished memoir present-
ed  to the  Faculte de Medecine, is  the  most  easily recognised in
all  the organs except the lungs, in which, owing to its colour, it is
sometimes very difficultly distinguishable from the black pulmonary
matter.
  In their early or crude state, these productions possess a consist-
ence equal to that of the  lymphatic glands,  and a homogeneous
and somewhat humid composition; they are opaque, and, in struc-
ture, very much resemble the bronchial glands.   When they begin
to soften,  a minute portion of fluid can be expressed from them, of
a thin reddish character, intermixed with small blackish portions,
which is sometimes firm, sometimes friable, but which, even when
friable, conveys to the touch an impression of flaccidity: in a more
advanced stage, these  portions first, and subsequently the  whole
mass in  which they are contained, become quite friable and  are
soon converted into a black paste.
   Melanosis may  exist in four different forms,  viz: 1st, encysted;
2nd, non-encysted; 3rd, impregnating,  or infiltrated  into the  na-
tural substance of an organ; and 4th, deposited on the surface of
an  organ.
   First  kind.  Encysted Melanosis.   The cysts enclosing  this 
110
DISEASES OF THE LUNGS.
 species are very regularly rounded, and  vary in size from that of
 a small  hazel-nut to that of a walnut.  At least, I have never met
 with any that did not come within these  dimensions.   They have
 a very regular and  equal thickness, which is never greater than
 half a line.   Cellular substance appears  to be the  only tissue that
 enters into their composition.   They adhere, by means of a very
 fine cellular tissue, to the substance of  the organ in  which they
 are situated, and from which they can be  readily separated by dis-
 section.   Their  interior  surface is rather smooth, but adheres to
 the morbid matter which  it surrounds.   The medium of this ad-
 hesion appears to me to  be a very fine imperfect  cellular  tissue,
 though it  cannot always be distinguished.  I have hitherto only
 found this variety of melanosis in the liver and lungs; and, in the
 latter organ, I have only as yet  met  with  a single mass of it.
   Second kind.   Un-encysted Melanosis.  This variety is  much
 less rare than the preceding: I have  met  with it in the lungs, the
 liver, pituitary gland, and the nerves.  The volume of masses of
 this kind is quite (indeterminate,—varying from that of a millet-
 seed to that of an egg, or more.  They are also quite  irregular in
 figure.   They commonly adhere very closely to the parts in which
 they are  situated; sometimes, however, they are  united to  these by
 a very fine, though  sufficiently visible, cellular tissue, which per-
 mits their removal without any  laceration.   In  this last case they
 are commonly of a rounded shape.
   Third kind.  Impregnation of the natural tissue with the mat-
 ter of Melanosis.   It frequently happens  that this morbid matter,
 in place  of being segregated in distinct  masses, is disseminated
 througbout the organs in which it is  found, and deposited  between
 the. particles or molecules of  the natural tissue.   The  appearance
 and  colour of parts affected in  this manner present a  good many
 varieties,  according to  the texture of the organ, the quantity of
 morbid matter deposited, and the particular condition of this mat-
 ter.   When the  infiltration is  recent, and in moderate  quantity,
 the appearance of the affected part merely differs from the natural
 condition  in being  intermixed with small black dots or striae, the
 intermediate portions being quite of  a healthy character.   As the
 flisease increases, the dots  and  striae enlarge in  number  and vo-
 lume, until the whole  of the natural tissue  of the  part is lost in the
 morbid degeneration.   It  is usually only at this  period of its pro-
 gress that the  melanotic matter begins to soften; but if the soften-
 ing takes place before the complete  removal of  the natural  tissue
of the part, it frequently happens that this softens also, and inter- 
MELANOSIS.
Ill
mingles with the  morbid matter, the  colour of which is thereby
changed to brownish, yellowish, or greenish.
  Melanosis, like all the other accidental productions which dif-
fer from the  natural tissues of the animal economy,  gives rise to
constitutional and  local disorder.  Among the constitutional or
general effects, the most constant are the gradual diminution of
the.vital powers, and a marked change in the process of nutrition,
whence result emaciation, to a considerable degree, and dropsy of
the cellular membrane, and, sometimes, of the serous membranes.
Tbe subjects whom I have known to  die in consequence of mela-
nosis in any organ, had no continuous or well-marked fever; and
this  is true of cases wherein the disease extended to a great por-
tion of the lungs, and is also observable in the two cases [Z() and
21) of the same  affection given in the work of M. Bayle.  If this
circumstance holds good generally, as I am much disposed to be-
lieve, it will assist in enabling us to distinguish, during life, Con-
sumption produced by Melanosis of the Lungs, from that depend-
 ing  on tubercles; which last, as  is well known,  is  accompanied,
 almost through  its whole course, by  a hectic  fever,  which is usu-
 ally characterised  by two  exacerbations,—one towards  mid-day,
 and the other in  the night.
   The most constant of the local effects produced by melanosis of
 the  lungs are dyspnoea, proportioned  to the extent of the disease,
 and cough, which is often dry, but sometimes attended  by a mu-
 cous expectoration intermixed with some puriform sputa.
   The  melanotic masses in the lungs may  be  sometimes  com-
 pletely softened, so  as to leave, after their  evacuation into the
 bronchia, cavities resembling those produced by the softening down
 of tubercles.  I have myself never  met with excavations of this
 sort in the lungs;  I have met with them, however, in the  liver;
 and the work of M. Bayle contains two cases (20 and 21) which
 incontestibly prove the possibility of  their formation in the  lungs.
 In these cases the pulmonary tissue, so much impregnated with
 melanotic  matter as to be as firm as liver (or even firmer) con-
 tained a  multitude of small excavations evidently formed by the
 partial softening of the same matter.
    Melanosis is  one of the  rarest species of cancer, and  is ex-
 tremely seldom  met with in the  lungs.   This may seem an  extra-
 ordinary assertion after the contrary assertion of M. Bayle, and
 the cases  given  in his work under the name of Phthisis with Me-
 lanosis.   Whatever distrust I may have of my own opinions  when
 they differ from those of that excellent observer,  with whose ex-
 treme correctness I had better opportunities  of being acquainted 
112
DISEASES OF THE LUNGS.
than any other person,—I cannot help, nevertheless, being of opi-
nion that he was deceived  on this particular point,  and that he
sometimes confounded with  melanosis, the natural black pulmo-
nary matter.   1 admit that  these  two substances are  very much
alike in their external characters, and I am not sure that the most
experienced observer could discover any difference between a me-
lanotic  mass in the liver  or any other organ, and  a bronchial
gland of  a  perfectly  black colour, such  as they are  often found
in very  sound lungs.   I  will not say that the following charac-
ters suffice  to distinguish the  two substances,  but they may at
least  assist us  in discriminating them:—The matter of melano-
sis, when softened,  and even that which  can be expressed from it
while yet solid, dyes the  skin black; but this colour  is not very
permanent,  and can  be  easily removed by  washing;  while  the
blackness produced by the matter of  the bronchial glands, if  this
be left to  dry before washing, will remain on the  skin for several
days.   The chemical composition of the two bodies  also  differs
very considerably.  The bronchial glands,  according to Fourcroy,
contain  a large portion of carbon and hydrogen, while the matter
of melanosis contains  neither of these, but is almost entirely com-
posed of albumen and a peculiar  colouring matter.
   Notwithstanding  its resemblance to this natural  substance, me-
lanosis is  evidently  a morbid and very deleterious  production,  in-
asmuch as it produces all the  local  and general  effects of other
cancers, when it exists in a certain extent; and  since  it is found
united with other morbid  productions in compound cancerous tu-
mours.
   When melanosis forms masses of considerable extent, or when
it impregnates the pulmonary tissue  so thoroughly as  to give  it a
deep black colour,  and a consistence equal to that of liver, it is
easily recognised; but when  the impregnation is recent, and  not
sufficiently abundant to  produce  any notable induration  of  the
lung, it can,  with difficulty,  be distinguished from the black pul-
monar}' matter.
   I have already mentioned this black pulmonay matter  several
times.  It has been little  noticed by anatomists; yet it exists so
commonly in the lungs, and even in those  of persons  in the most
perfect health, that we can hardly consider it as  an unnatural or
morbid production.  It  is found  more  or less abundant in  the
lungs of almost every adult, and seems to increase with the age of
 the individual.  In early infancy, we perceive no trace of it,  and
 the lungs are of as pure a rose colour as those of the ox, and se-
 veral other animals.   Perhaps this peculiar matter exists only in 
MELANOSIS.                     113
man, and the carnivorous animals; but I have been too little prac*
tised in comparative anatomy to advance any thing on the subject.
When it exists only in small quantity it merely gives to the  lung
a slight grey tint.   On the surface of the lung it appears in small
disseminated black dots, which are more numerous and thicker
along the intersecting  lines of the cells, so as to form striae, small
spots, or punctuated lines.   These spots,  still further crowded in
different places, as well in the  interior as on the surface of the
lung, form spots still laiger  and more numerous, so as sometimes
to give a black colour to large  portions  of these organs   In no
case, however, does this matter affect  the suppleness or permea-
bility of the lung, a circumstance which forms a striking contrast
with the melanotic infiltration.
   It is particularly in  the bronchial glands that this peculiar mat-
ter* is  found most abundant.   In adults,  and especially in old
persons, they are often found completely black; in others they are
only partially impregnated, as if  touched by a pencil.   A condi-
tion of parts so common cannot be regarded as morbid, especially
as it is often unattended by  any symptom  whatever of disorder.
This matter in the bronchial glands would appear to be the cause
of the grey colour of  the bronchial mucus, which many healthy
persons expectorate,  and of the small black  specks  found fre-
quently intermixed with  that  transparent secretion.  This  cha-
racter of  the  bronchial  mucus,  establishes  another distinction
between the black pulmonary matter and the substance of mela-
nosis, as the existence of the latter,  even in the greatest degree,
never gives rise to an expectoration of a black colour, unless, per-
haps, at the very moment of the escape of the softened melanotic
mass into the bronchia. (See Bayle's cases 20 and 21.)
   The formation  of tubercles in the lungs, and,  more especially,
the cicatrization of the tuberculous excavations,  frequently  pro-
duces, as I have previously observed, a more abundant  secretion
of the black pulmonary matter.   In some cases this abundance is
such, as—in conjunction with the  compression of the pulmonary
tissue produced by the tubercles, the cartilaginous cicatrices and
the chalky matter that accompanies them,—to  render the affected
part notably indurated, flaccid,  and more or less  impermeable to
air.   In extreme  cases of this kind,  it is difficult to say  whether
the colour and density of the affected part are the consequence of
black pulmonary  matter or of  melanosis.  The rule  of distinc-
tion we ought to follow in such cases is the following:—We ought

       * Orig. matierc de melanoses—evidently a mistake.—Trans
                              15 
114              DISEASES OF THE LUNGS.
not to admit  the  existence of [circumscribed]  melanosis, unless
we find  some of it in poriions of' some extent, and already soften-
ed, or, at least, so deposited and  shaped as to distinguish it  from
bronchial glands.  We  ought  not to  admit the existence of the
infiltration  of this matter, unless it has  produced in the lungs a
degree of induration equal to that of liver: and when this degree
of hardness can be traced to  the presence of  bony or cartilagi-
nous bodies, we ought to consider the black colour as derived  from
the black pulmonary matter.
   To render this  distinction more easy I shall here  detail two
cases.   The first  is an instance of melanosis occurring in the  lungs
and in several other parts of the body.  I prefer it because it ex-
hibits the disease in a great degree of development,  and because
it was drawn up neither by myself nor by my direction: it is ex-
tracted from the register of cases by the hospital pupils for 1816,
preserved in  the office of  the  board of administration.  The se-
cond case offers an example of the difficulty of  distinguishing the
black pulmonary matter from the matter of melanosis.
   Case  28.  A woman, aged  59, entered the hospital for an af-
fection of two months' standing, which  had  arisen after  violent
grief.  The disease commenced with greaf prostration of strength,
loss of appetite and sleep.   These symptoms were followed by
vomiting and diarrhoea,  and the development of small tumours, of
a black  colour, in different  parts of  the skin.   When she came
into hospital, a great  number of these tumours, of the form and
colour of grains of cassia (cassis) occupied the anterior part of the
thorax.  . The spaces between some of these were filled with small
spots  very like  flea-biles.   The  tumours were  so  close  on the
breasts as to form a large plate or crust.   Some of  the  same sort
existed in the abdomen,  the largest being two inches in circumfer-
ence.   The  arms and  thighs, especially on their  inside,  were
marked  in a similar manner; the fore-arms and  legs were without
any.  In addition to the symptoms already mentioned,  the respi-
ration was difficult, there was frequent cough, and  the  pulse  was
extremely quick.   These symptoms  gradually  increasing in de-
gree and being followed by oedema, the  patient  shortly after  died.
   On dissection the cutaneous tumours were found to consist of a
homogeneous substance, of a more or  less deep black colour, and
of a consistence in some cases very considerable, in others merely
pulpy. . These tumours  had all cysts of cellular substance, and ap-
peared to be evidently of the kind already described as Melanosis.
They were found in almost the whole  of the subcutaneous cellular
tissue; also  in the same  tissue which incloses the vessels, nerves, 
MELANOSIS.
115
and the lymphatic glands.  In some places they formed by  their
aggregation masses as large as the fist.  The nerves in their vici-
nity were sound, but the blood-vessels  could  not be separated
from  them without  rupture.  These tumours were found in the
thyroid gland; also,  in  small  quantity,  in  the lungs.   In the
neighbourhood of the bronchial glands they  were numerous and
larger:  the bronchial glands  themselves were not black.  They
were  seen in the substance of the  mediastinum, and under the
pleura; also,  in great numbers, in the mesentery and omentum.
All the abdominal viscera, except the liver, were sound, but the
cellular substance around them contained similar tumours.  The
heart  and brain were sound.
   Case 29.   A man, 60 years of  age, died after having laboured
under cough and expectoration, and other symptoms more or  less
allied to consumption, but not well  marking this disease.   For
several weeks there  were swelling and fluctuation of the abdo-
men.
  On dissection there was found, in the superior  lobe of each lung,
a large cartilaginous cicatrice, with an external depression similar
to those described in the chapter on  Phthisis.  The neighbouring
parts  contained a vast quantity of black pulmonary matter, so as
to give to the lung the blackness of ink, and were also interspersed
with bony and cretaceous particles.  The other lobes were slightly
tinged with black pulmonary  matter, and  contained a few imma-
ture tubercles.  There were adhesions between  the heart and pe-
ricardium, and the ventricles  were enlarged.   The abdomen con-
tained a large quantity of a yellowish limpid fluid.   The  whole
peritoneum was of a dirty grey colour, and studded with innumer-
able small, red, grey, or black points.  The  red points, united in
flakes, had all the marks of being the result of an ancient inflam-
mation.  The others seemed to be tubercles in the first stage, grey
and semitransparent; they formed small tumours on the surface of
the membrane, and some of them were of the size of large hemp-
seeds.  Those  which were of a black colour, and opaque, were
evidently formed of the  matter of melanosis.  These two species
of tubercles were most numerous  on the intestinal portion of the
peritoneum; the red spots or flakes were, on  the other  hand, most
plentiful on the mesentery and omentum.  This last was  rolled
together so as to form a sort of hard and irregular tumour in the
left hypochondrium.   The peritoneum seemed much  thicker and
much softer than natural; but  this arose  from its being covered
throughout, between the granulations above mentioned, with a thin
and soft coating or layer of albumen. 
116
DISEASES OF THE LUNGS.
   In the first of these cases there  can be  no doubt of  the  nature
of the black  tumours  found  in  the  lungs.   The  coexistence of
similar tumours in divers other parts of the body, and the absence
of the black  colour in  the bronchial  glands  themselves, leave  no
doubt on the  subject.   In the second case, the question as  to the
nature of the black matter in the indurated portions of the lungs,
is much more difficult.   The fact of the existence  of bodies an-
swering to the character already  assigned to  pulmonary cicatrices,
and, also, of  bony and  cretaceous tumours; and further, the imma-
ture tubercles in other  parts of the lungs, as well as on the surface
of the peritoneum—all lend to support the opinion of the  black
matter being  merely the common black pulmonary matter.   On the
other hand, the existence of some melanotic tumours on the peri-
toneum gives some colour to the  suspicion of the black portions of
the lungs having derived their origin  from the same source.  The
arguments, however, are decidedly in favour of the former opinion,
   I have already observed that M Bayle  appears  to  have some-
times confounded the matter of melanosis  with the common black
pulmonary matter   I think he has been equally wrong in classing
melanosis of  the lungs  as a species of phthisis.   In fact, the me-
lanotic affection, in  place of producing progressive emaciation and
hectie  fever,  the most constant symptoms of tubercular phthisis,—
rather  tends to produce cachexy and  anasarca, and  usually proves
fatal before the supervention of any marked degree of emaciation
If we  were to class diseases from so  feeble analogies, we ought to
range among  consumptive diseases chronic pleurisy,  peripneumony,
and catarrh, as well as several diseases of the heart,  or, indeed,
every disease attended  by dyspnoea and emaciation.
   In  medical writings we find  but few  cases which can be re-
ferred  to this  disease, melanosis;  a circumstance which, no  doubt,
proves its extreme  rarity, since  its  characters,  especially when
occurring in any other organ besides the lungs, are so  well marked
as hardly to be mistaken.   Haller relates some of  the best  mark-
ed  instances  of it.   " I have observed," he says, " a  horrible
species of pulmonary consumption.   In one man 1  found one lung
filled, not with pus, but  with a matter  black  as ink; and  in
another, I have since found a  similar  fluid  in the cavity  of the
pleura."  Notwithstanding the brevity of  these notices,  it is im-
possible to mistake, in  the first,  the  infiltration of the  lungs with
the melanotic matter in a soft state;  and, in the second, a  secre-
tion of the same matter into the  pleura. 
MEDULLARY TUMOUR.
117
                        SECTION SIXTH.

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

  This species of accidental  production,  which was described
for the first time in the Diet, des Sciences Med. (Art. Encepha-
loides),  is one of those that has been most frequently  confounded
under the  name of  Scirrhus and Cancer.   It is, indeed,  the  only
species of cancer found in the  lungs by M. Bayle, and myself.
It has received  its name  from its  striking resemblance  to the
brain.
  M. Bayle has considered this disease as constituting a variety
of consumption,  and  has  named it Cancerous Phthisis.  I  will
not here detail my  reasons for rejecting this species, as  they are
nearly the  same as  already adduced  against the admission of the
Phthisis with Melanosis of ihe  same author.  I may add, that  in
all the cases which I have met with of soft  cancer of the lungs,
death has been produced by suffocation before  the  period  when
any thing  like phthisical symptoms  could  have been produced.
And I am of opinion that  the cases  of  this cancer  uncomplicated
with tubercles, detailed in M. Bayle's work,—and  even his  gen-
eral description of the  disease,—tend to establish the same con-
clusion.   Soft cancer may exist under three  different  forms, viz.
1st, encysted,—2nd, in irregular masses,—and  3rd, without cyst,
and diffused  in  the tissue of an organ.  In  whichever of  these
forms it exists, it presents, in its progress, three  different and dis-
tinct stages,—viz   1st, the incipient or crude state;  2nd, its per-
fect state, in which it exhibits the  resemblance to brain which
forms its  especial  characteristic; and  3rd,  its soft or  dissolved
state.   I  shall first describe it as it is observed in the second, or
perfect, state;  as this  is the condition in which the three varieties
most  nearly  resemble each  other,  there being  much difference
between these in their first and last stages.
   Soft  cancer in  its perfect  state  is homogeneous,  of a milky
white, and very like the medullary substance of  the brain.  In
different parts it has  commonly a slight rose  tint.   It is opaque
when examined in  mass, but in thin  slices it is  in a slight  degree
semitransparent.    Its consistence is like that of the human brain,
but it is commonly less coherent, being more  easily  broken and
comminuted  by the finger.  According to  its degrees of density 
118
DISEASES OF THE LUNGS.
  it resembles one part of the  brain  more  than another, but it  is
  more  commonly like the medullary substance of a  brain  that  is
  more than ordinalily soft, (or like that of a  child's,)  than  any
  other part of the brain.  When existing in any  considerable ex-
  tent, this  species of cancer  is,  in general,  supplied by  a great
  many  blood-vessels, the trunks of which  ramify  on  the exterior
  of the tumours, or  between  their lobes only  while  the minuter
  branches penetrate the substance of the tumours.   The coats  of
  these blood-vessels are very  fine, and  readily ruptured: and  this
  accident gives rise  to clots of extravasated blood  in  the interior
  of the tumours, sometimes of considerable size,  which  bear oc-
  casionally  a striking  resemblance to those found  in  the brain  of
  subjects dead of  apoplexy.  Extravasations  of this  kind may
  sometimes be so considerable as to  supplant almost the  whole  of
  the brain-like matter, so that the true  nature of  the  tumour  can
  only be ascertained by some small  points, still remaining, of the
  original growth   This change  occurring in  superficial tumours
  of this kind, and being productive of much hemorrhage, appears
  to me  to have given rise to   the  name of fungus   Ho&matodes  ap-
  plied to certain  ca-ncers by modern  surgeons.   Under this name,
  however., I am also convinced thai  they have confounded tumours
  of different kinds,  especially those  commonly  called  varicose,
  which are  composed of an   accidental  tissue  very  analogous to
  that of  the  corpus cavernosum penis.   I have  never  observed
  any lymphatics in tumours of this sort, but it is probable that the
* circulating system is complete in them, as I have seen their  sub-
  stance deeply tinged with yellow in cases of icterus. . The mat-
  ter of  this  species of cancer  does not continue  long  in  the state
 just described; it  tends incessantly towards  a softer  condition,
  and in  a short  space  its consistence scarcely equals  that of  a
  thickish bouillie or  paste   Then begins the last  stage:  the  pro-
  cess of softening becomes more  rapid until the morbid matter be-
  comes as liquid  as thick pus, still, however, retaining its whitish
  or rosy-white tint.   Sometimes  at this period, or  a  little earlier,
 the blood extravasated from the vessels contained   in  the tumour,
 becomes intermixed with the morbid matter,  so  as to  give  it  a
 dark red colour, and the resemblance of clots of  pure  blood.  In
 a  short time  the extravasated  blood  is decomposed;  the  fibrin
 concretes, and, together with the colouring matter, unites with the
 brain-like matter of the  tumour; and the  serum is absorbed.  In
 this condition the morbid growth retains no resemblance to brain;
 it  is of a  reddish  or  blackish colour, and of a  consistence like
 that of paste somewhat dry and  friable.   Sometimes the change 
MEDULLARY  TUMOUR.
119
 of structure and appearance is so  complete, that one would be
 led to consider the tumours as of a peculiar kind, but for the ex-
 istence in them of portions of the original matter still unchanged.
 Jn other cases, contemporaneously with  tumours  that have  been
 changed in this  manner, there will be found others retaining the
 original cerebral character: so that,  in  all  cases, we are  able
 with a little  practice, to discover the true nature of the  tumour
 in all its stages.
   Such are the characters which  this species of cancer presents in
 its two latter  stages, and equally in all the three varieties.   I shall
 now describe the characters of each of these varieties in  the first
 or crude  state of the morbid  matter.
   First kind   Encysted Medullary Tumour.   The size of this
 species is very  various:  I have  seen the tumours as small as  a
 hazel-nut, and larger than a middle-sized apple.   I have found
 them as large as this in the  lungs.   The cysts are of pretty equable
 thickness; and this is never more than half ^ line; they are of a
 greyish white, silvery, or milky  colour, and  have a semitranspa-
 rency, more  or less, according to their thickness   Their  texture
 is altogether cartilaginous, and rarely fibrous;  but it is much softer,
 and less easily broken by bending, than cartilage: on this  account
 they must  be  ranged among the imperfect cartilages*
   The medullary matter contained  in these  cysts can be easily
 detached from  their  inner  coat.  It is commonly divided into
 several lobes, by a very fine cellular tissue, which maybe compar-
 ed with the pia mater, and the more so from  the  great number of
 blood-vessels  which traverse it.   The fineness and  brittleness of
 these has been already .noticed, and also their penetration of the
 cerebriform matter itself.   It is commonly in  their early or crude
 stage that these  tumours are divided  into distinct lobes.   These
 are especially observable  on their superficies, and have sometimes
 considerable resernblance  to  the  convolutions of  the brain. The
 cyst does not at ail enter between these  convolutions, nor does it
 even indicate on its surface their place or  configuration.   Inthis
stage the medullary matter is pretty firm,  often firmer than  the fat
of bacon.   It is of a  dull white, peari grey, or even yellowish
colour, and, in thin slices, has a slight degree of semitransparency.
When  cut into, it appears  interiorly subdivided  into  lobules
much smaller than those seen on its surface.  These lobules are in
such  close contact  as to leave  no interval whatever; and their
separation  is  merely indicated by the reddish lines traced by the
vascular cellular tissue by which their separation is effected.  These
lines rarely cross each other, but exhibit  many irregular curves
and convolutions. 
120               DISEASES OF THE LUNGS.
   When  these  tumours pass into the second stage, their texture
 becomes  more  homogeneous,  and all  distinction  of the  small
 interior lobules is quite lost; the distinction, however, of the  larger
 exterior lobes still continues.  The blood-vessels which run between
 these lobes, and in  the cellular tissue immediately investing  the
 tumour, are much more developed than in the  early stage of  the
 disease, and it is only at this second stage, or as it approaches the
 third, that the extravasations of blood take place.
   The third stage begins,  as I have already mentioned, when the
 medullary matter has  acquired a consistence like pap or paste, or
 like that of a brain  softened by  commencing putrefaction.  In this
 state it has siill  much  resemblance to cerebral substance.  1 have
 never found  that this morbid growth  ever softens still more,  or
 that it is  absorbed or evacuated, so as to leave  an empty cyst or
 cavity like tubercles.   Hitherto I have only found these encysted
 medullary tumours in the lungs, liver, and cellular substance of the
 mediastinum.
   Second kind.  Unencysted Medullary  Tumour. Medullary tu-
 mours of  this species are very frequently met with.  Their size
 is very  variable; I  have seen them from  the size of the head of a
 full grown foetus  to that of  a  hemp-seed.   Their shape is  com-
 monly spheroid, but occasionally flattened, ovoid,  or  altogether
 irregular.   Their external  surface is  lobulated,  but  the divisions
 are less regular  than in the encysted species; their internal struc-
 ture, in the two last stages, is precisely  the same.   The cellular
 membrane which invests them is more or less marked, according
 as they are placed in a loose cellular tissue, or  in the  substance
 of a  viscus of firm texture:  in the latter case, their investing mem-
 brane is thinner and less distinct.
   In their first  or  crude stage,  their semitransparency is  greater
 than afterwards; they  are  almost colourless, or have  a very slight
 bluish lint in  ocellated patches:  they are pretty hard, and divided
 into  numerous  lobes   The aspect of this morbid matter is  fatty,
 like  lard;  but  when incised it does not at  all grease jhe scalpel,
 and  it coagulates by heat without showing a particle of fat.  The
 transition  from  the first to the second stage takes  place  in the
 following  manner;—the substance of the tumour becomes  more
opaque, softer, whiter, and  its interior distinction into lobules  for
 the moss part disappears.  The  original texture is observed longest
in the neighbourhood of the external  interlobular  fissures.   In
 this situation I have found portions still in a state of induration  after
 the mass of the  tumours had passed into   the third stage.    I am 
MEDULLARY TUMOUR.
121
 led  to conclude that the  encysted medullary tumour follows pre-
 cisely the same progress as that just described.
   The non-encysted medullary tumours may exist in any part of the
 body; but they are most frequently met  with in the loose and
 abundant cellular  tissue of the limbs, and in  the larger internal
 cavities.  I have met with them in the cellular membrane of the
 fore-arm, thigh, neck, and mediastinum; they  are still more fre-
 quently found in the cellular substance around the  kidneys and the
 anterior part of the spine, and in these situations they often have a
 very large size.   Although they are frequently found in the viscera,
 they are,  however,  much rarer there than in the cellular substance.
   Third kind. Interstitial impregnation of organs by the matter of
 the medullary tumour. As I have never met with this variety in the
 lungs, I shall not describe it is this place.   I may  merely observe
 that it is  distinguished from the unencysted tumour by forming
 masses not at all circumscribed, in  which the  medullary  matter
 approaches nearer to the Imperfect or  crude state, the more distant
it is from  the centre of the tumour.   It exhibits, moreover, a very
heterogeneous appearance, produced by its intermixture, in different
proportions, with  the  different organic tissues  amid  which  it  is
developed.  In'the work  of M. Bayle there  is a case of this desease
in the lungs (case 36) communicated to him by me.   I  shall not
add any in this place, as  the medullary is  very easily distinguish-
able from  every other species of cancer. 
122
DISEASES OF THE PLEURA
fcOOK SECOND
OF THE  PLEURA.
                   CHAR  I.

OF PLEURISY, OR INFLAMMATION OF  THE
                    PLEURA.
                      SECTION FIRST.   *


                     Of Acute Pleurisy.


  Pleurisy is inflammation of the pleura.  It derives its  name
from the stitch in the side, which is generally its most characteris-
tic symptom.  Until very lately, there has been much difference
of opinion respecting the actual seat of pleurisy; some placing it
in the pleura, others in the lungs, others, again,  in both these, and
some  in the morbid  adhesions existing between  the lungs and
pleura.  By the term pleurisy, however,  we now  almost univer-
sally mean, inflammation of the pleura alone, and  it is in this li-
mited sense I shall use it in this chapter.
  It is, nevertheless, true, that, in many instances, pleurisy and
peripneumony exist together; that, in cases where the pleura alone
is inflamed, the  stitch of the side,  which constitutes the principal
symptom of the pleuritis of the ancients, and  also of many mo-
derns,—is either not at all, or scarcely perceptible, and then only 
ACUTE PLEURISY.
123
momentarily; whilst, in other cases where a violent peripneumony
is combined with a slight pleurisy, the pain of the side will be ex-
tremely severe: still it holds good, that both pleurisy and peripneu-
mony may,  and do, exist singly.   There are particular epidemics
in which they are ordinarily  conjoined, others in which they exist
separately: but we, in general, find more frequently on dissection,
peripneumony without pleurisy, than pleurisy without peripneu-
mony,—a circumstance which may be accounted for by the fact of
almost all the  cases of simple pleurisy being cured.
  Pleurisy is either chronic or acute.   The  anatomical character
of acute pleurisy, like that of the inflammation of all serous mem-
branes, is redness of the part affected.   This  redness is in some
sort punctuated, and looks as if one had traced with a pencil  upon
the pleura an infinity of small bloody spots of very irregular figure,
and  very close  to one  another.   These  red  points occupy the
whole thickness of the  membrane, and leave small intermediate
portions retaining  the natural white colour.   This punctuated ap-
pearance is unquestionably a character of the inflammation, and
not at all attributable, as some have supposed, to the partial disap-
pearance of the  redness after death.  Besides this particular red-
ness,—-and  even in those instances, where it is very inconsidera-
ble,—we-always find, the  superficial  blood-vessels of-the  pleura
redder, more  distinct, and more  distended  than  in  the  natural
state.
  Many consider thickening  of the pleura as  a very common con-
sequence of inflammation.   I  must  say,  however, that  I  have
never clearly perceived this; and  I think there can be no doubt,
that, in the  greater number of cases wherein it had been  thought
to exist, the supposed thickening has either been an extensive con-
geries of  miliary  tubercles on  the outer or  inner surface of the
pleura,—or a cartilaginous  incrustation on the parts covered by it,
or, lastly, false membranes, more or  less dense, closely adherent
to its internal surface.
  Inflammation of the pleura is always accompanied by an extra-
vasation on its internal surface, and which may be considered as
the species of suppuration proper to serous membranes.  This ex-
travasation appears to commence with the inflammation itself.  It
consists of  two very different  matters.   The one, of a  firmer,
semi-concrete  consistence, is usually termed false membrane, or
coagulable lymph; the other, very  thin and watery, is called sero-
sity or sero-purulent effusion.  Both of these exhibit great variation
,of character.
  The  false membranes consist of a yellowish white, opaque, or 
124
DISEASES OF THE PLEURA.
slightly semitransparent matter, varying from the consistence of t
thick pus to that of boiled white of egg, or of the buffy coat of the
blood, to which last substance, indeed, these adventitious mem-
branes bear a strong resemblance in all their physical characters.
This substance  closely invests  the  whole inflamed  portion of the
pleura, following it, when the inflammation is general, through its
whole course, as well on  the lungs as on the chest, and forming a
sort of complete inner lining of it.  When the inflammation is con-
fined to either the pleura pulmonalis, or costalis, the inflamed por-
tion  is alone covered  by the false membrane.  In cases of exten-
sive  inflammation, very frequently the portions of false  membrane
covering the lungs and costal  pleura, are united by bands of the
same, which extend from one to the other through the serous fluid
effused into the cavity.  In such  cases the false membrane ad-
heres but slightly to the pleura,  being readily separated by the
handle of the scalpel. These membranous exudations commonly
vary in thickness from half a line to two lines; for  the most part
they  are  of uniform  thickness,  though,  occasionally, they are
thicker in some  points,  especially on  the lower side of  the lung
and  the corresponding parts of the diaphragm.   In some instances
there are  partial  elevations  or  thickenings  of the  membrane
throughout its whole extent, in the form of lines which cross each
other so as to exhibit a sort of irregular net-work.   Sometimes
these linear elevations are so close together, as to give to the mem-
brane the appearance of being studded or granulated with small
irregular tuberosities.  In both these cases, the intermediate points
remaining comparatively thin  and diaphanous, when contrasted
with the elevated  portions, give  to the membrane an appearance
very similar to the  omentum  when moderately loaded with fat.
This resemblance is  particularly striking  when  blood-vessels  are
already formed in the false membrane.  Sometimes,  particularly
when the  extravasated serum  is in great quantity, the false mem-
brane is found either wholly, or in part, detached from the pleura
and floating loose in the  serosity.  We even find detached irregu-
lar globular masses, of considerable size, which look as if they had
never been adherent to  any part.  This, however, seems to  mt
 quite inconceivable; and I think it more likely that the masses in
 question were  formed in the angular parts of the pleura, near the
 attachments of the diaphragm  and roots of the lungs, and  that they
 have acquired  their rounded shape from the motion to which they
 had been subsequently subjected.
   The serous  effusion which  almost always attends tfie formation
 of false  membranes, is commonly of a lemon, or light yellow  co- 
ACUTE PLEURISY                   i£f,
lour, transparent, or with its transparency only slightly disturbed
by the  intermixture of small fragments, or filaments, of a concrete
pus or pseudo-membranous substance.  In the latter case it accu-
rately resembles unstrained whey.   This resemblance is so great
that some practitioners have really fancied that they had discover-
ed milk itself in the sero-purulent effusion of puerperal peritonitis:
and, truly, such a mistake might be  pardonable, did we  not find
an  effusion exactly similar  in the inflammatory affections of all
serous  membranes, and  in men as well as women.
  In some cases the serum is of a very deep tawny colour, ruddy,
and evidently  mixed  with blood.   Sometimes  it is quite bloody.
This colour, when very deep, seems to be caused by a secondary
inflammation that has been produced in the false membranes them-
selves, as, in such instances, we very generally find them very red,
or covered with a great number  of imperfect  yet very perceptible
blood-vessels.   The portions of the pleura situated beneath false
membranes exhibiting this appearance, are much redder than  in
the most acute recent inflammation.  The effused fluid is gene-
rally without any smell  in  the  acute pleurisy.  1 have found  it
fetid only in a single instance, in the case of a man who died of
pleuro-peripneumony after imperfect poisoning by opium.   In this
case the serosity and  false membranes had a sharp vinous odour
extremely nauseous.
   The relative proportions  of the effused serum and  albuminous
extravasation  are not at all fixed.   Sometimes the serum is  ex-
tremely abundant, and the membranous exudation very small, and
vice versa.  Generally  speaking, the more violent the inflamma-
tion, the more extensive and thick  is the membranous exudation.
In  weak leuco-phlegmatic  subjects, on  the  contrary, we find  a
great quantity of limpid serum, with a small portion of thin mem-
brane, often floating  in  it.   In  such  cases the pleurisy seems to
pass insensibly into  hydrothorax,, as we  shall see  more  particu-
larly hereafter.   In general the limpidity of the serum is propor-
tioned to the quantity of albuminous exudation.
   In some rare instances we find a pseudo-membranerus exudation
uniting the contiguous surfaces of the  pleura, without any serous
effusion.  This would, indeed, be a very common case if we took
into our account those pleurisies which  had  made some  progress
towards a cure, as we shall find directly  that  the absorption of the
fluid  is  the first step in the sanative process.   The  cases, how-
ever, to which I here advert, are those observed in  persons dying
of  some other  disease, and who were, at the same  time, affected
with a slight and partial  pleurisy.  In these cases we find a white 
12G
DISEASES OF THE PLEURA,
 almost colourless, semitransparent exudation, which, while recent,
 readily allows the separation of the parts it unites, and remains on
 the surface of each, exactly like a thick and moist paste which had
 united two leaves of paper.
   In cases of peripneumony, also, more especially those which are
 slight and partial, we sometimes find the pleura pulmonalis in the
 vicinity of the part inflamed, invested by a false membrane, with-
 out there having been any attendant serous effusion.   We observe
 the same thing  frequently in  cases  of phthisis, especially at the
 superior lobes.   Such  instances of partial pleurisy,—or, as we
 might name them in contradistinction to the others, dry,—are, for
 the most part, mere complications with some much more serious
 disease, and are often  unperceived, through their  whole course,
 both  by the physician and  patient.   A local  sensation of heat, or
 occasional slight  and transient pricking pains, are the only indica-
 tions of such an affection in cases of consumption.
   It is the character of the false membranes  produced in  pleurisy
 to be changed into cellular substance, or rather into a true serous
 tissue like that of the pleura; and this is the natural progress of the
 process when left quite  undisturbed.   This change  is produced in
 the following manner:  the  serous effusion  which accompanied the
 membranous exudation is absorbed, the compressed lung expands,
 and the false membranes investing it and the costal pleura become
 united into  one substance.   By and by,  this substance becomes
 divided into layers pretty thick and  opaque,  which are separated
 by a very small portion of serosity.   About this time blood-vessels
 begin to make their appearance  in it, the first rudiments of which
 have  the aspect of irregular lines of  blood, much larger than  the
 vessels which  are to take their  place.   The  blood  seems as if it
 had  been forced  into the substance of the false membrane by a
 strong injection;  and  we find the corresponding portions of the
 pleura redder than elsewhere, and as it were spotted with blood.
 After a time, the pseudo-membranous layers  become  thinner and
 less opaque;  the  lines of blood  assume a cylindrical  shape, and
 ramify in  the  manner of blood-vessels, but still preserving their
 augmented diameter.  On minutely examining  these at this stage,
 we find their  external coat consisting of blood scarcely yet con-
 crete, and very red; within  this there is  a sort of mould, or round-
 ed substance, whitish and  fibrous, and  formed  evidently  of con-
creted fibrine, perforated in  its centre, already permeable to the
 blood, and evidently containing it.  Eventually, the layers of the
false  membrane  become quite transparent, and nearly as  thin as
those  of the  ordinary cdlular tissue,  and the blood-vessels resenv 
ACUTE PLEURISY.
127
be ,n every respect those which ramify on the inner surface of the
pleura.  It wants, however, the firmness  of the  natural cellular
substance, being easily torn in our attempts  to examine it, and its
vessels still retain the large  diameter indicative of their  recent
formation; and it requires some considerable time for them to at-
tain the perfect character of the original tissues of the body.  These
productions are not homogeneous:—they  consist of many folds
which are  united  together by  surfaces which are cellular, like-the
inner surface  of the pleura, and which contain  the vessels; while
their exterior surface is smooth, shining, and evidently exhalent,
like the outer surface of the pleura to which  they adhere.  I have
sometimes, though very rarely, met with portions of fat in the du-
plicates  of these bodies.   These accidental  productions have,
for the.most part, a direction perpendicular to the surfaces where-
on  they originate; that is to say,  the line  of their direction from
the  opposite  points to which they are attached, forms in general
nearly a right angle with  the  pleura.   After having  attained this
stage, these bodies, whatever may  be their extent, do not, in gene-
ral,  affect the health; the respiration  even, except in some parti-
cular cases, does not suffer from their presence.   They possess, in
fact, all the characters of the  natural  serous tissues, being capable
of exhalation  and  absorption  like them, and often containing, in
cases of dropsy, a considerable quantity of effused serum.  Some-
times  they even  inflame,  and, in this case, become invested  by
false membranes similar  to what  they themselves had  originally
been.   This  is, however, very rare, as I have not met with more
than three  or four cases of it, whilst, as we know, nothing is more
common than  the  adhesions we have been speaking of.   It is even
worthy of remark that, in a second attack of pleurisy, the inflam-
mation, and the albuminous and serous extravasation, seem arrest-
ed in their progress by the old adhesions; so that we might almost
state it as a general principle, that the more violent has been the
attack of pleurisy in an individual, the less apprehensions may be
entertained of a second attack.   In  simple pleurisy we find  no
sign whatever of inflammation of the pulmonary tissue, even in the
vicinity of the most inflamed  portions of the pleura; only we find
the substance  of the lungs, in  such cases, more dense and  less cre-
pitous, by means of the compression produced by the effused fluids.
If the extravasation has been very  great, the lung becomes flatten-
ed and completely flaccid; it ceases to contain air, and conse-
quently to  crepitate; its vessels are compressed  and  contain little
blood; and the bronchia, with the exception  of  the larger trunks
are evidently rendered smaller.  The peculiar texture of the lung' 
l£$              DISEASES OF THE PLEURA.
however, is still very perceptible, there being no trace of disorgani-
zation like that  produced in peripneumony; and  if air  is blown
into the bronchia, the lungs become  expanded  more or less com-
pletely.   Sometimes, however, we observe, in such cases, certain
portions of the lungs, without being more dense than natural, pos-
sessing a redness quite like that of muscle, and a compact  homo-
geneous texture in which  we can  detect no trace of the air-cells.
When cut into, this species of degeneration presents a smooth sur-
face, without any of the granular character of lung inflamed in the
second or third degree; neither has it any of the spumous bloody
serum which is observed in lung inflamed in the first degree.   To
this  state of the lung 1  would willingly give the name of carnifica-
tion, which has  been  improperly applied  by some authors to  the
hepatization of the lungs, or peripneumony in the second and third
degrees.   We find this  morbid  alteration sometimes in the central,
posterior, or inferior  parts of the lungs,  in cases where the extra-
vasation has been inconsiderable,  while the superior parts of the
lungs are still crepitous.  In other cases, we find here and there,
in the middle of a lobe quite in its  natural state,  portions of the
size  of a  filbert or almond, in this state of  carnification.  I consi-
der this morbid condition to be  the result of a slight degree of in-
flammation which has  undergone a  partial  and imperfect resolu-
tion.
  I may  here notice one symptom  of pleurisy, accompanied by
effusion, as it is directly connected with the anatomical characters
of the disease: it is  the enlargement  of the chest.   In  cases of
copious effusion into  the cavity  of the pleura, this dilatation of the
affected side has  been   noticed  by all  writers on empyema  since
the time of Hyppocrates; but I have ascertained that the same
thing takes place in the effusions of a recent pleurisy.   I have of-
ten found it very  distinct after two days' illness.  It is, of course,
much more evident in lean than fat persons; and is very indistinct
in woman with large  mammae.  Ou  measuring the affected side with
a piece of ribband, we find it enlarged, but never so much as it ap-
pears to  the eye.   An  increase of half an inch on the circumfer-
ence  is very obvious to the eye.   In proportion  as the effusion
diminishes, the dilatation of the chest insensibly  disappears; and
somet  .ces, as we shall  see more particularly hereafter, the affect-
ed -side becomes narrower than  before the disease. 
CHRONIC PLEURISY.                 129
                       SECTION  SECOND.


                     Of Chronic Pleurisy.


   Chronic Pleurisy does not differ essentially, in its anatomical
character,  from the  acute.   In the chronic disease the pleura is
commonly  of a deeper red; the  serous effusion is  more abundant
and almost always less limpid, being mixed with a great quantity
of very small albuminous flocculi.  The abundance and minute-
ness of these are sometimes so considerable as to render the liquid
quite  puriform, even when left undisturbed.   More commonly, the
serum is of a lemon colour,  although still  less limpid than in the
acute disease,  and thickly intermixed With .the small  fragments
just mentioned,  which, like  coarse flour diffused  through  water,
fall to the  bottom when at rest.   In  such cases;  these puriform
fragments  accumulate in great  quantity in  the most depending
parts  of the thoracic cavity,  and by their consistence form a link
between the sero-purulent effusion  and  the  false  membranes.
These latter never have the consistence of boiled white of  egg as
in the acute pleurisy.  We break them  with the greatest facility
in detaching them from the pleura, they are friable, between the
fingers, and sometimes their cohesion is so  slight that we might
mistake them for a deposition of the  thicker parts of pus.   The
extravasated fluids in chronic pleurisy  are  rarely so  free from
smell as in the acute;  sometimes they have a heavy odour, more
disagreeable than that of healthy pus.
   Confining the term Chronic Pleurisy  to the  affection just de-
scribed, and,  therefore,  not  even including  those  cases of acute
pleurisy which are chronic in respect of  their length of duration,
we may say that the disease  has rarely any  natural tendency to-
wards resolution.   In cases  of extravasations which have lasted
several months, we find no mark of any  step towards the conver-
sion of the false  membranes into cellular substance.   A  cure,
however,  is sometimes  effected  in another  manner, as will be
shown presently.
   The  effusion, produced  by chronic  pleurisy tends,  most com-
monly, to become daily, more considerable.   The affected side be-
comes manifestly  larger.  The intercostal spaces  grow* broader,
and  rise to a level  with the ribs, and  sometimes even  higher;
                              17 
130
DISEASES OF THE PLEURA
The lung of the affected side, compressed towards the mediasti-
num and spine,  and retained in this position by the pseudo-mem-
branous  exudation  which covers it completely, is sometimes re-
duced to a  thi'kness of little more  than half an  inch, even in its
middle, and, without a careful  examination, might be considered
as totally destroyed.'  In this  state the pulmonary tissue is soft,
pliant, and dense like a piece of leather,  without iny crepitation,
more pale than natural, occasionally greyish, and entirely without
blood.   Indeed  the blood-vessels  are  often  seen flattened  and
empty.   The  cellular  texture  is nevertheless  still very distinct;
and  sometimes, though  rarely,  some points are found in the state
of carnfication  above  described.   This case  constitutes the Em-
pyema of auihors, at least of modern authors;  for I apprehend no
one  now considers empyema as the  product  of a vomica  which
has burst into  the cavity of the  pleura.   A softened tubercle may,
indeed, discharge its contents in this manner, and may thus be-
come the cause of a considerable  effusion  by exciting a chronic
pleurisy, but in  such a Ccfse the tuberculous matter must only be
considered in  the light of an extraneous body determining inflam-
mation,  and  consequent effusion, by its mechanical  or  chemical
qualities.  It  is also to this  species of plcivisy that we must refer
those histories of lungs entirely  destroyed by suppuration which we
find tecorclccl  in the older writers.
   Such is  the nature of true chronic pleurisy; and, restricted as  I
have done, it exhibits,  in  none of its stages, the intense  fever,
power of reaction, and acute pain, that characterise an active dis-
ease.  It commonly attacks subjects of a  worn out  constitution,
more especially  such as  have suffered from a tubercular affection
of the lungs or other organ.  This complication with  other dis-
eases,  as well as the usual  want of prominence  of its symptoms,
both general  and local, cause it, for the most part, to  be  overlook-
ed, and almost always misunderstood.
   There is still another species of  chronic pleurisy, viz. the acute
disease,  become so, from any cause which prevents  the absorp-
tion of the effused fluids and  the  conversion  of the false  mem-
branes into cellular substance.   The disturbing cause in this case
is, also,  generally one arising from a weak condition of body pro-
duced by other  diseases.
   The acute  pleurisy, after having passed into  a chronic state,
may exhibit many varieties.  Two of these we shall  notice  pre-
sently, and a third under  the head of Hydrothorax.   A  fourth
variety is. produced by a superfluous afflux of  blood taking place
to the false membranes, at the period of the  development of the 
CHRONIC  PLEURISY.
131
new vessels in these.   In this case the new-formed parts, and the
effused serum, are found deeply tinged with blood, and small  clots
of pure blood  are occasionally met with.  This  state of parts
furnishes a great obstacle to the cure of the disease, and seems to
be the cause of a peculiar modification of the adhesions, which is
to be taken notice of  hereafter.
                        SECTION THIRD.

     Contraction of the  Chest consequent on certain Pleurisies.

   There are some  cases of Pleurisy wherein  the  affected side
never becomes sonorous, in the trial of percussion,  although  the
disease has been completely cured and the effused fluids absorbed.
Although cases of this sort are not  very  rare, they  have not hi-
therto attracted sufficiently  the aitenion of  practitioners;  and  I
apprehend  that  the  pathological  character of  the  affection,
although noticed by several  authors, has not as yet been correctly
or completely described.  The  subjects of this-morbid alteration
are sufficiently distinguishable even by  their  external  shape, and
by their  gait.  They seem always  to  lean towards the affected
side.   This is always  manifestly narrower than he  opposite side,
there being  frequently more  than an  inch  of difference,  when
they are both measured by means of a  cord.   The  length of the
chest is equally diminished; the ribs are closer to  one another,
the shoulder  is lower,  and  the muscles,  especially  the pectoral,
are only half the size of those on the opposite side.   The differ-
ence of the two sides is so remarkable,  that,  at first sight, we
would think  it much greater than  it  is found to be by admeasure-
ment.   The  spinal column generally remains straight; sometimes,
however,  it  at length yields  through the effect  of  the habitual
leaning towards the diseased side.   This  habit gives to  the indi-
vidual the appearance  of  being somewhat,  lame.   (See Plates
VI. and VII.)
   The greater number of individuals in  whom I have detected
this  deformity attributed it to some severe  and  long continued
disease  of the  chest,  the exact  character  of which had  never
been ascertained.  I have more than once pointed out  this altera- 
132              DISEASES OF THE PLEURA.
tion of the form of the chest to individuals, in whom it existed in a
great degree, who were not themselves at all aware of its existence.
All these had experienced a severe disease of long  duration, the
principal site, of which  had seemed  to be in the thorax.  In several,
the disease appeared not to have been very  violent.   Some had had
pleurisies, or pleuro-peripneumonies with  very marked symptoms,
and which had  been long in  getting well.  I was long aware  of
this state of  the chest before I had  an  opportunity of ascertaining
its cause by  dissection.  Most of these patients were  short-breath-
ed, yet could not be said to have habitual dyspnoea.   Cases of very
great contraction are rare; but those of a slight degree of  it are
very  common.
  This morbid  contraction of  one of  the thoracic  cavities  arises
from  a somewhat  irregular termination of chronic pleurisy, or of
the acute pleurisy become*chronic.   In these cases the sero-puru-
lent effusion having contjnuedjor a long time, the false membranes
which invest the pleura  and  lungs acquire a particular hardness,
and an incipient organization, which render them incapable of being
converted into cellular substance.   When the effusion is absorbed,
the lung, long compressed by it, and further bound down by a strong
false membrane completely investing it, cannot dilate itself suf-
ficiently promptly to keep pace with the progress of the absorption;
the ribs, consequently, contract, and the cavity of the chest is thus
diminished.   When the fluids are  completely absorbed, the  costal
and pulmonary exudations come into close contact and finally  unite,
so as to form only one substance.   The  consistence of this becomes
daily firmer, and, after a few  months, acquires the consistence and
all  the other characters of a fibrous or fibro-cartilaginous  mem-
brane.
  If  we dissect carefully this species of membranous production,
we  find that, although  it adheres closely to the  pleura of the ribs
and of the lungs, it can be detached from these  almost entirely.
If we cut it transversely we  find  it composed of three different
layers;  two  exterior, which  are,opaque, white, and  completely
fibrous, sometimes cartilaginous and even ossified in certain points;
and one intermed iate, which is semitransparent, and resembling,
in every respect, the central  and most transparent portions of the
intervertebral cartilages.   This last layer  is evidently the medium
of  union  between  the two  others.  Although  it be obviously  a
posterior production, and can only have taken  place after the or-
ganization of the false membranes had been far advanced, I do
not. consider it as  strictly the product of inflammation.   I would
rather consider.it as analogous to the gelatinous and semitranspa- 
CHRONIC PLEURISY.
133
rent exudation which forms the first step in the union of bone and
tendon.  The ordinary thickness of these fibro-cartilaginous mem-
branes varies from two to  five lines.   This gradually  lessens for
a time after their formation,  and is proportioned to the thickness
of the layers which have given rise to it.   In some ca^ses of chronic
pleurisy I am disposed to believe that there may be an albuminous
extravasation on the pleura without any-observable serous effusion;
and that, in this case, there may be union of the lungs  to the side
by a fibro-cartilaginous membrane (formed of this)  which does
not exhibit the three distinct layers above described.
   These fibro-cartilaginous membranes have been commonly de-
scribed under the  name of thickenings of the pleura;  and this is a
mistake very likely to be committed by those who  trust to the mere
appearance of these, without further examination.   On dissecting
these  we can always separate them from the pleura, which is found
of its  natural thi<  kness.  We must not confound ihese membranes
with the fibro-cartilaginous  incrustations of a like nature, which
are sometimes formed  on the exterior  or  adherent surface  of the
pleura, and which I have described elsewhere.   (Diet,  des. So.
Med.)
   The contraction of the chest, which  coincides  with  the  period
of the absorption of  the serous  effusion, is  frequently not to  be
perceived till after several months of disease: frequently, even, the
patient has long been in a state of doubtful convealescnce before it
is at all manifest.  At length, however, after a long period of  ill
health,—sometimes of no less duration than two or three years,—
the patient regains perfect and often permanent health.
   On  examining the chests of those who had this contraction in a
very decided manner, I have uniformly found the fibro-cartilaginous
membrane  above described,  and I have further found  the lung in
that state of compression and flaccidity, which  rendered  it  ex-
tremely like a piece of muscle of which the fibres were so fine as
to be  undistinguishable.   Sometimes the  compressed  lung is  as
red as muscle, and at other  times, of a.grey colour more  or less
deep.   This last I consider  as the proper colour of lung  simply
compressed, and  imagine the red  colour to be given  by a  sort of
passive Congestion of blood  in the part.  The  morbid state of
parts  we have been describing seems to exclude almost the possi-
bility  of a  relapse; for, if this be rare  in  cases  where the  lung
and pleura are united by cellular substance, it ought to be infinitely
more  so  when  the uniting tissue is one so very little disposed  to
inflame as the fibro cartilaginous.
   Although in all cases of considerable contraction  I  have-found 
134
DISEASES OF THE PLEURA.
         the fibro-cartlaginous membrane, I am inclined to think that there
         may be a certain degree of diminution of the chest in cases where
         a pleuritic attack has terminated  slowly by means of cellular ad-
         hesions only.  Such adhesions, however, undoubtedly  exist very
         frequently without being attended by any contraction of the chest,
         or, indeed, by any perceptible affection of the respiration  or gene-
         ral health, since  we know that they  are found, more  or less,  in
         almost every adult body.  It is not  the adhesions, whatever be
         their nature, that occasion the contraction of the chest, but the
         more or  less tardy development of these.  The more rapid has
         been the absorption of the effused fluid,  in  a case of pleurisy, the
         less likelihood will there be of the contraction taking place.  The
         fact is, that  (he pulmonary  tissue,  like- every other part of the
«        living body,  the longer  it has been subjected to  compression, the
         less readily will it  return to its original slate when the compression
         is removed.   A limb long compressed  by a bandage  will regain
         its size much more slowly than one  thai has been bandaged  for a
         few hours.   The consequence of this is, in the case of the com-
         pressed lungs,  that as they do not yield sufficiently fast to fill the
        cavity left by the absorbed fluid, the thoracic parietes must  contract
        proportionally in order to prevent the vacuum that must otherwise
         take place.
           This contraction of the chest, consequent on pleurisy,  being but
        little known,  I  shall give  here  a few  cases  of it.   The first and
        second afford  examples of the disease  after it has passed  through
        all its stages; the third exhibits its progress, and, also,  the  state of
        parts  anterior to its final termination; the last  is a more curious
        complication  of symptoms.
           Case 30.   A woman,  aged 30, had  been affected  with cough
        for several years,   but much more severely within the last  four
        months.   She came into hospital in the last stage  of consumption,
        much emaciated, with hectic fever and purulent expectoration.
        She died  fourteen days  thereafter.   Upon  inspecting  the  body
        after death, the left side of  the  chest  was found  to be  evidently
        diminished in all its dimensions; the intercostal  spaces were so
        much contracted that the ribs seemed to touch each other.   The
        right side was of natural form and size, and appeared  larger  than
        the other by one-half.  This deformity had not been observed  dur-
        ing life, owing to the patient's  clothing   The right lung adhered
      .  to the  diaphragm  and the  mediastinum, in  its whole extent, by
     •   well organized  cellular  adhesions.   This lobe  contained many
        tubercles in every stage.   In the superior lobe  there was one tu-
        berculous excavation capable of containing  a small pullet's egg. 
CHRONIC PLEURISY.
135
The left lung was  one half less than the right; it  was retracted
towards the spine and ribs, so that its internal  surface was  turned
forwards, yet did not reach further than the origin of the cartilages,
and'did not at all cover the heart:  it adhered so firmly to the ribs
that it could not be separated without detaching it from its  invest-
ing pleura.  This  adhesion was effected by the medium of a sub-
stance altogether similar, in texture,  colour, and  consistence, to the
fibro-cartilaginous bodies.   This substance was about two lines in
thickness, and was divided into two  layers, which  were separated
from each other by a third, much thinner than they.   This was of
a bluish grey colour and semitransparent,—qualities which  form-
ed a contrast with the whiteness and opacity of the others.   This
intermediate layer resembled perfectly the  transparent  central
portion of  the  intervertebral  fibro-canilages;  it was  less  solid
than the other two, yet possessed, with them, the fibrous structure.
The pleura pulmonalis and costalis,  especially  the  former,  were
very distinct exterior to these  false  membranes.  The pulmonary
tissue, more flaccid and rtddei than natural, had lost its  crepitous
feel, and was of the aspect and consistence of muscle.
   Case 31.   In March 1818, a man, aged 18, came into hospi-
tal, affected with recent diarrhoea  and a  complaint of the  chest
of some standing.  In the winter of  1816 he had  been affected
with a violent  cold, attended  by severe cough, much  dyspnoea,
and great pain of  the left side.   This  side of the  chest was now
evidently smaller  than the  right  in  every  dimension; and the
shoulder'being  thereby lower, the man had  the appearance of
being  lame.   JHe  bent the left leg more than the  right, and  when
he stood upright he seemed to support himself on his  left hip.
This side yielded  a dull sound, on percussion, and  the  sound of
respiration was scarcely audible (by the stethoscope) in  any part
of it:  both these were otherwise on the right  side.  This  man's
diarrhoea  continued  with  some intervals of  amelioration, but
eventually  with  the  addition of abdominal tenderness,  and  he
had an attack of  severe pain  of the right side increased by cough
and inspiration.   These symptoms,  especially the diarrhoea, ex-
hausted his powers, and he died in August.
   The left side of the chest was found one-third  smaller than the
right,  and the intercostal spaces much narrower.  The  lung on
this side  was intimately united to  the pleura of the ribs, in its
whole extent, by  a false  membrane one line thick in its superior
 part, and  two  lines in its inferior  part.   It was white,  of a con-
 sistence almost equal to that of fibro-cartilage, and of a texture
 somewhat similar; as fibres, both longitudinal and transverse, were 
136
DISEASES OF THE PLEURA.
very visible  in  it, especially  at its  inferior part.   In several
places  tbis false membrane  was united to the pleura by means of
cellular substance  containing serum; in  other  places, these two
were closely united, yet still very distinguishable from each other.
The lung was flattened upon the mediastinum.  Its substance was
still somewhat crepitous, but flaccid and  injected with serum.   It
contained many  tubercles, for the most part miliary.
  The right  lung adhered to the  costal pleura by means of  a soft
false membrane, which  exhibited reddish vascular points on  its
surface.   A still thicker layer of the same kind invested the dia-
phragm and adjoining lung.  There was a little reddish serosity
in the cavity  of the pleura.  The tissue of the lung was crepitous,
containing a  considerable quantity of  serosity, and,  also, several
miliary tubercles.
  Case 32. A man,  aged  66, in October  1817, caught a severe
cold, marked  by cough, and  subsequently by great pain  in  the
chest and hemorrhage from the  lungs.  This  attack was  followed
by hectic fever, constant cough and dyspnoea.   He came into hos-
pital in March, affected with much cough, very viscid  yellowish
expectoration, and hard and frequent pulse.    In the left side of the
chest percussion elieited  a clear sound, and the murmur of respi-
ration was distinctly heard  through the stethoscope: both  these
indications were considerably less distinct in  the right side.  The
disease seemed to decrease for several weeks in this and the follow-
ing  month; but the cough and  expectoration  still continuing, artd
his lower extremities becoming swelled, he lost ground in the end
of May, and  emaciated considerably.   In the beginning of June
we  first perceived  the  intercostal  spaces  on the right side to  be
diminished in width: by  the middle of the month the general con-
traction  of this  side  of the chest was very  distinct.   This man
died towards  the end of the same month.
  On  examining the chest after death,  it was found  that the dia-
meter of the  right side,  both laierally and from before backwards,
was less by an inch than that of the left; and  the intercostal spaces
were narrower.
  The left lung was  of natural  size,  had no adherence to  the
pleura, and was  crepitous throughout.  It was gor«ed with blood,
especially on the posterior part.   It contained some tubercles in
the  early stages.  The left lung was one-third Jess than the  right,
and adhered  intimately  to  the  costal  pleura by its  whole  upper
lobe as low down as the second and third ribs.  This aihesion
was effected by a well organized  cellular  tissue,  evidently  of
ancient date.   The remaining pleura of the lungs and ribs, in the 
CHRONIC  PLEURISY.
137
wliole of the lower part of the lung and the  anterior portion cor-
responding with the false  ribs, was also closely unittd; but this
adhesion, which was evidently of recent  date, was effected by
means of a concrete albuminous layer, three  lines in thickness, of
a  yellow colour and  opaque, and  partially tinged with  blood.
This membraniform  layer  could  be removed in  plates or folia,
which were of greater firmness  the nearer  they apprdached the
pleura,  on  either side,—especially the pleura pulmonalis,—on
which they had a degree  of consistence nearly equal  to  that  of
the fibro-cartilages.   On  the contrary,  the centrical layers were
hardly of a tenacity double that of boiled white of  egg.   At the
point of junction of the ribs with  their cartilages and on the an-
terior and exterior parts  of the lung, this  albuminous stratum di-
vided into two layers, one  of which invested all that  portion  of
the lung remaining unattached t6 the side,  and the other the cor-
responding portion of the pleura; and these two afterwards united
so as to form  a shut sac or pouch.   The inner surface of this sac
was nearly throughout of  a bright  red colour, which seemed as if
applied with a pencil, and amid which no  traces of vessels could
be distinguished.  This red colour did not at all enter into the
substance of the albuminous stratum, which  was,  throughout, of
a yellowish  white, and slightly semitransparent, becoming more
white and opaque as it approached the pleura. This sac contained
about two glassfuls  of a bloody but limpid  serum,  which com-
pressed, at this part, the lung towards the mediastinum, leaving a
space between it and the ribs of an inch and half at its greatest
width.   Eight or ten pseudo-membranous  bands crossed this ca-
vity, being attached, at each end,  to the pleuritic layers.   These
were softer and more fragile than old cellular  adhesions; they were
very thin,  diaphanous,  and colourless, towards their middle, but
at their  extremities  they assumed greater  firmness,  and also the
opacity and colour of the layers to which they are attached.
   In the top  of this lung there was an  external depression,  cor-
responding with a fibro-cartilaginous substance internally, such as
formerly described under phthisis pulmonalis, and which I showed
to be a true  cicatrization of a tuberculous  cavity.   In its interior
parts the lung was  flaccid,  not  crepitous, dry,  and  resembling
muscular flesh.  In the upper portion there were many immature
tubercles.
   The pleura, in the parts corresponding to the false membranes,
was much redder than natural.  The heart was sound.
   The cavity  of the peritoneum contained  about four  pints  of a
reddish serosity, partially limpid.   The whole of the peritoneum.
                              18 
|3g              DISEASES OF THE PLEURA
as well on the abdominal parietes as on the mesentery and uites
tines  was studded with innumerable small, grey, semitransparent
tubercles.   Upon the  mesentery and bowels  these  were quite
transparent, and of the size of millet-seed; on the abdominal pa-
rietes they were flatter, greyer, and less diaphanous.   The perito-
neum was, moreover, marked in different places, by red, punctuat-
ed spots, which were either of a bright red, or almost black.   In
these points, on scraping with'the scalpel, a  small quantity of a
semitransparent exudation",  of a  grey colour and mixed with dots
of blood, could be detached.   This  matter  was very  like paste,
only a little firmer.  It was so  thin as only to be discovered  by
scraping: after its removal  the peritoneum appeared somewhat les3
red.  The tubercles seemed to  be so  intimately  connected with
the peritoneum,  as not to be detached by scraping: this membrane
was not sensibly thickened.
   Case 33.   A boy, 12 years of age, was attacked with a severe
pectoral affection, marked  by violent  cough,  acute pain of side,
dyspnoea and fever;  followed, in a few days, by  considerable hae-
moptysis, and, subsequently, by  expectoration of a purulent fluid
in great quantity.  The disease then took a chronic form; and, in
the course of a few months, an abscess pointed externally between
the cartilages of the seventh and  eighth ribs, which, when opened,
discharged a considerable quantity of pus.   Since then (now six
years) the aperture has remained fistulous, daily discharging  one
or two spoonfuls  of pus   Occasionally, during  a temporary ob-
struction of the  orifice, the expectoration of this patient  has be-
come augmented, and  the  sputa have been then always perfectly
like the pus usually  evacuated from the abscess.
   At this period I examined the patient.   He was much emaci-
ated, but not like one wasted by consumption, the emaciation be-
ing confined rather to the bones  and muscles, than to the  cellular
membrane.   He was extremely small for his  age. The left side
of the chest was at least one third narrower than  the  right,  and
this contraction was most remarkable at the inferior margin and in
the antero-posterior diameter.  On examining the thorax the whole
rigbt side yielded a clear sound on percussion, but one less distinct
on the left.   The respiration was quite distinct over the whole of
the light side; it was very  indistinct in the  superior  part of the
left side, and quite inaudible  in the  whole inferior portion.  Pec-
toriloquism, also, existed in the lateral and  superior  part of the
same side.
   From all these circumstances it is evident that in  this  case, in
the first instance, the maturation of one or more tuberculous masses 
CHRONIC PLEURISY.                 189
nad  been attended  by an acute  pleurisy; that, although Ihe tu-
bercles, when softened, had been expectorated, yet that a commu-
nication between the remaining excavations and  the pleura  had
been subsequently established, which had given rise to the external
abscess.   The eventual formation of a fibro-cartilaginous mem-
brane had produced  the union  of the lungs and  pleura, and  the
consequent contraction of that side of  the chest.   As this patient
has already lived so  long  with this affection, it is probable, if the
expectoration does not  greatly increase, that  he  may survive a
long time yet.   Willis relates a case similar to the above.*
                       SECTION FOURTH.

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

   Gangrene of the pleura is a very rare disease.   It is always
 of very small extent, is scarcely ever a primary affection, or a ter-
 mination of the acute inflammation.  Mos" commonly it is the con-
 sequence of the bursting of a gangrenous abscess of the lungs into
 the pleura, (see  page 66) and occasionally it supervenes to chronic
 pleurisy.
   This disease presents the appearance of soft  gangrenous spots,
 of a brownish or blackish green, round or irregular, and  not  ex-
 tending beyond the pleura.   When these gangrenous patches have
 been removed by the softening down of their substance,  the bor-
 ders of the ulcerated part left behind, remain blackish for a long
 time.   Sometimes the  parts beneath the pleura are affected to a
 very small depth; and almost always the  cellular substance  be-
 comes greenish and filled with serum to some distance around the
 eschar.  In softie instances the intercostal muscles, the neighbour-
 ing portions of the lung, and even the ribs, participate more or less
 in the  disease; and all exhale the gangrenous fetor.
  A general inflammation of the  pleura, and the  consequent forma-
lion of false membranes to a great extent,  and a copious effusion,
 always follow gangrenous affections of the pleura, if these are not
 the consequence of an old pleurisy.   In every case the false mem-
 branes, whether old or  new,  put on the gangrenous character in
 i greater or less degree.  This is particularly  observable in the
* Op, omn. Lib. ii. Cap. xiii, Sect, 1 
140
DISEASES OF THE PLEURA.
case of a gangrenous abscess bursting into the pleura.   Only onc<
have I found this state of the pleuritic membranes, in a case where
tlie gangrenous abscesses were  still  without  any  communication
with the cavity of the pleura, and where the gangrene of the false
membranes seemed to  be idiopathic.  It sometimes  happens  in
chronic pleurisy that a gangrenous eschar forms on the pleura, and
permits the effused fluids to escape through the intercostal muscles,
so as to be finally evacuated, either naturally or artificially, and
that the empyema is  thus  cured.   This  species  of  abscess has
been long known.  It is, however, very rare; M. Recamier has
only seen  it twice, and I have only met with one case of it.
   Besides gangrene  of  the  pleura, nature has one other way of
evacuating, externally, the sero-purulent effusion of the chest; this
is by the formation of an abscess between the  layers of the inter-
costal muscles, or between these  muscles and the skin, which, burst-
ing both externally and  internally, affords  a  passage  for the dis-
charge of  the  contained fluids.   I have met with a single  case  of
this kind.   A cure has frequently followed the evacuation procured
by means of these kinds of abscesses.  This is, however, rarely
complete;  and it is more common for Ihe disease to degenerate into
an incurable fistula, which is frequently kept up by a carious state
of the neighbouring ribs.
                       SECTION FIFTH.

                   Of circumscribed Pleurisy.

   It  occasionally happens, particularly in chronic pleurisy, that
the effused  fluid is  confined to a partial  space of small extent,
owing to the obliteration  of the remainder of the cavity of the
pleura by former adhesion.  These circumscribed, pleurisies  are
observed in  the three following situations chiefly: 1st, the inferior
and lateral part of the cavity  of the pleura;  2nd, the  space be-
tween the base  of  the rungs  and the diaphragm;  and  3rd,  the
fissures between the  different lobes.   In these  cases  the effused
fluid,  which is commonly puriform,  is enclosed in a false mem-
brane which lines very exactly the surrounding  parts.
   When seated  in the  fissures  between the lobes, the  edges of
these  are  found closely adherent by  means of cellular substance
of recent formation,  while  the opposing surfaces of the  lobes
themselves are separated by the  interposed effusion.   Bayle  was 
CHRONIC PLEURISY.
141
the first who described this species of partial pleurisy, which an
inattentive observer might easily mistake for  an abscess of the
lung.   This  species is very rare, a thing  which  seems rather
singular, when we consider how often we find the edges of these
interlobular fissures  adherent in cases of peripneumony attended
by a slight pleurisy.  In such  cases it would seem that the resolu-
tion of the peripneumony leaves these fissures converted into a sort
of sac, which will  occasion  the circumscribed effusion we  have
been describing, in  the event  of that part of the pleura being af-
terwards attacked by inflammation.
  The second variety of  circumscribed  pleurisy is equally  rare,
and presents precisely the same anatomical characters. The third
variety is not  uncommon.  These partial collections of matter,
when in any considerable quantity, press forcibly on  the side  of
the lungs (as this is the only direction in which they can extend)
and produce a sort of cavity  in these, as  if there were actually a
loss of substance. If, however,  on evacuating the pus, we remove
the false  membrane which lines the apparent abscess, we immedi-
ately perceive that  the luug is merely compressed, and that  even
the pleura is uninjured.
   I shall conclude this account of the several varieties of pleuritic
inflammation, with  several cases which  illustrate many  of the
statements already made.   In all of them will be found the com-
plication of air effused into the cavity of the pleura, a complication
which will be treated of  more particularly, by and by, under the
name of Pneumo-Thorax.                        \
   Case 34. A man,  aged 32, was seized for the first time, in May
1817, with a catarrhal affection, attended by eough,  dyspnoef, &c.
which continued,  with variable  severity, until the beginning of
November, when he came under my care.  At  this time there
were  considerable  emaciation, hot skin, small and frequent pulse,
short  and quick respiration, much cough,  and considerable expec-
toration of opaque, yellow and very viscid sputa. The stethoscope
gave indication of tuberculous excavations in the lungs.  The Ye
brile  and  inflammatory  symptoms continued; and,  during  the
course of the following month,  acute pain in different parts of the
chest  supervened: at the same time, the cough became more trou
blesome,  and to the  yellow opaque sputa there was now super
added  a  copious  discharge  of transparent  and  frothy mucus.
Percussion of the  thorax  yielded a much  clearer sound on  the 
142              DISEASES OF THE PLEURA.
right  than  on the  left side;  while  the respiratory murmur was
distinct in the latter,  and not  at all perceptible in the former.
The  tinkling  metallic sound, already alluded to (and which we
shall hereafter find to be  characteristic of the  simultaneous ex-
istence of air and some  liquid in the chest,) was, also, very audi-
ble on the right side.  The  patient lay almost  constantly on the
right side, the intercostal spaces of which could  now be perceived
to be  wider and  more prominent than  natural,  and the subcuta-
neous  veins more  obvious.   All these symptoms indicated the
supervention of a pleurisy, with effusion  of both air and a liquid
of some sort into the right side of  the chest.   Towards the end of
January the patient first perceived the fluctuation of a liquid in
his chest when he turned himself: the same thing was  very dis-
tinctly heard by the bystanders when the trunk was  shaken in a
sitting posture.  In  February the sputa amounted to about six
ounces in the twenty-four hours;  they were yellow, opaque and
puriform,  intermixed  with bubbles of air, and swimming, as  it
were, in a  large proportion  of  a transparent and diffluent mucus,
in which there  were sometimes  streaks  of blood.  One day in
this month, he expectorated, after a fit of coughing, as much as
he usually did in the whole twenty-four hours.  At this  time the
operation  of empyema  was  performed, between  the sixth and
seventh ribs, by means of a trocar only one line in  diameter.
Two pounds of matter  flowed  in twenty minutes.  This matter
was puriform, opaque, of a slightly greenish yellow colour, and
scarcely fetid.  As it flowed it was intermixed with some air-
bubbles; and, on settling, it separated into two portions,—the one,
opaque  and yellow, and  composed of small  yellowish flocculi,—
the other, thinner and transparent.   The patient  felt  relieved in
proportion as the matter  flowed,  and  this alleviation  continued
for two days, but he Sunk on  the 12th day after the operation.
   On examining the  body after death, we found that the succus-
sion of the trunk produced the sound of fluctuation as before.  On
puncturing  the thorax a  gaseous fluid escaped.  The right side of
the thorax was larger than the left,  and contained two pints of a
serp-purulent fluid.   The whole extent of  the pleura, on  this  side,
was lined by a thick layer of coagulable  lymph, the consistence
of which varied in different  places,  from  that  of soft cheese to
one nearly equal to that of cartilage: it was softer on the surface,
ind more dense where it touched  the pleura.   It was several
lines thick on the lungs, and on the right side of the mediastinum
and diaphragm; it  was thinner, softer,  and more easily detached,
>n the pleura of the ribs and remaining portion of the diaphragm, 
CHRONIC PLEURlSf.                  ] #:
both of which were of an intense punctuated red colour.  The
pleura of  the lungs had none of this punctuated appearance, and
the layer in contact with it, which was of a cartilaginous firmness,
could not  be detatched from  it.  The lung was compressed  to-
wards the spine and  posterior part of the ribs  (to which it closely
adhered,) so that  it  hardly occupied one third part of the cavity.
The pulmonary tissue  was flaccid, but  still somewhat crepitous,
and permeable  to the air in its posterior part.   There were several
tubercles  in this lung,  from the size of a cherry-stone to  that of a
filbert, and almost all  softened to the consistence of curd.  Five
of  these,  of a  somewhat larger  size, quite softened and  nearly
empty, communicated  on the  one side with the bronchia, and, on
the other, with the cavity of the pleura, by openings of from one
to three lines  in diameter.
   The left lung  was of the natural size, and  contained, also, a
great many tubercles in different stages of  maturity:—the greater
number  being small and diaphanous;—a few, quite softened  but
not communicating, with  the  bronchia.  The mucous membrane
was  very  red through its whole extent, and there was a small
ulcer  in  the  posterior part of the larynx.   There was  a small
quantity of serum in the pericardium, and, also, in  the peritoneum.
   Case 35.   A man,  aged 20, who had been  unwell (he said) for
six months, and  who had suffered  from diarrhoea for the three
last,  came into hospital in January, exhibiting all the usual symp-
toms of confirmed Phthisis, and, among  others, that of a  very dis-
 tinct pectoriloquism at  the  superior part  of the  left side of the
chest.  In the beginning of March a sudden alteration took place
in the symptoms:  the respiration  becoming more difficult, attended
with pricking pains in  the right side, the pulse getting quicker,
 the skin hotter, and the face flushed.   On examining the chest at-
 this time by percussion and the stethoscope, it was found that the
 right side, which on the day before had  yielded only a dull sound,
 now resounded more than the other; while the respiration was very
 perceptible on  the left side,  and  not at all on  the right.  These
 symptoms I regarded as indicating pleurisy, arising from the irrup-
 tion of tuberculous matter into the cavity of the pleura, and attend-
 ed both by liquid and gaseous effusion.   I wished farther to ascer-
 tain  the effusion  by the  succussion  of the chest, but the patient
 was  too weak to  undergo the trial, and he  died four days after the
 marked change in the symptoms.
    The fluctuation of  the fluid in the right cavity of the chest was
 very perceptible,  on succussion,  after death.   This side appeared,
 \lso, larger than  the left; when struck  it emitted  a  clear sound: 
144
DISEASES OF THE PLEURA.
 and when punctured an elastic fluid escaped from it with a hissing
 noise.  There was found in the cavity of the pleura a considera-
 ble  quantity of a sero-purulent liquid, of a greenish yellow colour,
 and semitransparent, notwithstanding the great portion of puriform
 fragments that floated in it.  The  pleura  was lined  throughout
 with an opaque albuminous exudation, of a yellowish white  colour,
 easily scraped off by the scalpel, and of the consistence of curdled
 milk.  This layer was of considerable thickness on some parts of
 the ribs and diaphragm, and thinner  on  the lungs.   The lung on
 this  side  was compressed into one-third  or one-fourth its natural
 volume against the spine and mediastinum, to which last it  closely
 adhered.  It was flabby and very imperfectly crepitous through its
 whole extent, and contained hard  tumours, which were evidently
 tubercles.   On the closest examination no opening  could be dis-
 covered on  its surface.   In  the very summit of the superior lobe
 there were found three tuberculous excavations; two of which, of
 the size of a hazel-nut, were full of soft matter, and the third, six
 times  as large, and capable of containing  a pullet's egg,  nearly
 empty.  This vast cavity was lined by two  membranes, the inte-
 rior  (that in  immediate, and  close contact with the pulmonary tis-
sue) of a semi-cartilaginous density,  and  the exterior soft,  almost
 entirely opaque, and easily torn.  The former existed only in some
points; the latter  was  complete.   The remainder of the lung was
filled by miliary tubercles.   The left lung  appeared quite  sound,
 only containing a few miliary tubercles.
   Case 36.   A man, 35 years  of age, while in hospital  for a
 chronic affection of the knee^ was suddenly attacked, in January,
 with  pleuritic  symptoms, viz. headach,  pain  in the chest  aggra-
 vated by respiration, frequent cough, and expectoration of white
 and very copious sputa.   Getting better he left the hospital in the
end of February, but returned again in the middle of March.  At
this time there were decided symptoms of pleurisy with effusion
into  the chest, and also of phthisis,—according to the indications
of the stethoscope:  the  common  symptoms were—hot  dry skin,
frequent  pulse, quick short breathing, frequent cough, and expec-
toration (not very copious)  of a frothy  mucus  intermixed with
sputa of a yellow colour and opaque.
   The same symptoms continued, with increase of emaciation and
cough in  June and July.   In August, diarrhoea supervened, with
increase of cough and fetid  purulent expectoration, to the  amount,
for a short time, of a pound and half in the twenty-four  hours.
In October,  there was again copious fetid expectoration, with
 dyspnoea and  much cough, and  inability to lie on the right side 
CHRONIC  PLEURISY.
145
At this time both sides yielded the same sound on percussion, but
respiration could be perceived in the right side only.   Fluctuation
in the left side was also  perceptible on suc< ussion,  by means of
the cylinder, but not without it.   The patient said that a momen-
tary attempt to lie on the right side increased the frequency of the
cough and greatly  augmented  the expectoration.   He was not,
however,  sensible of any fluctuation in the chest.  He died in the
beginning of November.
  On  examination  after  death, the left side of the thorax was
found larger than the right; the-left intercostal spaces were wider
and raised to  a level with the libs, while the right were sunk be-
low that level.  On puncturing the thorax on  the left side, an ex-
tremely fetid gas made its escape with a hissing sound.  On lay-
ing it open it  was found to contain about three pints of a blackish
grey liquid, extremely  fetid, and having somewhat of the smell of
garlic.   The lungs on  this side  were  compressed against  the
spine, and were not larger than  the hand.   Their surface was co-
vered  with a layer  of a  half-concrete white matter, intermixed
with a very soft black  substance    On it there were  two openings
of the size of the finger, which terminated, interiorly, in the sub-
stance of the lungs, in culs-de-sac not communicating with the
bronchia.   They were evidently  the remains of tubercular exca-
vations which had discharged their contents into the  cavity of the
pleura.  The whole of the false-membrane  which invested the
pleura was  black and  soft, on  the  surface, but  below this it was
firmer and whitish.
  The right lung adhered to the pleura throughout by old attach-
ments, and contained,  internally, a great  number of miliary tuber-
cles.   In  its upper  lobe  there  was an empty excavation, of the
size of a filbert, and lined  by a  well organized semi-cartilaginous
membrane.   In the  middle of  the same lobe  there were found
several white  bands resembling  ancient cicatrices.   (See Book I.
Chap. I. sect  2.)  Two of these united in the  form of the  letter
V, and contained between them  a mass of tuberculous matter.*
  Case 37. A man, aged  29,  caught a  severe  catarrh from ex-
posure to  much  cold in the  beginning of October, which he ne-
glected, as he had done a cough with which he  had  been affected
in the preceding spring.   This catarrh, after a few weeks, was
followed by spitting of blood for several days, and,  subsequently,
by a continual cough,  dyspnoea and emaciation.  In the begin-

  * This case affords another proof of the cicatrization  of tuberculous cavi-
ties, and also of their conversion into fistulac.
                               19 
14$             DISEASES OF THE PLEURA.
ning of February he' came into hospital.  At this time he was evi-
dently in a confirmed  consumption—being affected with  great
emaciation, frequent cough, yellow opaque  sputa, dyspnoea, diar-
rhoea,  pectoriloquism.  Things continued  much in the same  way
uniil  the seventeenth,  when  the supervention of  more febrile
symptoms  indicated a  slight  peripneumony.   On  applying the
cylinder, it was found that respiration was  not at all audible on
the anterior and lateral portions of the left side of the% chest; while
percussion gave a much distincter sound than on the  right side;
arid succussion of the trunk produced the  characteristic noise  of
fluctuation.  From  all  these  circumstances, being convinced  of
the existence of both air and pus in the cavity of the pleura, and
seeing no other means of alleviating  the patient, I proposed the
operation of empyema   This, however,  was not performed,  as
he died the same day, although at the  hour  of the visit there did
not seem  any thing indicative of so sudden a termination  of his
disease.
   On examining the body  after death, the  left side of the  chest
appeared to me evidently enlarged; but this  was doubted by some
of the persons  present.   On  percussion  it certainly  yielded  a
much clearer sonnd than  the  other,  and succussion of the trunk
produced the noise of fluctuation.
   On  puncturing the thorax  with a  scalpel on  the  left  side, a
nearly inodorous gas continued to escape, with a hissing noise, for
nearly a minute; and, on  opening it,  it was found  three-fourths
enlpty, the lung being found only of one-third its natural size, and
compressed towards the  mediastinum,'but without adhering to it.
In the same cavity there was scarcely a pound of a liquid resem-
bling  whey, of a whitish colour,  turbid, and containing portions
of yellowish half-concrete  albumen.    The whole of the lung, on
this side,  was  covered With an irregular albuminous membrane,
which in several places greatly resembled an omentum moderately
loaded with fat.   In the top of the superior lobe there were two
excavations, containing only a little soft tuberculous pus, arid each
capable  of containing a walnut.  Both these were lined  by  a
double membrane, and communicated with bronchial tubes.   The
Whole  lung was filled by tubercles in every  stage.   The upper
lobe of the right lung adhered to the pleura, and contained a series
of large tuberculous excavations, partly empty, and all lined by
the semi-cartilaginous  membrane.  -This  lobe further contained**"
many immature tubercles: the  other lobes were sound.
   Case 38.  A man, aged 22,  became affected, in the beginning
of October, with a  severe  catarrh,  which he attributed to drink-
* 
CHRONIC  PLEURISY.                 147
ing cold water while hot.  This was followed by a constant cough
and considerable haemoptysis.   He went  into an  hospital at the
end of two months,  and after remaining there a fortnight and be-
ing bled, his cough  having become somewhat better, he left it.
Having had a fresh  attack ten days thereafter, he came into the
hospital  under my care.   At this time he was affected with pros-
tration of strength, impeded  respiration, frequent cough with vis-
cid, frothy, and somewhat  adhesive expectoration, and acute pain
in the whole  right  side of the  chest.   Respiration  was perfect
over the whole of the left side, but was  not perceptible on the
right, except  under the clavicle.  Being  considered as  affected
with pleuro-peripneumony of the right side,  he  was bled and put
on  proper regimen.   After a continuation of this treatment the
pain of the  side  disappeared, and  the  respiration  became  freer,
but the patient did not recover  strength, and he was, further, at-
tacked  with  diarrhoea.  Suspecting the existenceof tubercles, I
examined him  with  the stethoscope, and detected pectoriloquism
about the right shoulder-blade.   I  further  found at this time that
the respiration continued to be  very  indistinct in  the right  side,
while percussion  elicited from it a  much clearer sound than  from
the left.   This fact, and the additional sign of the metallic  tink-
ling, convinced me of  the existence both of pleuritic effusion and
effused  air (having  a  communication with the  bronchia) in the
right side of the chest.  This was  further  confirmed  by the noise
of  fluctuation  produced  by  the hippocratic  succussion.   There
was, at this time, no appearance of oedema on the right side; the
intercostal spaces were not at all enlarged; nor  did the  liver ap-
pear to be at all pressed .downwards into the abdomen.  However,
as the patient had lost scarcely any flesh, and his strength seemed
rather oppressed than exhausted, I entertained hopes of saving him
by  the operation of empyema.   Immediately  after this determina-
tion, the patient expectorated a  very great  quantity of a very  fetid
pus quite different from his usual sputa;  and  this was followed by
increased difficulty of  respiration, and other  symptoms indicating
a recent peripneumonic attack on the left side.
  The operation was then performed, the incision being made be-
tween  the fifth and  sixth ribs (counting from  above), about  their
middle;  but no matter flowed, although the passage of air by the
wound during respiration proved the penetration of the chest by
the incision.   Shortly afterwards he again expectorated  a  large
quantity of very fetid pus, and died four hours after the operation.
  On examining the body after  death, the  right side of the thorax
V 
148
DISEASES OF THE PLEURA.
appeared  somewhat smaller  than the left*  Succussion  of the
body produced  the  sound of fluctuation, but less  distinctly than
before death.   On puncturing the right side of the chest, near the
junction of the third rib with its  cartilage, a large  quantity of ex-
tremely fetid gas made its  escape;  and, on making a puncture
about  the middle of the fourth  intercostal space, a very great
quantity  of pus flowed out, very liquid, of a slightly greenish
yellow colour,  and of  an intolerable  gangrenous  fetor.   The
whole  of the fluid contained in this cavity of the chest amounted
to about  a  pint  and half.   The lung  was much  flattened to-
wards  the mediastinum, being only, an inch thick  at its  superior
part; it gradually enlarged downwards, and at its  inferior margin
was two  inches and a halt  in  width.  The lung  had thus three
sides:—the  one  in.ernal, attached  by means of  short cellular
adhesions to the mediastinum; the other  anterior, of a triangular
shape, and attached by old cellular adhesions to  the  sterno-costal
pleura; and the third external, separated from the ribs by a space,
nearly four fingers' breadth wide, which  formed the inner wall  of
the excavation  which had contained  the effusion  This excavation
(of which the  ribs  and diaphragm formed the remaining bounda-
ries) was  completely lined by a false membrane, of a degree  of
consistence intermediate between that of boiled  white of egg and
car'ilage,  of a  pretty uniform thickness of from a line to a line and
half, and of a pearl grey colour, and  semitransparent.   It seem-
ed composed of two layers, the under being firmer than the upper.
About  the middle of the fourth rib this membrane was pierced by
a small ulcer, of the size of the nail,  which extended to the rib,
and had all the characters of one produced by the detachment  of
a gangrenous eschar.   A somewhat, similar ulceration, but extend-
ing only through the false membrane and  subjacent pleura, Was
perceptible on  the; external side of the compressed lung.   It had
the gangrenous  fetor, and was, obviously, an example of the partial
gangrene of the pleura and false membranes. On the same exterior
border of the compressed lung, at its posterior margin,there were two
more openings,  which were found to  communicate  with two large
tuberculous excavations in the substance of the lung partly filled with
purulent  matter.  On blowing into the trachea, air made its escape
into the cavity  of the chest, into  which these fistulae opened, yet
we could  not detect the exact  medium of communication  with the
bronchia.   The substance of the lung,  though  flaccid, was still

  * This is contrary to the usual state of things in Hydrothorax and Empy
ema.  In the present case it was the consequence of an anterior attack  of
pleurisy. 
CHRONIC PLEURISY.
149
crepitous, and  contained  some  tubercles.   Upon removing the
lungs it was evident that this side of the chest was much shorter
than natural.   The diaphragm was found intimately adhering an-
teriorly to the seventh rib, through two-thirds of its length, the ad-
hesion sloping  backwards to the ninth rib, so as to leave on the
lower and posterior part of the chest, a species of cul-de-sac, not
more than two  fingers' breadth wide.  This state of parts account-
ed for the result of the  operation.  The  incision  had  penetrated
through the diaphragm into  the cavity of the abdomen,  parallel
with the upper surface of the  liver.
  The left lung was of the  natural size, and contained, in its up-
per lobe, a cicatrice of the  kind described  in  Book  I.  Chap, h
about an inch in length, as wide, as the  finger, and of the thick-
ness of two lines in its centre.   Around  this cicatrice the pulmo-
nary tissue was quite sound  and crepitous. A little lower, and also
in the superior and posterior part of the  same lobe, it was  indu-
rated to the  degree-of  hepatization, and was granular when cut
into.   The remainder of the lung was crepitous, but much redder,
than the right lung, and gorged  with a bloody serum.   It contain-
ed some small  tuberculous masses like the right lung.   The liver
was quite  sound,  and entirely concealed beneath the false ribs.
Between it and the diaphragm passed the incision made  in  ope-
rating.
   The failure of the operation in the above case was inevitable:
the same thing would have happened if the incision had been made
three inches further back; and Still  more  certainly  had it been
made in the place of election.   I am not  aware that this operation
has before been frustrated by a  similar obstacle.   I apprehend so
close an adhesion of the diaphragm to the pleura of the  ribs must
be very rare.   In  the present case I conceive it must be attributed
to a pleurisy long  anterior to that which  caused  the  death of the
patient.   I have met with cases where the liver, ascended as high
as the'fifth rib, and where the  diaphragm  lay in juxta-position
with the pleura, all the way from its natural attachments to this
point, without  there being any disease of the lungs or pleura.   In
such cases an attack of pleurisy must have  produced  the exten-
sive adhesion described in the last case.
   For this and several  other reasons, we ought to change the usual
place of operating for empyema.   To make, the present  place of
operation the most depending, as it is said to be, we must have our
patient in the upright posture; but the natural posture for a person
affected with an effusion into  the thorax, is that of lying on the
affected side.   In this position  the most depending  point  is the 
 156             DISEASES. OF THE PLEURA.

 middle of the space comprised  between the fourth and seventh
 ribs.
   On the other hand, experience proves to us—1st, that the upper
 part of the lungs adheres more frequently to the parietes of the
 thorax than any other part; 2nd, that the  inferior part of  these
 organs adheres very frequently  to the diaphragm; 3rd, that, in cases
 of effusion consisting partly of albuminous concretions and  sero-
 purulent fluids, the thickest portions  of the  false membranes are
 accumulated in the vicinity of the diaphragm and  adjoining  parts
 of the thoracic parietes; and, 4th, that the middle and  lateral part
 of the chest  is that in which the  greater portion of the effused
 fluids is accumulated.  For these reasons I am of opinion that the
 place for performing the operation of empyema  ought to be the
 middle of the space between the fourth and fifth rib, counting from
 above.  With regard to theoperation itself,  I am of opinion that
 it  is  one of much less severity than is usually imagined.   Its
 success depends less on the condition of the  pleura, than on that
 of the lungs; and when this viscus is not too deeply  affected  by
 numerous tubercles, or by,a  large gangrenous  eschar, it  ought
 almost always to succeed.   The admission of air into the cavity
 of the pleura is probably,  also, less dangerous than is commonly
 believed.   This is, indeed, proved by the cases of wounds of the
 thorax, and the history of recoveries after the operation of em-
 pyema.
  I have not met with any example of acute inflammation of the
 pleura supervening to the  operation;  and  I am  not even  sure
 whether the supervention of such an inflammation might not  be
 the means of a  speedy and certain cure  of the  disease, by pro-
 ducing an union between the  lungs  and  ribs.   At all events,  in
cases  where the severity of the symptoms presented little hope of
a cure from the  operation, some benefit, .and  no  danger, might
result from simply puncturing the chest.  Perhaps, even, it might
be useful to  draw off the fluids in this manner  in all ca%es  of
chronic pleurisy, repeating, if  necessary,  the puncture, five or six
times.   This slight  operation  would be attended  with no incon-
venience, and. the puncture will  heal up immediately.  Morand,
in one of the cases already cited  by me,  made two punctures  of
this sort,  after which  he  performed the operation of empyema
 and effected a complete cure. 
HYDROTHORAX.
151
      CHAP. II.

OF HYDROTHORAX.
                        SECTION FIRST.

                  Of Idiopathic Hydrothorax.

   This  disease is very generally considered as one of very fre-
 quent  occurrence, and  as a  common  cause  of death.   This,
 however, is far from being the case.   Instances  of death from
 idiopathic Hydrothorax  I considec to be  as  rare  as one in two
 thousand.   Many diseases are often  ranged under this, which
 however  are  entirely  different,—for  instance—diseases of the
 heart and great vessels,  irregular  consumptions, and even scirrhus
 of the stomach and liver.
   One circumstance which has more especially led to  the  belief
 of the frequency of this disease, is the common  mistake of taking
 a sero-purul£nt effusion  for it.  This has arisen from the  transpa-
 rency of a part of these  effusions.  Indeed, it is only within these
 few years that the nature  of the  pleuritic effusion has been pro-
 perly known;  and the mistake we have mentioned has been made
 by men of great eminence  at no very remote period.   For exam-
 ple, Morand gives under the name  of dropsy of the chest, a case
 of pleurisy cured by the  operation of empyema *
   Idiopathic  hydrothorax commonly exists only on one  side.  Its
 anatomical characters are simply anaccumulation of serum in the
 cavity of the pleura;  this membrane being quite healthy  in other
 respects; and the lung being compressed towards the mediastinum,
 flaccid,   and  destitute of air,  as  in cases of pleuritic effusion.
 When the  effusion is very great, the  affected  side is evidently
larger than  the other.  This disea'se may exist in a very great
 degree  without any other symptom of dropsy  in any other part of
the body.
  The chief, and almost the  only symptom of this disease  is the im-
* Mem. de l'Acad. de Chir, torn, ii, 
152
DISEASES OF THE PLEURA.
 peded respiration: its progress, and the state of the general symp-
 toms, can alone distinguish it from chronic pleurisy.
   There are cases, even, where the distinction between these two
 diseases is difficult in the dead body.   Whatever may be the'dif-
 ference, both  in the  general symptoms and the  organic  lesion,
 between a case of hydrothorax and an acute pleurisy; or between
 a  case of  ascites from general debility or organic disease of  the
 heart or liver,  and the sume disease from an attack of peritonitis;
 —ror, in short, whatever may be the difference in  general, between
 a dropsy and an inflammation,—there can be no doubt that these
 two affections,  so opposite in their extreme degrees, are neverthe-
less often very nearly allied in their slighter shades  We frequent-
ly find  albumirious concretions  amid  the  serum of ascites, and
purely serous   effusions in  inflammatory affections of the  chest.
 These facts  explain the admission  made, by certain authors, of
inflammatory dropsies, and  the fact of blood-letting  being occa-
sionally beneficial in dropsy, and injurious in diseases truly inflam-
matory.  This last is especially the case when the inflammation is
of a chronic kind, or  originates  in a cause which is not within
the control, of antiphlogistic treatment.
   The  causes  of diseases are unfortunately, for  the most  part,
beyond our reach, yet we learn from  daily experience, that the
particular character of these, occasions greater differences among
them  (especially as regards their cure) than the nature of the dis-
ease itself.  Many cases  of pleurisy and peritonitis  are equally
untractable by  venesection, as a bubo or venereal ulcer,  or as the
local inflammation of gout, or that which precedes hospital gan-
grene.
                       SECTION SECOND.

                 Of Symptomatic Hydrothorax.


  Symptomatic  hydrothorax is  as  frequent  as  the idiopathic is
rare.   The symptomatic dropsy may accompany almost every dis-
ease, acute or chronic, general or local; its presence almost always
announces their approaching  and fatal termination, and often pre-
cedes this only a few moments.  It is not, perhaps, more frequent 
HYDROTHORAX.
153
in cases of ascites and anasarca (leucophlegmatie) than  in other
diseases.   It is most commonly met with in  persons dead of acute
fever, disease of the heart, or tubercles or cancer of different or-
gans.  Its symptoms, which are in every respect like those of the
idiopathic  disease, do not, in general, make their appearauce but
a few days, or even hours, before death.  When the effusion takes
place on both sides of the chest, it produces a very painful suffo-
cation.   Sometimes, however, we find a considerable effusion in
both sides, in cases where there had  been no very notable dysp-
noea before death.   Might not the effusion in such cases take place
in the very moment of dissolution,—or even after  death?  We
know that the functions  of the capillary system do not cease im-
mediately after death.  The  quantity of serum effused varies from
a few ounces to one or two pints.  It is commonly  colourless or
yellowish, sometimes tawny,  reddish, or even bloody.
                       SECTTON THIRD.

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

   There is another variety of symptomatic hydrothorax, which
arises from organic  affections of the pleura.   These affections are
cancerous tumours, or tubercles  (such  as affect the  lungs) deve-
loped on its surface.   The first are commonly of the variety called
medullary or soft cancer, of varying size, but rarely bigger than an
almond: they adhere  strongly to the  pleura, and have the usual
characters of the  variety of cancer to which they belong.   They
are commonly surrounded by a redness of the pleura to some dis-
tance, and this  part, as well  as their basis, is often intermixed with
black striae   They are rarely found in great numbers.
   The tubercles that form on the surface of the  pleura are gene-
rally very numerous, and vary in size from that of a millet to  a
hemp-seed.   They  are  placed very close to each other, and  are
often united by means of  a soft semitransparent false  membrane.
Near  the period of their development  we can sometimes scrape off
this false membrane, and with it the greater number of the tuber-
cles, which are evidently rather  developed in  it than in the pleura 
154              DISEASES OF THE PLEURA.
itself.   At a later period of the disease, the false membrane dis-
appears, or, at least, is united and confounded with the pleura,
which then seems thicker.   In this case the tubercles adhere very
firmly to the pleura, and seem imbedded in its substance.   Some-
times these tubercles are in their first stage, namely, semitranspa-
rent, greyish, or almost colourless, and sometimes in the second,
or opaque and yellow.   I never met with any in the last stage, or
softened.  The interstices of these tubercles  are often very red,
and often contain distinct vessels.   In this state the appearance of
the pleura is analogous to that of the  skin in certain cases of mi-
liary eruption.   We find, also, black striae intermixed with  the
redness, which appear to be of the nature of melanosis.
   We find also, occasionally, on the pleura, another  variety of
granulations, which  resemble  some  other  cutaneous  eruptions.
This consists of small,  white, opaque,  flattened grains, placed very
close  together, and of a firm texture like that of fibrous mem-
branes.  This variety  is also accompanied  by thickening of the
pleura.  It appears to  me to be the result of the imperfect organi-
zation of a false membrane, such as I have already described (page
123).   These  two varieties of morbid growths are very rare on
the pleura, but very frequent  on  the  peritoneum.   Bichat is the
first who noticed  them, though he does  not seem to have known
the Teal nature of  them: they are always accompanied  by hydro-
thorax.  The  cancerous tumours  mentioned  are  also  generally,
but not always, attended by  the same disease.  In  all cases the
effused serum  is almost always red or bloody.  The bony, carti-
laginous,  or  fibro-cartilaginous incrustations  developed in  the
pleura, or rather on its external surface, scarcely ever give rise to
hydrothorax, and, in all  probability, produce little or no disorder
in the functions of the  part 
EFFUSION OF BLOOD.
155
                       CHAP. HI.


OF BLOOD  EFFUSED INTO THE CAVITY OF  THE
                         PLEURA.

  Penetrating wounds, or even a severe contusion of the chest,
may produce  an effusion of blood into the cavity of the pleura.
The same thing takes place in  certain  cases of disease,  and may
follow the rupture of an  aortic aneurism.   In  some cases, also,
there is no doubt that a very copious exhalation of blood may take
place spontaneously, without any solution of continuity or external
violence.  I do not here allude to those effusions which, as  we
have already seen, sometimes attend the formation of blood-vessels
in the false membranes, or which confer on certain other effusions
a sanguineous tint merely;—but to a primary and idiopathic effu-
sion of blood analogous to the hemorrhages, active or passive, of
other organs.  This case  is doubtless very rare; yet some cases
can bear  no other explanation.  These  various cases constitute
what has been improperly called sanguineous empyema.  The
most common  of these is, unquestionably, that originating  in  the
false membranes; and all those which I have seen become the sub-
ject of operation have been of this kind.   The most dangerous spe-
cies is the spontaneous, inasmuch as, being usually the effect of a
general  hemorrhagic diathesis, the removal of it, however effected,
will, in all probability, be followed by a similar effusion in some
other  place.   Blood effused in this  manner may be absorbed as
readily  as in  other situations;  when  this does  not take place
quickly, the blood is sometimes decomposed, and an  aeriform fluid
is disengaged, producing  particular  symptoms,  as  we shall  see
more particularly in a subsequent chapter. 
156
DISEASES OF THE PLEURA.
                    CHAPTER  IV.

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

  The pleura, like all the serous, and even mucous membranes of
the  body, may be so altered in its nature as to secrete tuberculous
or cancerous matter in  place of its natural fluid.   This matter
may be formed  in  such quantity as completely to fill one of the
cavities of the chest, compressing the lungs upon the spine.  This
is a very different  case from that already mentioned, of the de-
velopment of tubercles on the surface of the pleura: in this latter
case the  tuberculous matter  is  not secreted  by  the pleura, but
originates in the false membranes of pleurisy.  Such morbid pro-
ductions as we are  now considering are very rare.   There is no
well described case of the kind  on record; but I apprehend those
scirrhous masses mentioned by authors as filling one of the thora-
cic  cavities must be of the kind in question.   Boerhaave appears
to have found the medullary tumour, or soft  cancer, in this situa-
tion in the  person of the Marquis Saint Auban *  and Haller, as
I have already observed,  seems to have met with a large quantity
of the matter of melanosis in the same cavity.  In two instances
I have  myself discovered a considerable  quantity of tuberculous
matter in this situation.   In  both these, the  matter was in differ-
ent  degrees of consistence.  It  was most solid at the  bottom of
the  cavity,  and over the  whole  of the surface  of the pleura, on
which it formed a layer of more than  an inch thick; the remain-
der of the matter was quite soft, and was contained in the centre
of this sort of sac.  The following case, communicated to me by
M.  Cayol, is the third instance of the same kind.
  Case 39. A negro child, 6 years of age, entered the children^
•See Zimmerman, Traite de l'Experience. 
ACCIDENTAL PRODUCTIONS.
157
hospital in 1S07.  Nothing respecting his previous history could
be ascertained.  He had a deep and painful ulcer on the temple,
constant  diarrhoea, frequent dry cough, unaccompanied by dysp-
noea;  he  had irregular fever.   He died, gradually exhausted, in
less than a month.
  On  examination after  death, the bones in  the vicinity of the
ulcer  were  found  extensively diseased,  and partly removed  by
caries.  On the outside of the cranium there were two tubercles,
one of the size of  a large nut, and the other one half less.  They
were  not  encysted, and were entirely  composed of tuberculous
matter in  the first degree of softness.  One of them was contained
in a hollow on the surface of the cranium.
  On opening the  thorax, the right  lung seemed completely trans-
formed into one tuberculous mass, but a more  close inspection
showed it to be compressed by this tuberculous growth, which was
contained in, and completely filled the cavity of the pleura.   This
matter was of the consistence of cheese,  and exhibited no distinct
tubercles.   It was about the thickness of  two fingers on the ante-
rior and posterior parts of the lung, and somewhat thinner on the
side.   A  portion of it, of the size of a walnut,  had formed a
passage outwards  between the seventh  and eighth ribs (which
were  carious), and  adhered to  the skin.  This portion was as
fluid as pus in its centre.   Another portion  united the diaphragm
to the base of the lung, and also to the ninth and tenth ribs.  On
detaching this layer from  the surface of the pleura, this, in place
of being smooth, was found unequal, like the surface of  the cysts
of tubercles; and some very short fibres, like a fine cellular tissue,
extended  from it  into  the morbid production.   In the  midst of
this mass the lung, compressed to one-fifth of its  natural size, was
found  in  other  respects sound, and did   not contain the slightest
trace of tubercles.   There was  a  small quantity of serum in the
left pleura, and also in the cavity of the peritoneum, and the liver
was not quite sound.   The mesentery, and other viscera, were in
their natural condition.
   Tumours of different kinds are  also found  developed between
the pleura of the ribs and thoracic  parietes.   I have met with, in
this situation, only the medullary tumour, tubercles of small size,
and cartilaginous incrustations..  Haller found, in this situation, an
immense  cyst, containing a serous fluid, and compressing the lung
into the  size of the hand.*   M. Dupuytren found two enormous
cysts of the same  kind, in the body of a  young man, who died of
* Opusc. Pathol, obs. xiv. 
158
DISEASES OF THE PLEURA.
suffocation, after having  long  laboured  under a progressively in-
creasing dyspnoea.   Each of these nearly filled one of the cavities
of the chest,  and compressed the lungs into a small compass on
the anterior part of the cavity.*  It is not improbable that these
cysts were hydatids.
                       SECTION SECOND.

   In cases of wound, some part of the abdominal viscera has
passed into the thorax.f   The same thing has followed a rupture
of the diaphragm, occasioned by a fall,  by great exertions,:]: or by
an enormous distention of the stomach.§   The same derangement
has  taken place  from original malformation  of the diaphragm;||
and even  by the  natural  openings in that muscle.1T  On the other
hand, a hernia has been  formed by the  lungs through  the  inter-
costal muscles.   Grateloup  has published a  case  of this kind,
which was produced by violent coughing.**  Boerhaave records a
similar  instance  arising from the  exertions during labour;ff and
Sabatier mentions  another, supervening on the cicatrization of a
bayonet-wound between  the  fifth and  sixth ribs.JJ  A fourth ex-
ample is  given in  Richter's Journal (Bibliotheque  de Chirurgie
Allemande.)§§

  * Essai» sur l'Auat. Path, par J. Cruveilhier.  Paris, 1816.
  f Vide Ambros. Pare"—Leblanc—Fabric, de Hildan.  Fanton.
  $ Journ. de Desault, torn iii.—Richter on Herniae.
  § Haller. Disput. Chir. torn. iii.
  U Hist, de L'Acad. roy. des Scienc. 1729 & 1772 ; & Richter.
  II Richter on Hernia.             ** Journ. de Med. torn. 53.
  ffDe Haen Prelect. inBoerhaav.  *t Med. Oper. torn. 2<
  §§,Tom. 3. 
PNEUMOTHORAX.
159
                         CHAP V.

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

  Occasionally we find aeriform fluids in the cavity of the pleura.
These are sometimes without smell, more commonly fetid, and of
a fetor resembling that of sulphuretted hydrogen gas. These fluids
are sometimes in such quantity as  very forcibly to compress the
lung,  and to distend the thoracic parietes in a very sensible manner.
In this case the ribs are found more or less  separated,—and the
diaphragm  projecting into the cavity of the abdomen and forcing
the viscera before it.
  Although this affection cannot be said to be of excessive rarity,
it has hitherto been but little  noticed by medical men.  All that
we find respecting it in practical writers  are  a few examples of
the disease very imperfectly described; and, in general, we  know
it merely from the casual observations of anatomists and surgeons,
who have occasionally noticed the escape of air in opening the
chest  after  death, or in  performing the  operation of empyema.*
There exists no special memoir on this subject, to the  best of my
knowledge, but an inaugural dissertation  of twenty pages, by M.
Itard, at present physician to the  institution  for the deaf and
dumb.f  The disease  is named by M. Itard, Pneumothorax.  He
details five  cases of it, three of which are original, one extracted
from Selle, and the fifth furnished by M.  Bayle.  In all these the
aerial  effusion  coexisted with phthisis and chronic pleurisy.   In
all of them the lungs of the affected side were compressed into a
small compass towards their roots.  The fluid was more or less
fetid.   The cavity of the pleura was invested by a false puriform
membrane, at least in the instances noticed with any degree of de-
tail, and contained a few spoonfuls  of pus.   The author of this
memoir, in conformity with the then established notions, considers

  • Vide Riolan, Enchirid. Anat. lib. iii. cap. ii.—Pouteau, OZuv. Post. t. 3,
  f Dissertat. sur le Pneumo-thorax, &c. Paris, 1803. 
160
DISEASES OF THE PLEURA.
 the pneumo-thorax as an affection always consequent to and de-
 pending on a latent phthisis; and that its exciting cause is " the
 decay of the lung  by  means of a chronic  suppuration, together
 with  the partial absorption and decomposition of the pus owing to
 its long stagnation in a confined cavity."  We have already  seen
 that this consumption of the  lung (pulmones assumpti, Lieutaud)
 is not owing to the destruction of  that viscus by suppuration, but
 that the  collection  of purulent matter  is the cause and not the
 effect of the diminished  size  of the lungs.   This  fact, which  I
 believe M. Corvisart was the first to  demonstrate in  his clinical
 instructions, is now considered as unquestionable  by  every one
 well acquainted with morbid anatomy.   In former pages we  have
 ourselves shown that the  lungs may be reduced  to a very small
 volume by purulent or watery effusions, without containing tuber-
 cles, or showing any mark of suppuration.
   All the cases of M. Itard, then, are to be considered as pneumo-
 thorax consequent on a latent pleurisy, which coexisted with the
 phthisis, and in  which the greater part of the effused  liquid had
 been  absorbed.  It is sufficiently probable that, in these cases, the
 gas was  the product of decomposition of some portion of the effused
 albuminous and  puriform  matter: the  character of its smell leads
 to this opinion.  This species of pneumo-thorax is pretty frequent.
There are  several other  varieties sufficiently distinct.   1 have
 several times discovered this affection coexisting  with a consider-
 able sero-purulent  effusion of the pleura, and  a communication
 between this cavity and the bronchia, owing to  the rupture  of  a
vomica, or softened tubercle, simultaneously into the bronchia and
pleura.  I  consider this species as the commonest of all; at least,
I have met with it most frequently.  In this case it is reasonable
to believe the air contained in the cavity of the pleura to be  simply
the atmospheric air conveyed  thither  by the bronchia.   I shall
subjoin several remarkable instances of this variety.
   It is possible that, in  this case,  the introduction of the air into
the pleura  may excite inflammation of that membrane, and  that,
 consequently, the pleurisy  may be the  effect of its  presence,  and
 not the cause, as in the  instances given by M. Itard.  It is, how-
ever,  also  possible,  that a vomica may burst  into this  cavity
without at the same time communicating with the  bronchia, and
may thus exite a pleurisy, and consequent pneumo-thorax, through
the decomposition of the pleuritic fluids.  This case comes under
the head of those of M. Itard, with this  difference, that the original
effusion is here considerable.
   Pneumo-thorax  may  also  be conjoined with  hydrothorax.  I 
PNEUMO-THORAX.
161
 have not met with a case of this kind, but svereal cases prove its
 occurrence.   It is, doubtless, true that  many supposed cases of
 this kind have been true pleuritic effusions, mistaken  for the simple
 serous exhalation; but M. Bayle  gives one incontestible instance
 of this Sort, in a person where there was  found  a small portion of
 serum and a  great quantity of air in the pleura.   (See  his case

   Pneumo-thorax also almost always occurs when a gangrenous
 eschar of the lungs  is dissolved and evacuated into the cavity of
 the pleura.   In this case gas is evolved  during the chemical de-
 composition of  such matter;  and  this,  together with the fluids
 effused by  the irritated pleura, compresses the lung, and dilates
 the affected side.   We have already given  two examples (cases
 12  and 13) of this species of pneumo-thorax.   Gangrene of the
 pleura, also,  commonly produces the same effect.  A case of  this
 kind will be  subjoined.  The same effect results from the decom-
 position of blood effused into this cavity.   On examining the body
 of a man that died after an illness of five days, Littre found in the
 chest  two pints of'blood, and an enormous quantity  of air.  This
 affection may, further, be produced by rupture of the pleura of the
 lungs  from external  violence.   A  case of this kind is mentioned
 by Hewson *   It is likewise probable that in the case of emphy-
 sema  of  the lungs,  with rupture of some of the  air-cells and ex-
 travasation of air under the pleura, this membrane may sometimes
 be ruptured, and the disease in question be thus formed.   I think
 I have seen something of this kind.  Finally,  an  aeriform  fluid
 may be formed in  the cavity of the chest, without there being any
 solution of continuity, any other effusion, or any perceptible change
 of structure whatever.  I have often  perceived the escape of an
 inodorous gas, in opening the thorax,  where there was  no per-
 ceptible  affection of the pleura.   Sometimes, indeed, this mem-
 brane appeared to be drier than natural, and I remember one case
 in which it was,  in some  places, almost as dry as parchment.
 Even  in  these cases a rupture of the pleura, so slight as to be un-
 perceived,  may be  imagined;  but,  independently of the circum-
 stance that such  rupture cannot well be  supposed  without some
external violence, we know  that an idiopathic formation or secre-
tion of air can and does take place in the animal system.  It is
 thus that we sometimes find air, in considerable quantity, in the
 pericardium,  in cases where there exists no other effusion  in that
 cavity; we find the same, also, though  more rarely, in the cavity
* Med. Obs. & Inq.vol. 3,
          21 
162             DISEASES OF THE PLEURA.
 of the peritoneum.  It would even appear that air, or an  aeri*
 form fluid, exists naturally, in small quantity, in the cavity of the
 pleura.   At  least,  M. Ribes  assures me that he has found, in
 opening the  serous  cavities of dogs, a small quantity of air con-
 stantly to escape.   This  may probably, however, be merely the
 natural serous exhalation in a state of vapour.  The following case
 will show that air introduced into the cavity of the pleura, in the
 most simple  and natural way—that is, by  secretion—may not be
 productive always of a fatal, or even very severe pleurisy.
   Case 40.   A man,  aged 65, of a strong constitution, subject for
 two years to a cough which did  not  prevent him from following
 his business,  was suddenly seized one evening with violent pains
 in the abdomen and died the same night.
   After death, the body, though emaciated, still retained consider-
 able muscularity. The right side  of the chest was evidently larger
 than the left, and yielded  a louder sound on percussion  than even
 the chest of  a healthy person usually does.  The left  side yielded
 a sound  comparatively obscure through  its whole  extent.   There
 were found some diseased  appearances in the brain.  On penetrat-
 ing by the scalpel the right cavity of the chest,  an inodorous  gas
 escaped, and in large quantity, to judge by the force and duration
 of the sound occasioned by its exit.  The lung on this side was
 somewhat compressed  towards  its roots, but still retained three-
 fourths  of its natural  dimensions.   This  side of the chest  was
 considerably  dilated, and,  besides  the lung, might have contained
 about two pints of liquid,—the quantity, no doubt, of gas that had
 made its escape.   The whole of  the pleura was drier than usual,
 and rather unctuous  than  humid; there were no false membranes
 nor any  effused fluid.  The lung adhered to  the costal  pleura at
 its superior lobe, by means of cellular layers an inch in length,
 which seemed of no very ancient date.  This adhesion was attach-
 ed at one end to a species  of cartilaginous  incrustation of the  size
 of the palm of the hand, which adhered closely to the pleura  pul-
monalis. In detaching the  cellular adhesions from this fibro carti-
 laginous body, there remained in the centre of the latter, a small
oval opening, about a line and half in diameter, which communi-
 cated with an excavation in the lung, which could have contained
 an orange.   (I am  not quite certain whether the oval opening,
 above  mentioned, existed  before, or  was  formed by the  act of
detaching the lung  from its adhesions; though I am  inclined to
 consider it as previously existing.)  The excavation  was nearly
empty, containing only about a spoonful of pus.   Its parietes were
immediately formed  by the pulmonary tissue, except in that space
answering to the  cartilaginous incrustation, where, to the  extent 
PNEUMO-THORAX.
163
 of more than  an inch square, they consisted  solely of this  false
 membrane.  There were many tubercles, in different stages, and
 also  numerous  hard  melanotic  tumours in  different parts of the
 lung.   The left  lung adhered to  the  costal pleura in its whole
 extent. It, also, contained tubercles and melanotic tumours. There
 was, likewise,  here  a  tuberculous cavity, of considerable size in
 the upper lobe.  There was disease in the large intestines.
   Whatever may be our opinion respecting the source of the air
 existing in this case,  in the cavity of the pleura, the appearances
 prove that air may exist there without exciting much  inflammation.
 The case further shows, that phthisis  may pass through all  its
 stages without producing any violent symptom; and I am  disposed
 to believe, from the appearances observed,  that this  patient would
 have been either completely, or, at least temporarily, cured of this
 disease, had he not been carried off by another.
   It is extremely probable, as Hewson,* and M Rullierf have sup-
 posed,  that pneumo-thorax offers  the  best  chance of success for
 the operation of  empyema.   This opinion  is supported by the de-
 claration  of Riolan, who tells us that he saw theoperation several
 times performed  for supposed dropsies  of the chest,  in which air
 alone, in place of water, made its  escape   with a sort of explo-
 sion.:):
   In many cases already detailed in this work, (see  cases 14, 34,
 35, 36, 37, 38,) the existence of pneumo-thorax was  recognised
 during the life  of the patient, and the  following  is  an additional
 instance of the same  kind.
   Case 41.  A women, aged 26, of  a feeble  frame, came  into
 hospital  affected with  what she  called  a cold of three  months
 standing.   Within  the last  month only,  had  she  lost  her   ap-
 petite, or been  unable to work at her business.   She had, for se-
 veral years, had the lymphatic  glands in  the  axilla  enlarged.
 When this woman came into hospital she was evidently in a state
 of hopeless consumption.   The greater part of the chest  yielded
 a  pretty good  sound on percussion except on the  left  superior
part, in which situation the  stethoscope gave indication of the ex-
istence  of  tuberculous  excavations.  This patient survived  two
months.   The  day before  her death, the  stethoscope applied to
the left side conveyed  the metallic sound, characteristic of the
existence of a  cavity containing both  air and liquid, and com-
municating with the  bronchia (see Part  II.), while  respiration

        * Med. Obs.       f Diet, des Sc. med. Art. Empy^me
       i Enchirid. Anat. 
164
DISEASES OF THE PLEURA.
was scarcely perceptible in any part of it.  The same side sound-
ed  much  better on percussion  than the right,  in  which   the
respiratory murmur  was  very  distinct.  Convinced by   these
symp'oms of the existence of a pneumo-thorax combined with a
pleuritic effusion, I confidently expected that the Hippocratic suc-
cussion of the chest would let us hear the fluctuation of the liquid,
and I was not mistaken.   The patient died the night following.
   On  opening the  chest a  great quantity of an'inodorous  gas
made its escape from the left side, which  appeared half empty,
the lung being compressed upwards  and backwards  to  one-third
of  its  natural size.  The  surface of the pleura  was  partially
marked by a punctuated  redness, and its cavity contained  about
half a pint of a transparent, yellowish liquid, mixed with  a few
whitish flocculi.  Almost the whole of the superior lobe adhered
to the  costal pleura; and, on the outer side, there  was an opening
or ulceration,  of the size of the nail, covered with a thick yellow
matter, and discharging bubbles of air on pressure being applied
above  it.   This proved to  be the outlet of  a short  fistulous  canal,
capable  of admitting the finger, which  communicated with a
vast internal cavity, which occupied a great  portion of the  lobe.
This excavation was irregular, and was lined by a very  soft false
membrane.   It was nearly empty,  and two or three  bronchial
tubes of the size of a crow-quill opened into it.   In short, it re-
sembled a  true tuberculous excavation—such  as have been de-
scribed in Book I. Chap. I.
   The right lung filled the cavity of the pleura and closely ad-
hered  to it, in almost its whole extent, by a short  well  organized
cellular tissue.  It was filled with white tubercles of the size of
a cherry-stone. 
HYPERTROPHIA.
165
                   BOOK THIRD.


OF  THE  HEART  AND  ITS APPENDAGES
CHAP. I.
OF DISEASES OF THE HEART.
SECTION first.
     Of Hypertrophia, or simple enlargement of the Heart.


  By Hypertrophia I mean simple  increase  of the muscular
substance of the heart, without a proportionate dilatation of its
cavities, or even with a  diminution of these.   This  affection  is
by no means common, and appears to  have escaped  the notice
of M. Corvisart, as, through his whole work, he seems  to con-
sider enlargement of the  parietes of the heart, as being uniform-
ly accompanied by a proportionate dilatation of the cavities of that
organ.
   This enlargement of the heart is  always  attended  by a con-
siderable increase of its consistence, except  when conjoined with
another  affection  of this organ, to be  noticed presently,  viz:
softening of the heart.
   Hypertrophia may exist in one or both ventricles, with or with-
out a similar  affection of the auricles.  Most commonly the au- 
166              DISEASES  OP THE HEART.
  rides are  not  affected, but occasionally  they are  so,  while the
  ventricles are sound.
    When  affecting the left  ventricle,  I have  seen its  parietes
  more than an inch ihick at the  base,  that  is, double  that  of its
  sou.»d state.   Commonly,  this  morbid thickening  diminishes in-
  sensibly from the  base to the  apex of the ventricle, where  it is
  scarcely perceptible; sometimes, however,  the  apex partakes  in
  the enlargement;  as I have seen it from two to four lines thick,
  which is double or  quadruple the natural  size.   The columns
  carneae of ihe ventricle and of the valves acquire a proportionate
  enlargement.   The septum between the  two ventricles  becomes
  also notably thickened in the  disease of the left ventricle, (which
  fact seems to mark it as belonging to  this rather than the  other
  ventricle,) but never so much so as the other parts.
   The muscular substance in  these cases is of  a degree of con-
  sistence sometimes double the natural, and  is of a redder  colour.
 The cavity of the  ventricle appears to have lost in  capacity  what
 its parietes have gained to thickness.   Sometimes  I have  found
 this so small, in hearts twice the size of the fist of the individual,
 as scarcely *o be capable of containing an  almond in its shell.
 The right ventricle, in such cases, is flattened along the septum,
 and does not extend to the apex of the  heart   In extreme cases,
 it seems as if it were merely included within  the parietes of the
 left  vemricle.
   In hvpertrophia of the right ventricle the appearances  are some*
 what different  The thickening is here more uniform, and never
 so grent as in die other: 1  have never found  it greater  than  four
 or five  lines.   It is always  a little greater in  the vicinity  of the
 tricuspid valves, and at the origin of the pulmonary  artery.   The
 columnar carneae are  much  enlarged,  considerably  more  so, in
 proportion, than those in the left, in disease of that side.   Simple
 enlargement  of the right ventricle, without dilatation, is much
 rarer than  that of the left.   When this disease  affects both ven-
 tricles at the same  time, the only difference  from the description
just given is, that each side assists to form the apex of the heart. 
DILATATION OP THE VENTRICLES-          16^
                       SECTION SECOND.

                Of Dilatation of the  Ventricles.

  This disease of the heart, which has been named passive aneu-
rism by M.  Corvisart, consists in  dilatation of the cavities of the
ventricles,  with  decreased thickness of  their  parietes.  With
these conditions there are commonly  conjoined a notable degree
of softening of the muscular substance, and a colour, either more
violet, or paler,  than  natural.   Sometimes the softness is so  con-
siderable, especially in the left ventricle, that the muscular  sub-
stance can be destroyed  by  mere  pressure between  the fingers;
and  the parietes of the same  ventricle may be so much diminish-
ed in thickness,  as to be only two  lines in  the thickest point, and
scarcely halt a line at the apex, while  the right ventricle is some-
times so completely  extenuated, as to appear merely composed of
a little fat  and its investing membrane.   The columns carneae,
particularly of the left ventricle, are more remote than in the na-
tural condition of  the part.   The  septum  between the ventricles
loses less of its  thickness and of  its consistence than the  rest of
the parietes.
  Dilatation may be confined  to one  ventricle, although it  more
commonly  affects both at the same time.  When one only is af-
fected, the apex of it extends  below the other, but not  in so re-
markable a degree as in the case of hypertrophia.  The augmen-
tation of the cavity seems to be more  in its breadth" than length.
This is particularly observable when both the ventricles are  dila-
ted at the same time;  as, in this case, the heart assumes a rounded
shape, being nearly as wide at the apex as at the base.
                       SECTION THIRD.

  Of Dilatation combined with Hypertrophia  of the Ventricles.

  This reunion, which constitutes the active aneurism of M. Cor-
visart,  is extremely  common; much  more  common than simple 
168
DISEASES  OP THE HEART.
dilatation, and still more so than simple thickening without dilata-
tion.   This complication may exist in one or both ventricles.   In
the latter case  the heart acquires a  prodigious  size,  sometimes
more than triple that of the hand of the individual.  As the aug-
mentation of volume  is here the  effect of dilatation and thicken-
ing,  the  muscular substance acquires the great firmness already
described.   The apex  of the heart becomes blunter, but this is
rarely so great as  to give to  the organ the rounded form noticed
in the case of simple dilatation.
   Dilatation of one ventricle is sometimes conjoined with hyper-
trophia of the other,  but this is not so common  as the complica-
tion in individual  ventricles,   i  h' 'e  met with the following  va-
rieties of this complication:  1st,  Hypertrophia  with dilatation of
the left ventricle, and simple dilatation of the right;  2nd, Hyper-
trophia with dilatation  of the left ventricle,  and simple  hypertro-
phia of the  right;  3rd,  Hvpeitrophia with dilatation of the right,
and simple dilatation  of the  left; 4th, Hypertrophia of the right,
with dilatation  of the  left;  this  last  is  the  rarest.  I  do not  re-
member  to have met  with hypertrophia of the left  ventricle (with
or without dilatation)  complicated with dilatation of the right.
I  would even be disposed to consider such an union as impossible.
                       SECTION  FOURTH.

                  Dilatation of the  Auricles.

   Dilatation of the auricles is  an extremely rare disease, and it
appears still more so compared  with the frequency of the  same
affection of the ventricles.   Sometimes we  find in subjects affect-
ed with hypertrophia or dilatation of the ventricles, the  auricles,
also proportionably enlarged; it is, however,  much  more common
to find these retaining  their natural  size even in cases where the
ventricles are enormously enlarged.   Sometimes also,  but  more
rarely still, the auricles are dilated when the  ventricles are of the
natural  size.
   Before  we can judge of the extent  of this affection we  must
have precise ideas respecting the natural proportion of the various
cavities of the  heart.   As far as the cavities are concerned,  we
must admit  that they are very nearly of equal size; but as  the 
DILATATION OF THE AURICLES.           169
parietes of the auricles are much thinner  than those of the ven-
tricles, the former, when simply full and  not distended, compose
only about  one third  of the whole organ,—in other  words, the
size of the auricles is about one half that of the ventricles.   Both
the auricles have^ the same capacity,  although  some anatomists
have  considered  the  right larger, no doubt misled by the greater
length of its sinus, and more especially by  the distended  condition
in which it is commonly  found after death.  A similar distention.
though more rarely, takes  place  also in the  left  auricle;  and this
accidental and temporary enlargement is sometimes so considera-
ble, owing to the great extensibility of the auricular structure, as
almost to equal the size of the  ventricles.   In order to distinguish
the real  from the factitious  dilatation, we have only to empty the
auricles  through the vessels that enter into  them, when, in tht
latter case,  these cavities  will immediately  resume their natural
size, and, in the former, they will still nearly retain their acquir-
ed volume.   There is likewise another mark by  which we can at
once discriminate the enlargement produced by the accumulation
of blood during the few last hours of life,  from the permanent in-
crease of capacity of  the auricles.   In the first cage, the parietes
of the auricle  are greatly  distended by the contained blood, and
the colour  of this appears  through the thinnest portions;  while,
in the latter, the auricles,  although very voluminous, are still ca-
pable of containing more blood, and their parietes remain opaque.
   I have never met with decided dilatation of the  auricles with-
out some thickening of their walls; and, on the other hand, I have
never seen  thickening of their walls  without an  augmentation of
their capacity.   I may here remark that it requires much experi-
ence to  judge correctly of hypertrophia of the auricles,  as, owing
to their  great natural thinness, a  considerable increase (say  double
the natural  thickness, and  the increase is  rarely so much) is not
obvious  to a person little accustomed to such examinations.
   The  most common cause of dilatation of the left auricle is the
contraction of the orifice between it  and the ventricle,  in  conse-
quence of cartilaginous or bony induration of the mitral valve, or
of caruncles on its surface.   The same causes sometimes occasion
the retraction of this valve, and consequently the  permanent pa-
tency of the auriculo-ventricular orifice.   In this  case  dilatation
and thickening may arise from the mere action of the ventricle on
the auricle.   I have  never seen any change  in the  auricles with-
out some alteration in the valves.  Dilatation  of the right auricle
Is most commonly the consequence of thickening of the right ven-
                           -   22 
170
DISEASES OF  THE HEART.
tricle.   The  diseases of the lungs which  M.  Corvisart  reckons
amorig the ordinary causes  of this dilatation,  seem to  me to pro-
duce, in general, merely the accidental distention above noticed.
                        section fifth.

               Partial Dilatation of the Heart.

  M. Corvisart found, in the person of a young negro who died
from suffocation, a partial dilatation of the left ventricle which was
truly aneurismatical.   " On the superior and lateral  part of this
ventricle there was a tumour almost as large as the heart itself.—
The interior of this tumour contained several layers of coagulated
blood,  very dense, and exactly like those found in aneurisms of the
limbs .... The cavity of this tumour communicated with the ven-
tricle by a small opening, smooth and polished."*  A similar case
is cited by M. Corvisart from the  Miscell. Nat. Curios.  I  have
myself never met with any thing of  the kind.
  There is another  rare species of dilatation  described  by Mo-
rand,!  a second case of which was communicated  by me to  the
Soc. de la Facult  de Med.}  This is a dilatation  formed in  the
middle of one of the lips of  the, mitral valve, resembling a  thim-
ble, or glove-finger projecting into the auricle.
  There is still one other variety of partial dilatation of the heart,
which  I have several times met with, and which is probably, in a.
great measure, the result of original malformation.  In the natural
conformation of the  heart, the right ventricle seems to  consist of
two distinct parts united together,  the one of which descends to-
wards  the apex of the heart,  while the other, almost at right angles
to the  former, is directed to the left side, and forwards towards the
pulmonary artery.  The  dilatation to which I now  allude, seemed
to exist in both these divisions, while the point of union of the two
retained its natural dimensions.   It is, however, more common to
find the. anterior  or  pulmonary division of the ventricle dilated
without the other portion; and  in every case  of dilatation of this
ventricle, the former portion is always more dilated than the other

    • Op. cit. p. 283.         f Hist, de l'Acad. des Sc.  1729.
    i Bulletin, No. 14. 
INDURATION.
171
This difference becomes still more evident when the dilatation is
conjoined with a certain  degree  of thickening, as, in this case,
the pulmonary portion of the ventricle frequently acquires such a
degree of.firmness that its parietes do not collapse when laid open,
a thing which hardly ever happens to the lower portion of the ven-
tricle.
                        SECTION SIXTH.

                   Induration of the Heart.

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

                    Softening of the Heart.

   I have already noticed this condition of  the heart.   In  it the
muscular substance is  sometimes so soft as to be almost friable,
the fingers  passing easily through the parietes of the ventricles.
Whatever may have been the patient's disease, the heart is  rarely
filled with blood, and the ventricles  equally collapse whatsoever
may be their varying  thickness.  This affection  of the heart is
almost always attended by some  change of  colour  in  the  organ.
Sometimes this is deeper, and even quite violet; and this is  parti-
cularly the case in fevers of the kind named adynamique by Pi-
uel.   More commonly, however, the softening of the heart  is at- 
172
UlsEASES OF THE HEART.
tended by a striking loss of colour, so as to resemble  the  palest
dead leaf.   This pale or yellowish tint does not always occupy the
whole thickness of the heart; sometimes it is strongly marked in
the central portions, and  very little on the exterior or inferior sur-
faces.   Frequently the left ventricle and interventricular septum
exhibit this appearance, while the right ventricle retains its natural
colour, and even a degree of firmness greater than natural. Again,
we sometimes find here and there spots of  the natural colour and
consistence  in hearts which are, every where else, much softened
and quite yellowish.  This variety of yellowish  softening is  par-
ticularly observable in those  cases  where  dilatation  is conjoined
with a slight degree of thickening.   It is also found  in simple di-
latation, although it is more.common to find this state accompa-
nied by that species of softening which is marked  by an augmenta-
tion of the natural  colour of the  organ.  There is a  third variety
of softening of the heart, which  will  be noticed in  another  place,
and which is attended by a pale  white colour of the muscular sub-
stance.   In this, the degree of softening never reaches that of fria-
bleness; often it is  scarcely perceptible;  but the  parts are flabby,
and the parietes of the ventricles  quite  fall together on   being
opened.   This condition will be noticed  under  the  head  of in-
flammation of the  pericardium, as  it is peculiar  to  that disease.   .
   It would seem that the softening of the heart discovered in sub-
jects whose death has been very gradual, is an acute affection; it
is evidently still more  so where it exists only partially in the sub-
stance of the organ.   On  the contrary, in  cases where the  heart
is softened and yellowish throughout,  it  is  probable that the  affec-
tion has existed for a long time.   The deep-coloured softness ob-
served in subjects dead of fever,  may, I think, be compared to that
adhesive  softness of the other  muscles often observed  in  these
cases,  and  which  is also accompanied by a degree  of redness
greater than natural.  This  softening of the heart, as well as the
analogous gluey or fishy (gluant ou poisseux) state  of the muscles,
is particularly observable in  putrid fevers, particularly when these
exhibit the  phenomena formerly considered as marks of putridity
—viz:  livid intumescence of the face, softening  of the  lips, gums,
and internal membrane of the mouth, black coating on the  tongue
and gums, earthy aspect of the skin, distended abdomen and very
fetid dejections.   I cannot assert that this  softening of the heart
exists in all kinds  of continued fevers, but I have met with it con-
stantly  in such cases as  I have attended to.  Could  it  accountjbr
that frequency of pulse which exists, sometimes for several weeks,
in convalescence from fevers, although the patient  continues to re
gain flesh and vigour? 
ATROPHY.
173
                      SECTION EIGHTH.

                    Atrophy of the Heart.

  It is an important question whether the heart be susceptible of
diminution of size and  power like other  muscles;  and,  if so,
whether this affords any hope of cure, by debilitating measures, in
cases of hypertrophia.  This much is certain, that, in cases where
there is much  emaciation, as in Phthisis and Cancer, the heart is
generally found small.   From this consideration, I have in many
cases of hypertrophia attempted the method of cure proposed by
Valsalva in aneurism!   Almost all my  patients got shortly tired of
the extreme severity of the regimen, and alarmed by the frequency
of the bleedings.   In  three cases, however,  I  have  been so far
successful that I am led'to believe that this disease is not entirely
beyond the resources of art and nature.  * Two of these were young
women, the one 12 and the other  IS years of age, both of whom
presented symptoms of hypertrophia in  a high degree.  The pri-
vation of  one-half of their ordinary diet, and  some occasional ge-
neral and local bleedings effected the gradual diminution,  and,
eventually, the complete  cessation of all their symptoms.  The
youngest  has  now been cured four years, and  has long ago  return-
ed to  her usual regimen.    The other  still follows the prescribed
regimen, and  is now quite reconciled to the diminished quantity of
food.   Blood-letting has not been found necessary for  the last
year, and  the general symptoms of the  disease have  disappeared,
although  the unnatural thickness of the parietes of the heart is still
 recognisable by the stethoscope.   The third case is still more con-
clusive, as I have been enabled to ascertain the state of the heart
 after death.   I shall therefore state it more  particularly.
    Case 42.   A woman, 50 years of  age,  had been affected for
 twelve years with all the symptoms of disease of the heart, in  a
 very high degree, viz* strong and frequent palpitations/;habitual
 dyspnoea, breathlessness on using the  least  exercise, sudden start-
 ing^ from sleep,  almost constant cedema of the lower extremities,
 and lividity of the cheeks, nose,  and lips.   These symptoms had
 increased during the last year,  so that she  could scarcely  move
 from  her chair without the feeling of suffocation.   In  this state I
 recommended the treatment of Valsalva, which she agreed to.  I 
 174             DISEASES OF THE HEART.

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


               Fatty Degeneration of the Heart.

  In medical writings we find many examples of the heart being
overloaded with fat in a surprising manner, and to which change
of structure  various symptoms, and even the sudden death of the
individuals, were  attributed.  M. Corvisart thinks that  an  enor-
mous accumulation of fat around the heart may, in fact, produce
such effects,  although he has met with no similar, or other perma-
nent derangement, in persons whose hearts were found to be  much
loaded  in this manner.  I have also  met  with a great many case15 
FATTY DEGENERATION.
175
of hearts, overloaded in this manner, in subjects dead  of various
diseases.   In these the fat was deposited between  the muscular
substance of the heart and  the investing  pericardium, and chiefly
at the union of the auricles and  ventricles, at the  origin of the
great vessels, and  along the tract of  the coronary arteries,  also
along the two edges and at the apex of the heart.  "Sometimes the
posterior face of the right ventricle is- covered by this  deposition
in its whole extent; a circumstance which rarely has place on the
surface of the left ventricle.
  The fatter the heart is, the thinner, in  general, are its parietes.
Sometimes these are extremely thin, especially at the apex of the
yentricles,and the posterior side of the right ventricle. On examin-
ing  ventricles  affected  in this  manner, they present the usual ap-
pearance internally; but on  cutting  into  them from  without, the
scalpel seems to reach the cavity without encountering almost any
muscular substance, the columnar  carneae appearing  merely as  if
bound together by  the internal lining  membrane.   In these cases
the fat does not appear to be the  product of  degeneration of the
muscular fibres, as  these can be separated by dissection.  Some-
times, indeed,  portions of fat penetrate deeply between the mus-
cular fibres; but, even  in this case, the distinction between the
two  tissues is still  very  marked, and  they are confounded  by no
mutual gradation of colour or consistence.  It would seem proba-
ble from this, that,  from pressure or some unknown  aberration of
the powers of nutrition, the muscular substance has wasted in pro-
portion as the investing  fat has increased.   It  would seem reason-
able to expect rupture of the heart from an affection of this kind;
such an instance, however, has never occurred to me.   Very com-
monly we find, in such subjects, a large quantity of fat in the lower
part of the  mediastinum, particularly  between the pericardium
and  pleura.   This  fat, much reddened by its small vessels,  and
covered by its pleura, assumes  the figure  of a cock'.s comb and is
firm.   The fat surrounding  the heart, on the contrary, is almost
always of a pale yellow colour.   I have not  observed, any more
than M. Corvisart, any symptoms  that could  directly denote the
existence of an  accumulation of this sort.  I apprehend it must
exist in a very great degree  before it gave rise to any serious com-
plaint.  This is not, therefore, the condition I wish to  denote by
the  name of Fatty  degeneration of the Heart.  This latter is an
actual  transformation of the muscular substance into a substance
possessing most of the chemical and physical properties of fat.   It
is precisely  similar  to the fatty degeneration  of the muscles  ob- 
176               DISEASES OF THE HEART.

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

 Cartilaginous or Bony induration of the muscular substance of the
                            Heart.

   I have never met with ossification of the muscular  substance
of the heart,  and only a small  number of examples of this  are
on record.  M. Corvisart found, in the case of a man  who  died
of hypertrophia of the left, ventricle, the whole apex of the heart,
and more partially the columnar carneae, converted  into cartilage
(op  cit.).
   Haller (Opusc. Pathol.)  found,  in  a child,  whose  heart was
of the natural size,  the  inferior  part of the right  ventricle,  the
most  muscular parts of the left auricle, and the  sigmoid valves of
the aorta and pulmonary artery,  in  a state of ossification.   M.
Renauldin has published, in  the Journal  de Med. for 1816,  a
very  interesting case of the same  kind.  The patient was a man
33 years of age,  much addicted to study, and subject  to  violent
palpitations on the slightest  motion.   " On applying the hand  to
* Opusc. Pjtthol.       t Tom. v. 
CARDITIS.
177
the region of the heart a sort of motion of the  ribs was felt, and
even the slightest pressure produced very acute pain, which lasted
long  after the pressure  was  discontinued.  On  examining the
body after death the heart was found extremely  hard and  heavy.
On attempting to cut the left ventricle great resistance was found,
owing to the total conversion of the muscular fibre into  a  sort of
petrifaction, having in some places a sandy character, in others a
resemblance to saline crystallization.   The grains of this species
of sand were very contiguous to each  other,  and  became  larger
towards  the  interior  of the ventricle.  Thej  were continuous
with  the  columnar  carneae,  which  were  themselves  converted
into a similar substance, but still ratained their original form, only
much enlarged.   Some of these sabulous concretions were of the
size of the point of  the little finger, and resembled small  stalac-
tites shooting in different  directions.   The ventricle was thicken-
ed.  The right ventricle  and great arterial trunks were  sound.
The temporal and maxillary arteries,  and also a part of both the
radial  arteries, were ossified."   We frequently find on the  interior
surface of the ventricles, especially the  left,  cartilaginous scales
continuous with the  lining membrane, and apparently  deposited
between it and the musc'ular substance of the heart.  These are
generally small.  I  have never found  them ossified.
                      SECTION ELEVENTH.


                         Of Carditis.

   Inflammation of the heart is  a rare affection, and is,  conse-
quently, very imperfectly known both in a practical  and patholo-
gical view.   There  are two  varieties of it, the general, or that
affecting the whole  heart;  and the partial, or that  confined to  a
small extent of it.   There • perhaps  does not  exist on  record  a
satisfactory  case of  general  inflammation of the  heart, either
acute or chronic.  The  greater  number of cases so called, and
particularly those given by M. Corvisart, are evidently  instances
of Pericarditis attended  by  that degree of discoloration  of the
heart which we shall find frequently  to accompany  that  affection.
Nothing proves that the paleness  of  the heart in such cases is the 
178              DISEASES of the heart.
 consequence of inflammation.   This affection generally increases
 both the redness and  density of the parts  which  it occupies;—
 but the discoloration in the cases alluded to is conjoined, in gene-
 ral, with a perceptible softening of the heart.  It is further obser-
 vable that, in these cases,  the  pericardium  was filled  with pus,
 while not a particle was found in the substance of the heart  itself:
 now, pus must be considered as the most  unequivocal  indication
 of  inflammation.   The  only  case which  I  have met with  of
 general  inflammation  of  the  heart possessing  this unequivocal
 murk, is noticed by Meckel  in  the Mem. de  1'Acad.  de Berlin.
 But this case is described with so* little precision, as  merely  to
 prove the possibility of Uie fact, and affords no help  towards a
 general description of  the  disease.
   Instances of partial  inflammation of the heart, characterized by
 the presence of an abscess or ulcer  in its parietes, are much more
 common.  Bonetus has recorded a  good  many such cases in his
 Sepulchretum.   I have only met  with  one  instance of the  kind.
 In this (in a  child  twelve years old) the abscess was  situated in
 the parietes of the left  ventricle, and might  have contained a fil-
 bert: it  was  complicated with pericarditis.   In another case, of
 a man of 60 years old, I found an albuminons  exudation, of the
 consistence of boiled white of egg,  and of the colour of  pus, de-
 posited  among  the  muscular fibres of  the  left  ventricle.   The
 patient had presented symptoms of an acute inflammation of some
 of  the  thoracic viscera,  without   precisely indicating  its site.
 Orthopnoea, and a feeling of inexpressible anguish, had been the
 chief  symptoms.
  Ulcers of the heart have been still  more frequently observed
 than abscess;  they have been met with in its external and internal
 surface.*  All the  cases,  however, recorded under this name are
 not quite correctly designated.  In the Sepulchretum we  frequently
 find a case of pericarditis, attended with  a rough  and uneven
pseudo-membranous exudation, mistaken for  an  ulcer of the exte-
rior surface  of the  heart.  This has been  noticed by Morgagni
(Epist. 20 and 25).  That true ulcers of this surface, however,
have been observed, is beyond  doubt.   A  case of this kind is
described by  Olaus-Borrichius in the following words:   " Cordis
exterior caro, profunde' exesa, in lacinias et villos cameos putres-
centes abierat;"f and similar cases are  recorded by PeyerJ and
Graetz.§  Ulcers on the internal surfaces of the heart are perhaps
* Morgagni, Epist. xxv.
f St-pulchret. Lib. It. obs. 86.
§ Disput. de Hydr. pericard. sect. 2,
* Ibid. sect. 11. obs! 21 
CARDITIS.
179
more common than on the external; or, at least,  there  arc on re-
cord a greater  number of incontestible  examples of the former.
Bonetus, Morgagni and Senac have collected a great many of these.
I have myself only met with one  case of this  kind.   The ulcer
was on the internal surface of the left ventricle,  and was an inch
long  by half an inch wide, and was more than four lines deep in
its centre.   This patient  had laboured under hypertrophia of the
left  ventricle, which  had been recognised before death: this was
occasioned by rupture  of the ventricle.   This terrible and,  fortu-
nately, very rare accident, is almost always the result  of ulcera-
tion  of the  ventricular parietes.   Morand  has collected several
cases of this kind in the Mem. de  l'Acad. des Sciences for  the
year  1732,  and  Morgagni  has  described a similar instance—
(Epist. 27).
  Rupture  of  the  heart  from violent exertion, without previous
ulceration, is much rarer still; and the  number of  incontestible
examples of  this is very small.  Several cases, recorded as such,
are so imperfectly described, as to  leave a doubt whether the al-
leged rupture might not have been  rather the consequence of the
incisions of an  inexpert dissector.   The  best authenticated exam-
ples of this  kind of  rupture are  those  given by Haller (Elem.
Physiol.), and Morgagni (Epist. 27).
  It is surprising that the great thinness  of the parietes of the
ventricles, in the cases of accumulation of fat,  does not give rise
to rupture, more especially towards the apex and  posterior part of
the right ventricle.  This  is, however, so far from being the case,
that ruptures of the right ventricle are much rarer than those of
the left, and that, in this last,  the rupture, when  it occurs,  is very
rarely towards the apex.
  M.  Corvisart has given, for the first time, examples of another
species of rupture of the  heart, of a less certainly  dangerous  na-
ture;—that,  namely,  of the tendons  and  fleshy  pillars  of the
valves.*
  In the three cases related  by him the  rupture appears to have
been the consequence of violent efforts in lifting great weights, &c.
A sudden and very intense feeling of suffocation was the immediate
result  of this accident,  which  terminated in  exhibiting all  the
usual  symptoms of disease  of the  heart.   I shalhhave occasion
to notice in a subsequent  section a  case  of the  same kind, only
produced, apparently, by ulceration of the tendons.

            * Corvisart on the Heart, obs, 33, 40, and 41. 
180              DISEASES OF THE HEART.
                      SECTION TWELFTH.

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

   The mitral and sigmoid valves  of the  aorta are subject to be-
come the site of cartilaginous or bony productions, which increase
their thickness,  alter their shape,  and obstruct, sometimes almost
totally, the orifices in which they are placed.  The tricuspid and
sigmoid valves of  the  pulmonary artery are  much less subject to
these alterations, although  they are not quite exempt  from them,
as Bichat thought.   Morgagni found (Epist. 37),  in  the case of
an  old woman, both these partially indurated.   He likewise
found, in a young  woman,  the sigmoid  valves of the  pulmonary
 artery agglutinated by  means of a cartilaginous induration, partly
ossified, so as  considerably to diminish the diameter of the artery.
M  Corvisart has twice met with a cartilaginous induration of the
base of the tricuspid valve, and I  have myself sometimes observ-
ed slight cartilaginous incrustations, both  at the base,  and on the
points  of this valve.   1 am not, however, aware that  any one has
found these indurated portions completely ossified;  nor do I believe
that the induration has ever been so considerable  as to occasion  a
serious state of disease.   For these reasons I shall confine my re-
marks to the valves of the left ventricle.
   The  cartilaginous induration of the mitral  valve is sometimes
confined to the fibrous bands found in its base.   In this  case it  has
the appearance of  a  very smooth, though unequal roll,  lessening
the orifice in which it is situated.  This sometimes has the con-
sistence of  perfect cartilage, sometimes only that of imperfect  car-
tilage.   Similar incrustations sometimes are met with in other parts
of these valves.  The  bony indurations present the same charac-
ters as to situation and inequality of thickness. Though formed in the
interior of the valve, they often projectfrom it quite uncovered. These
ossifications are never perfect bone; they are whiter and more
opaque, more fragile, and evidently contain a  greater proportion of
phosphat of lime.   On this account they have  been frequently
named stones or calculi.   In fact, they frequently  bear a striking
resemblance to small pieces of stone, of very irregular surface, re-
cently broken.   When they are situated in the floating extremities 
INDURATION OF THE  VALVES.
181
of the valve, these are sometimes united together, so as to reduce
the orifice to  a mere slit, which will, sometimes, scarcely admit
the blade of a knife or a goose quill.  M. Corvisart found the
orifice between the auricle and ventricle reduced to a channel three
lines  wide, and bent like the canalis caroticus, from  the  thicken-
ing of the ossified mitral valve.  Sometimes, though rarely, the
tendinous  cords  of the  mitral valve  are affected  in the  same
manner; and M.  Corvisart in one  case found  the  whole of one
of its pillars ossified.*
   The ossification of the sigmoid valves of the aorta may  com-
mence, like that of  the mitral,  in  their base or their loose edges,
—and much more frequently in one of these situations than in the^
intermediate portion.   When in the loose extremity, the  ossifica-
tion seems most  frequently to originate  in  the  small tubercles
known by the  name of the Corpora Sesamoidea.
   When the ossification  is  confined  to  the  floating edge of the
valves, or when  the base though ossified  is little  thickened, the
valve may still perform its functions,  provided the middle portion
of it be still sound.  But when the ossification is extensive, the
valves grow together,  and  get incurvated, either  towards  their
concave or convex side,  so  as to acquire  the  appearance of cer-
tain shells.  In this state they are  immoveable, being either fixed
 on the side of the aorta, or in the orifice of the ventricle.   Very
 frequently, of the three valves one is bent in a direction opposite
 that of the two others.   In one case, M  Corvisart found  all the
 three valves ossified in their closed position so as to leave  merely
 an extremely  small slit for  the passage of the blood.   The evil
 of this was partly obviated by one of the valves,  although  ossi-
 fied and very thick, still  retaining, at its  base, sufficient mobility
 to allow an increase of one or two lines to the orifice  during the
 action of the heart.
* Op. cit. p. 212,214. 
182
DISEASES OF THE HEART.
                    SECTION THIRTEENTH.

      Of Accidental or  Extraneous Productions in the Heart.

   Or all the organs of "the body the  heart  is perhaps  the  least
liable to these productions,  if we  except ossifications.   Twice
only have I found tubercles'  in  its  muscular substance,  and not
once melanosis, medullary sarcoma, on any other species of can-
cer.  M. Recamier, however, informs me that he has  found the
heart partially converted into a scirrhous matter resembling  lard,
in a person who also had cancers  in  the  lungs.   In the Sepul-
chretum we find several examples of tumours in the heart, which
appear  to  have been   cancerous.   Columbus found  two  hard
tumours of the size of an  egg  in  the parietes of the left  ven-
tricle.*   Morgagni" relates a  case where there were numerous
small tubercles on the external surface of the  right  auricle,  in  a
subject which exhibited similar, but larger, tumours in the medi-
astinum, lungs, lymphatic glands,  and cellular substance of the
thorax and  abdomen (Epist.  78).
   Encysted serous tumours are equally rare in this viscus. When
they do occur they are  most commonly found between the muscu-
lar substance  and investing  pericardium.  Examples have  been
recorded by Baillou, Houlier, Cordaeus, Rolfinckius,  Thebesius,
Fanton, Valsalva,  Morgagni, and Dupuytren.  The  latter found
cysts of this kind in the  parietes of the right  auricle,  projecting
inwardly, and distending it to a size equal  to  the  whole of the
other parts of the heart.   Morgagni describes  a tumour, which
was evidently a  hydatid,  implanted  on the  surface of the  left
ventricle (Epist  21),  and   which appears to  have  been  that
variety named by Ruclolphi Cysticercus finnus.
* De re Anat. lib. xv. 
POLYPI.
138
                    SECTION FOURTEENTH.

                   Of Polypi of the Heart.

   It  was formerly customary to attribute to the polypous concre-
tions of the heart observed after death, the symptoms which truly
depend on the enlargement of that organ. The incorrectness of this
opinion is proved by the fact, that these concretions are very fre-
quently found in persons who have never exhibited any symptom
of disease  of the  heart: in  truth, they  are  met with  in three-
fourths of dead  bodies.  It is equally erroneous to  believe,  with
some  modern authors,  that  polypi never  begin  to form until  the
moment of death.   Many facts prove that these concretions can
be  formed  during  life.   The phenomena  of aneurisms  alone
prove this.   Hailer found the carotid artery  and internal jugular
vein quite  obstructed by very  firm concrete fibrine in  one case;
and the inferior  vena cava  in another*   Vinckler,f Stancari and
Bonaroli have met with similar cases.J
   I have myself observed, in a consumptive subject, an oblitera-
tion of the inferior cava for the space of four fingers'  breadth.
This.obstruction was produced by a whitish fibrinous concretion
which filled  the whole caliber of the vein.  The exterior layers
of  this concretion  were like  the buffy coat of the blood,  only
much firmer, and adhered strongly to the inner coat of the vein;
the inner portions were, on  the  contrary, of a yellowish colour,
more completely opaque, and of a friable character like  certain
kinds of cheese.  In another case I found a similar obstruction in
the carotid artery; and, in a  third, I observed the  whole of the
vessels of the pia mater, in a circumscribed space about  the size
of the palm of the hand, injected with a similar concretion. None
of these, individuals had exhibited any symptoms indicative of such
an affection, nor did there exist in any of them  any obstacles to the
course  of  the blood  which  might account for them: we  must,
therefore, attribute them to spontaneous coagulation of the blood,
and reasoning, a priori, therefore, nothing  is more  probable  than
* Opusc. Pathol, obs. 23, 24.
\ Dissert, de Vasor. lithias.
* Morgagni, Epist. 64. 
184
DISEASES  OF THE HEART.
 that the blood may coagulate during life, in the heart also; at least
 at the very close of life, when the circulation is  performed only
 in an irregular and imperfect manner.   M. Corvisart was  there-
 fore correct in distinguishing polypi into such as are of a  formation
 posterior to death, and such as have been produced  while the  in-
 dividual was still alive.  These two kinds are easily distinguished
 from each other   The former, or those of recent formation, ex-
 hibit merely a slight layer of  whitish opaque fibrine partially en-
 veloping the coagula  of blood contained  in  the heart and  large
 vessels.  This fibrinous or buffy layer never completely surrounds
 the coagula, and does not adhere to  the parietes  of the heart or
 vessel in which it is contained.   Sometimes this layer is thicker,
 and, in this case, especially if the subject is  dropsical, it is semi-
 transparent and tremulous like jelly.
   On the other hand, the polypi of more ancient formation are of
 a  much firmer consistence, and adhere more or less strongly to the
 parietes of the heart.  In the ventricles  and auricular sinuses, this
 adhesion is partly caused, no doubt, by the intertexture of the con-
 cretion with  the columnae  carneae; but, even here, the  principal
 part of the  attachment is independent of any mechanical  structure
 of the  parts.  The^e concretions are of a more distinctly  fibrinous
 texture than are the  recent formations or the  buffy coat of the
 blood, and they are, further, of a pale flesh or slight violet colour;
 while the more recent are, as already mentioned, of a white  or
 yellowish colour.
   These ancient  concretions  are found  most  frequently in  the
 sinus of the right  auricle, and in the right ventricle.   When  in
 the former, they completely obstruct its cavity, but in  the ventricle
•they only double in thickness its parietes (thereby  lessening its
 cavity) and obstruct the  descent  of the  tricuspid valve.   In this
 case, one may remove all the loose coagulated  blood without injur-
 ing the concretion; it is even possible that this might be mistaken
 for the natural  boundaries of the cavity.
   The  columnae carneae to which these concretions are attached,
 are commonly perceptibly flattened; a circumstance which, of itself,
 would  prove their formation to be anterior to death. M. Corvisart
 was the first, as far as I know, to observe this flattening of the co-
 lumnar: in  the case noticed  by him they were quite effaced.   I
 have not met with any case so strongly marked as this; but it is by
 no means rare to find cases  wherein the  thing is very perceptible.
   There is still a third species of concretion, evidently more an-
 cient than those just described,—of a formation, perhaps, several
 months anterior to the patient's death.   These are  found adhering 
EXCRESCENCES  ON THE VALVES.
185
to the parietes of the heart, sometimes so firmly as only to be de-
tached by scraping with  the  scalpel.  Theit  consistence is less
than that of those just noticed; being not  at all fibrinous, and re-
sembling  rather a dry friable  paste or a fat and somewhat soft
cheese.   They have lost  the  semitransparency of recently con-?
creted fibrine, and resemble in evety respect those layers of de-
composed fibrine met with in false aneurisms.   I have only met
with concretions of this kind in the auricles.
                     SECTION FIFTEENTH.

Of Excrescences on the Valves  and internal Parietes of ihe Hearh

  There are two very distinct varieties  of this affection.  The
first has been described by M.  Corvisart under the  name  of Ex-
crescences of  the Valves;  the other, which does not appear  to have
been hitherto described, I shall notice under the name of globular
excrescence.   The first kind might very well be named warty ex-
crescence, inasmuch as  they are  extremely like warts, especially
those  of venereal origin on the  parts of generation.  Like these,
the excrescences in the heart sometimes resemble small cherries,
in their form and tuberous surface; at other times they are  elon-
gated into the form of a small  cylinder or cord, and, occasionally,
they are so short and  so crowded together, as  merely  to  give  to
the parts on which they are situated  a rough or  rugged surface;
more  frequently, however, they are either isolated or ranged in a
single line along the loose, or the attached border of the  yalves.
I have never observed any longer  than three lines.  The colour
of these excrescences is sometimes whitish like that of the  valves,
and hardly so opaque; more commonly they are either wholly or
in part tinged with  a  reddish or light violet colour.  Their tex-
ture is fleshy, like venereal warts, only of somewhat less firm con»
sistence.   They adhere immediately to the subjacent parts; some-
times  so strongly as to be only separable  by incision; more com-
monly they are easily  removed by scraping.  The venereal origin
of these excrescences, entertained by M. Corvisart, appears to me
very improbable, when we consider their rarity and  the frequency
of venereal complaints, and when we meet with them, as we do,
in individuals  who,  in  all probability,  never had this disease.
                             24 
186
DISEASES OF THE HEART.
 Whatever may be the remote cause  of these bodies,  the  manner
 of their formation seems to me more explicable.   In dissecting the
 more voluminous excrescences, it has always appeared to  me that
 their texture has borne a strong resemblance to that of the more
 compact polypous concretions.  Frequently we observe  in their
 centre a violet or sanguineous tint; and sometimes I have even
 found a very small, but distinct, coagulum of blood.  From these
 circumstances I am led to  believe,  that  these  excrescences  are
 merely  polypi organized by the same process which transforms the
 false albuminous membranes into true adventitious membranes, or
 into cellular substance.
   In like  manner as  M  Corvisart, I have  only  met with these
 excrescences in the following situations, viz.  the mitral, tricuspid,
 and sigmoid valves, and  (much more rarely) the  interior of the
 auricles, especially the left.   In general they are more common in
 the left than the right  side of the heart.   I may here remark that
 the view  of the  fromation of these excrescences, given above,
 proves  that they are not likely to occur  but in subjects  already
 affected with some serious disease of  the heart or  large vessels; a
 circumstance, as we shall find, in another place, which must render
 their diagnosis very difficult.  [In  the following notice of a case of
 this affection, I shall, as in many of the former cases, omit several
 of  the symptoms with the  intention  of again noticing them  in
 another part of this work.]
   Case 43.  A man,  aged  35, at the period of his coming into
 hospital, had  been  affected for  five months  with great dyspnoea
 and violent palpitations on  making  .any considerable exertion^
 starlings from sleep, and occasional spitting of blood.   For a few
 days past he had laboured under a  severe diarrhoea.   His  counte-
 nance was tranquil, with some colour, the pulse small,  hard, and
 regular,  and the  respiration oppressed.  The action of the heart
 was not quite regular, but  there was  no distention of the jugular
 veins.   This patient died on the third day.
   The  pericardium contained half a pint of serum.   The heart
 was double the size of the patient's fist.  The right ventricle was
 very large, its parietes being at least four lines thick, and its co-
lumnae very large.   The tricuspid  valves,  and the  sigmoid of the
pulmonary artery, were of  a deep violet red colour.   The right
auricle  was sound.   The left ventricle was one-third larger than
 natural, and its walls were six lines thick, and its  columnae very
thick.   One of the tendons affixed  to the edge of the mitral valve
was ruptured  about  its middle.   This rupture appeared  to have
been the consequence of progressive wasting of its middle part; and 
EXCRESCENCES ON THE VALVES.
1ST?
one of the other  tendons of the same valve  was unequally exten-
uated, but still whole.   The  whole floating border of the mitral
valve was covered with small excrescences such as I have describ-
ed, varying in size, form, and consistence.   Altogether they gave
to the valve a thickened and fringed appearance.  The sigmoid
valves of  the  aorta, and  the lining  membrane of  this artery,
were extremely red, and exhibited  in this respect a striking con-
trast with the inner membrane of the ventricle.  The whole inner
surface, and indeed the whole  parietes, of the left auricle,  were of
the same red colour; and, above the opening of the left pulmonary
veins, and about  two lines from the auriculo-ventricular  opening,
there was about an inch square coated with  a congeries of excres-
cences similar to  those on the mitral valve, and very firmly attach-
ed. The muscular substance of the heart was of moderate firmness.
The pleura contained about a pint of serum on  each  side.  The
lungs were sound.
   The  globular  excrescences  have a quite  different  appearance
from those just  described, resembling little  balls or cysts, of a
spherical  or oval  shape, and  of a size from  that of a pea to a
pigeon's egg.
   The exterior surface of these is equal, smooth, and of a yellow-
ish white colour, and the thickness of their  parietes  is  very
uniform, being never more than half a line.  The substance com-
posing their parietes is opaque and very similar  to that of ancient
polypi, its consistence  being firmer  than boiled white of egg.  The
inner surface of  these  parietes (the cyst) is  not  so smooth as  the
exterior,  and it  appears  to be composed of a  softer  substance,
which occasionally has the appearance of passing gradually into
the matter contained within  it.   This matter may exist in three
different states, all of which may be found in the  same subject, but
in different cysts.  These are, 1st,  a liquid resembling half-coa-
gulated blood, only turbid  as  if intermixed  with some  insoluble
powder, and sometimes containing  a few clots of perfectly coagu-
lated blood; 2nd, a more opaque matter,  of a pale violet colour,
of a pultaceous consistence, and very like the lees of wine; and
3rd, yellowish, opaque fluid> like  thick pus or thin paste.  I have
only met with cysts of this kind  in the ventricles and  auricular
sinuses.   They are found as frequently in the right as left side of
the heart, generally near  the  apex of the ventricles, and  always
adherent to the walls of the cavity.  They are attached by means
of a pedicle, which is often so slightly connected with the  co-
lumnae carneae as to be detached  from them without being  rup-
tured   This pedicle, although forming part of  the excrescence,
resembles  the common polypi  more than the other portions, and 
188
DISEASES OE THE HEART
seems as  if it were of  more recent  formation  and  less perfectly
organized.  I have never found these bodies more organized than
I have described, and I have considered those containing clots of
blood as the newest, those containing a  fluid  like the lees of wine
as next in order, and  those containing  a puriform matter as  the
most ancient.  I have met with these excrescences in  subjects dead
of different diseases, but all of whom  had  remained in a dying
stale (agonie) for several days or even weeks.
  The only case that I  have met with in medical writings, which
seems to me to agree with the above description, is recorded  in
the Miscei. JVatur.  Curios.  The affection, nevertheless, does  not
appear to  be extremely  rare, as I have met with  several  case?
of it.
                      SECTION SIXTEENTH.

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

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

however, the auricle participates in the affection, but scarcely ever
the  ventricles.   This redness is  attended  by no sensible thick-
ening  of the  part, and it  entirely disappears after a  few hours
maceration..
   M.  Corvisart has slightly noticed this affection; and has avowed
his ignorance of its nature and cause.   Franck, who has observed
it through the whole  tract  of the  arteries, considered it as the
cause  of a particular and uniformly fatal fever.  My own obser-
vations are far from leading to the same result, although I confess
myself ignorant of the nature of this affection   The most natural
idea respecting it is, that it is the result of inflammation.  But
mere redness, without thickening of parts, does not  sufficiently
characterise  this  state; while  the  abrupt  termination, and exact
circumscription presented by  the  redness in certain cases, seem
not easily to accord  with the  nature of inflammation.   On the
other  hand,  it  may,  indeed, be said, that,  in the serous and mu-
cous  membranes, this sort of  redness by stains is more character-
istic of inflammation  than the mere sanguineous  infarction of the
capillaries, which might take place either at, or after, death. The
following is an example of" this affection.
   Case 44. A  young woman, fresh-coloured and plump, came
into hospital complaining only  of intense headach, of three days'
duration.  At the end of two  days the  disease assumed the ap-
pearance of acute hydrocephalus, the pulse being very slow, very
regular and of moderate strength. The cerebral symptoms increas-
ing rapidly, this  patient died at the end  of ten days from the in-
vasion of the disease, after the application  of the usual measures.
and particularly the employment of a great number of general and
local  bleedings  indicated by the violence  of the headach.  For
two days before death, the pulse became  more frequent, but not
stronger,  nor  more irregular.   On  examining the body, besides
the hydrocephalus, there were found tubercles in the lungs, large
tuberculous ulcerations in the  intestines, extensive emphysema in
several portions of the mucous coat of the  intestines, unequivocal
marks of confirmed lues, and, finally, a very intense redness of all
the valves of the heart, the  aorta, and particularly of the pulmo-
nary artery.
   One of my pupils informs me that he found in an aorta intensely
reddened, some  small  purulent collections, resembling miliary
pustules, situated  between the internal and middle coats.   This,
however,  must have been the consequence of disease of the mid-
dle coat itself, as we can hardly suppose that inflammation of the
.internal coat would terminate in suppuration of its adherent sur 
190              DISEASES OP THE HEART.
 face.   I do not, however, mean to deny the possibility of the in-
 flammation of blood-vessels.   On the contrary, I think  it proba-
 ble that the affection we have  been describing is  of this nature;
 and I would be  disposed  to consider the various concretions  of
 blood already mentioned,  for example, those which produce obli-
 teration of veins, and the warty excrescence,  as  the result of in-
 flammation.
   The  second species of  redness of the large vessels has a quite
 different appearance, being, in place of a bright red, of a violet
 hue.   It is also usually extended at the same  time to the aorta,
 pulmonary artery,  valves, auricles  and ventricles.   This variety
 is not so exactly confined to  the lining membrane, as we find the
 muscular substance of the auricles and ventricles, and even the
 fibrinous coat of the aorta and pulmonary artery, participating in  it,
 at least  partially.  I have found this variety of colouring in sub-
jects  dead  of putrid fevers, emphysema of the lungs, and disease
 of the heart.  All these individuals had remained long in a mori-
 bund condition, with suffocation; and I have thought that the vio-
 let tint was deep in proportion  to the intensity and duration of the
 latter symptom.   From this  circumstance I am disposed to con-
 sider this condition of the  vessels as the effect of deranged circu-
 lation and  congestion of  the blood in the capillaries; being ana-
 logous to the livid  hue of the  cheeks, &c. observable in persons
 dead  of disease of the heart.   It is, in fact, an effect of death,  or
at most produced in articulo mortis.
   I would here  beg to observe, that it is often difficult to distin-
guish mere congestion of the capillaries from actual inflammation.
 The distinction, however, is of great importance, both in morbid
anatomy and  practical medicine, the more so, as both these affec-
tions  may  exist  simultaneously.   In proof of this I may refer  to
the controversy that has for some time existed respecting the con-
dition of the mucous  membrane of the intestines in  fever.
  I am  far from denying the  influence of irritation, ulceration,
aphtha;,  and consequent inflammation of the intestinal tunics  in
continued fevers; and, although they have been more or less notic-
ed and appreciated in all ages, M. Broussais has truly benefited
his profession by calling  the  attention of practitioners more par-
ticularly to them, and by  showing the injurious error of former
periods in withholding the employment of general and local bleed-
ings in fevers.  But we should fall into as great, although an op-
posite, error, if we concluded that all continued  fevers depended
on the intestinal irritation that  accompanied them, and that every
kind of  redness  observable in  them after  death indicates a dis- 
REDNESS OP INTERNAL MEMBRANE.         191
order  requiring  venesection  for  its  treatment.  The  mucous
membrane of the stomach and bowels is naturally pale only in
persons of pale skins;  its degree of colour may be judged of by
that of the lips, mouth, anus and vulva, in different individuals.
No one will set down the livid gums of a dropsical or scorbutic
patient, or the swelling and blueness of his hands and feet, to in-
flammation, or think of treating these  affections by blood-letting.
Now, in many cases, I conceive, the  redness of the mucous  coat
of the intestines  has much more relation to this  passive congestion
than to inflammation.  If, then, such appearances (as is most  pro-
bable) only took place in such subjects, at the same time as the
lividity of the face and of the dependent parts  of the body—that
is  to say, some days or hours  before  death; it would be absurd to
look to such condition  of parts for the cause of the fever,—more
especially, as we often find,  in such cases, traces of  as great or
greater disorder in almost every texture of the body.   For  ex-
ample:—the  skin is dry  and harsh; the lips,  gums,  and lining
membrane of the mouth are swollen, soft and chopped; the mem-
branes of the brain are gorged with blood  and  containing serum;
the lungs are charged  with a sero-sanguinolent  fluid; the mucous
membrane of the  bronchia is  swollen  and of a violet hue;  the
heart is flaccid, livid and soft; the blood fluid and imperfectly co-
agulable; the lining  membrane of the  arteries or veins  livid  as if
stained by blood; the muscles^s% (poisseux);  the spleen enlarg-
ed; the capillaries of almost every organ, and of the surface, gorg-
ed with blood; and, lastly, the intestines are in the same state, and
their lining membrane livid,  ulcerated  and thickened in diverse
places.—Now, to which of these affections  shall we attribute the
disease?   All are posterior—often many days—to the fever.  Is
it  not, therefore, more rational to consider, that none of these
local lesions are the cause, but that, as in small-pox and measles,
some unknown cause, acting generally on the system, has produc-
ed both the fever and the local affections—whether active or  pas*
sive—which accompany or follow lit?
   In the very case  where there exist simultaneously aphthae and
exulcerations in  the intestinal tunics, and  redness,  lividity,  and
capillary congestion of the mucous  membrane,  we ought to con-
clude, from analogy, that the two former states are the result of
inflammation, active or passive,—and the three  latter the result of
debility of the circulation in the capillaries; that the first may re
quire venesection, but that this very  means, carried to too great
lengths,  may give rise to,  or increase  the last,  by increasing the
general debility.  The haematemesis and bloody fluxes which oc 
152
DISEASES OF THE HEART.
cur sometimes in continued fevers ought rather, in my opinion, to
be attributed to  purely passive congestions of the capillaries, than
to inflammation.  In the instances just  mentioned we find the
whole  of the  intestinal tunics  in the affected  part tinged  with
blood,  and softened, without any notable increase of thickness of
the part; while  inflammation  of every mucous membrane  uni-
formly increases both the thickness and density of the  part.  We
may farther add the fine observation of Bichat, that, of any  mor-
bid affection,  inflammation  has the least tendency  to  propagate
itself by contiguity, especially in membranous  parts   Peritonitis
and dysentery leave untouched the muscular coat of  the intestine,
but the lividity  consequent on fatal  fevers often extends to thf
whole  three tunics.
                    SECTION SEVENTEENTH

                Of Malformation of the Heart.

  There exist two varieties of unnatural communication between
die cavities of the  heart,  viz. the perforation  of the  septum of
the ventricles, and the continued patency of the foramen of Bo-
tallus.   The first variety is very rare,  there being  not more than
five or six instances  of it on records   In all  these the  unnatural
aperture  was  smooth, evidently very  ancient, if not congenital.
The continued  patency of  the  foramen of Botallus is much more
common.   Sometimes this is produced by the imperfect union of
the two plates of the foetal  valve,  so that a probe, or even a fe-
male sound, can be passed  obliquely from one auricle to the other
This condition of parts is not very rare, and does not appear to be
productive of any kind of inconvenience.   In other cases we find
the foramen continue constantly open so as to admit  the  finger.
I have myself seen it sufficiently large to receive  the thumb.   It
is commonly believed that  this species of malformation is always
congenital;  but from some cases which  I have  met with, I am
disposed  to  believe  that such a perforation may be produced by
an accident; or, at least, when such a  condition of parts exists as
 tbove described,  that a blow, fall, or violent exertion,  may  cause
the dilatation of the oblique opening, and its progressive enlarge-
ment,  The history of several cases on record, especially of some 
DISPLACEMENT.
193
of M. Corvisart's, would seem to countenance this opinion, since,
in several of these, the individuals had enjoyed good health, with-
out any symptom of diseased heart, until they  had experienced
some of the accidental causes above mentioned.
   I  do  not know  that any of  these  unnatural  communications
have  existed  without consequent  thickening and  dilatation of
either the whole, or part of the heart, especially the right  side.
The symptoms of the latter affection are, consequently, combined
with those of the former.   These are  principally the four follow-
ing:  1, a great sensibility  to  the impression of cold;  2, frequent
faintings; 3, the respiration more constantly impeded than in  most
other diseases of the heart; and 4, a  violet or blueish colour of
the skin much more extensive  than in any other  disease,  and,
sometimes, even general.   This last symptom has been named by
several  authors the blue jaundice,  or  the blue  disease.   On the
other hand,  all the above mentioned symptoms  have been found
to exist in subjects who had no other malformation  than the  con-
tinued natency of  the foramen  of  Botallus;  and still  more so in
those cases where the pulmonary artery was found to originate in
the left ventricle, and the  aorta  in  the right, or where the latter
has opened at once into both ventricles.   In some diseases of the
lungs, especially emphysema, the blue  colour of the  skin is some-
times quite as intense  and as extensive as in the case of malfor-
mation of the heart.  On the other  hand,  the foramen of Botallus
has been found  dilated very considerably, without there being
present any degree of lividity except on the face  and extremities.
The  case of dilatation noticed by myself, above  mentioned,  was
of this sort.
                    SECTION EIGHTEENTH.

                 Of Displacement of the Heart.

  The  heart, although retained  in  its place by. the diaphragm,
large.vessels, and peculiar structure of the mediastinum, and, still
more, by the constant state of plenitude of the chest, may, never-
theless, in certain cases, be thrown to the right or left by a solid,
liquid, or aeriform effusion into either sac of the pleura, by exten- 
194
DISEASES OF THE HEART.
sive tumours in the lungs, and, as we have already seen (page 8b'),
by emphysema of this organ.  In like manner, a tumour in  the
superior mediastinum, or a large aneurism of the arch of the aorta,
may press it downwards, so  that that part  of the diaphragm on
which it reposes shall project into the abdomen.   Sometimes even
this depression has taken place without any visible cause, in which
case the affection has been  named by some  authors prolapsus of
the heart.
  These various kinds of displacement produce no perceptible in-
convenience when they exist in a slight degree; when more mark-
ed, they may produce bad effects; but in  this case, they are them-
selves consequences of lesions much more serious.
                    SECTION NINETEENTH.

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

  On examining the bodies of persons who have fallen victims to
organic affections of the heart, besides the organic lesion and  the
serous  effusions which almost always accompany it, we find  all
the  marks of congestion of blood in the internal capillaries.  The
mucous membranes, especially those of  the  stomach and intes-
tines, are of a red or violet tint; and the liver, lungs,  and capilla-
ries situated beneath the serous mucous and cutaneous tissues, are
gorged  with blood.   The augmented  colour of the mucous mem-
branes  varies much in degree and extent.   Sometimes it is  ob-
served  only here  and there, under the form  of small  points  or
specks, disseminated over the surface of  the membrane: at other
times it occupies the whole extent of the  surface, and has the  ap-
pearance of being attended by some swelling of the part.   These
two latter appearances are sometimes so considerable, that, if  we
looked   to them merely, without examining the  condition  of  the
heart, and  without  reference to the  history of the patient, (who
had been found capable of taking into his stomach wine and.other
stimulant matters without experiencing  any pain, even  up to  the
period  of his death,) we might be tempted to believe that the fatal
disease had been a violent inflammation of the stomach and bowels, 
CAUSES.                       195
In fact, the degree of redness of these membranes  observed after
diseases of the heart, is often  much  more intense  and extensive
than is found after true inflammation of these parts, as, for exam-
ple, in dysentery; a fact, among many others, sufficiently proving
the insufficiency of mere  redness to characterise inflammation of
the mucous membrane of the intestines.
   Lancisi and Senac,  after  Hildanus, consider gangrene of the
limbs as a  consequence of disease of the heart and large vessels.
The late M. Giraud was of the same opinion, and, since his time,
many practitioners have considered the gangrene of old persons as
usually caused by ossification of the arteries.   M. Corvisart justly
doubts whether, in  such cases, there  is any  thing else but mere
coincidence of independent diseases;  and I think that the single
circumstance of the rarity of the spontaneous gangrene of the limbs,
compared with the  frequency of disease of the heart and ossifica-
tion of the arteries, is sufficient to render the thing quite improba-
ble.   This is equally the case with the notion of Testa, that oph-
thalmia, and sometimes the loss of the eye, maybe ranged among
the consequences of diseases  of the heart.*
SK
                     SECTION TWENTIETH.

            Of the Causes of Diseases of the Heart.

  The causes of diseases of the heart  are, like the diseases them-
selves, various in their nature.   Ossifications  are the  result of
some aberration of the process of assimilation which is not easily
understood.   I have  already stated my opinion respecting the ori-
gin of the excrescences on the valves.   The dilatation and thick-
ening of the ventricles, diseases of much greater frequency, also
may arise from numerous causes; but  these  are in general  more
easily traced to their effects than the former.  All diseases which
give rise to severe and long-continued  dyspnoea  produced, almost
necessarily,  hypertrophia  or dilatation  of the heart, through  the
constant efforts the organ is called on to perform, in order to propel
the blood into  the lungs against the resistance opposed to it by the
* Delle Malattie del Cuore,  Bologna, 1810, 
196
DISEASES OP THE HEART.
cause of dyspnoea.   It is in this manner that phthisis pulmonalis,
empyema,  chronic  peripneumony, and  emphysema of the lungs,
act in producing disease of the heart; and that those kinds of ex-
ercise which require great exertion, and thereby impede  respira-
tion, come  to be  the  most common remote causes of these com-
plaints.
   On the other hand, it is found that diseases of the heart, on the
same principle  of mutual influence, give rise to several diseases of
the  lungs   They are thus among the most  frequent  causes of
cedema of  the lungs and haemoptysis.   When, however,  diseases
of the heart  are found to coexist with  chronic pleurisy, phthisis,
emphysema, and, in general, with chronic disease of the  lungs, it
will usually be  found, on close examination, that the latter are the
primary diseases.   It follows from  these, and other facts noticed
under the  head of Emphysema and Pulmonary Catarrh, that a
neglected Cold is frequently the original cause of the  most severe
diseases of the heart,
   To all these  causes must be added the congenital disproportion
between the size of the heart  and the diameter of the aorta.   M.
Corvisart has, perhaps, gone too far in asserting that there can be
no dilatation of the heart without the previous existence of a dis-
proportion  of this  kind, or of a contraction, or some similar ob-
struction to the circulation, at a greater or less distance from the
heart; it is, however, true, that it is very common to find  an aorta
of small diameter  in cases of hypertrophia or dilatation of the
heart.  Still, this is not always  the case,  and  however  rational
such a  cause may be, we  can  readily conceive many others.   We
know that the energetic and reiterated action of all muscles notably
increases their size, as in the case of those of the right arm of the
fencer, the shoulder of the porter, and the hands of most artisans.
On  the same principle we must admit that even nervous  palpita-
tions,  or such  as originate from moral causes,  may, by frequent
recurrence, produce a true enlargement  of the heart.
   There is yet another congenital  cause of disease of the heart,
which  appears to me to be of greater  frequency than  the  small
caliber of the aorta, above mentioned,—I allude to a disproportion-
ate  thickness of one  or  both sides of the heart.   1 am satisfied
that in a great  many persons the parietes of one or both  sides of
the heart are either too thick or too thin from birth.  In  such cases
there can be no doubt that the usual exciting causes will  be more
apt to produce formal disease of the heart  than in individuals in
whom this disproportion does  not exist. 
FERICARDin*
197
              CHAP.  II.

DISEASES OF THE PERICARDIUM.
                       SECTION FIRST-

       Of Pericarditis, or Inflammation of the Pericardium


  Pericarditis is inflammation of the serous  membrane which
lines  the  fibrous sac of the  pericardium, the heart and large
vessels.   It niay be'either acute or chronic.  This inflammation,
like  that of all  membranes  of the same kind, is marked by red-
ness,  more or less deep, a concrete albuminous exhalation and a
sero-purulent effusion.   The redness is almost always but slight
in the acute disease.   When it exists, it is for the most part only
partially.   It is most  commonly punctuated, and looks as if the
surface of the membrane was  covered, here and therewith little
specks of blood very close to each other.  I have never perceived
that this redness was accompanied by any thickening of the part.
In  some cases,  wherein, to judge  by the thickness of the false
membranes, the inflammation appears to have been very great, no
redness whatever can  be discovered on the  serous membrane, on
removal  of the  membranous exudation.   This concrete albumi-
nous  exudation commonly invests  the whole surface of the peri-
cardium, as well on the heart and large vessels, as on the sac.  It
rarely presents the  appearance of an equable membranous layer,
like the false membranes of pleurisy; on the contrary, its surface
is most frequently marked  by a great'number  of rough and irre-
gular prominences.   Sometimes  the knobbed appearance of this
exudation is very like what  would result  from the sudden separa-
tion of two pieces of slab joined by a pretty thick layer of butter;
at other times,  it is more like the internal surface  of the second
stomach of the calf,  an observation  made, in one  case, by M.
Corvisart.  In certain  cases  this aspect  of the false membrane
 has given rise to a singular  error,  having, been mistaken for a 
198          DISEASES OF THE PERICARDIUM.
 variolous eruption in subjects dead  of the  small-pox.   The con-
 sistence of this exudation is usually  greater than that of the false
 membranes of pleurisy; it is also thicker, and  more firmly adhe-
 rent to the subjacent parts; its colour is,however, the same, being
 of a pale yellow analogous to that of pus.
   The serum effused in inflammation of the pericardium is limpid,
 of a pale yellow colour, or slightly brownish.  It contains few
 fragments of semi-concrete albumen; at.least, it very rarely con-
 tains  enough of these to  give  it a milky and  turbid  character.
 The quantity of this  effusion is usually considerable in the com-
 mencement of the disease, often as much as a pound.  M. Corvi-
 sart found it, in one case,  to  amount  to  four pounds.   It would
 seem  that the  quantity of effused serum diminishes quickly, as
 soon as the violence of the inflammation begins to subside; as we
 usually find the proportion of serum and of albuminous exudation
 nearly equal, while in pleurisy and peritonitis the serum is com-
 monly from  twenty to fifty times greater than  that of  the extra-
 vasated  lymph.  Very commonly even, in very violent cases, we
 find no effused serum,  and only a thick and highly concrete albu-
 men filling the  whole cavity of the pericardium, and uniting the
 heart and  large vessels  to the  exterior or  loose  portion  of this
 membrane.  In this case we may suppose that  the effused serum
 has  been quickly absorbed, and  the two layers of false membrane
 cemented  together; although  it  is not impossible that, in some
 cases, th^more solid exudation  may be the only one.   We have
 seen that the same thing occasionally takes place in certain  partial
 and  sub-acute inflammations  of the  pleura; and several  observa-
 tions have led me to believe  that the  cartilaginous  patches  that
 sometimes are met with on the exterior of the lungs (see page 51
 and  page 132) are produced in the same manner.
   When  the disease  terminates favourably, the  pseudy-mem-
 branous exudation, after a certain time, is converted into cellular
 substance, or rajher into laminae of the same nature as the serous
 membranes;  that is to say, the  lamina?  are double, the exterior
 surface being exhalent, and the interior cellular, or adherent, and
 containing the vessels  distributed to  the part.   Sometimes these
 laminae are long, sometimes so short  that the pericardium  seems
 intimately adherent to the heart.
   Before the conversion of false membranes into  cellular tissue
 was  well understood, the adhesion of the Dericardium to the heart
was  regarded by divers authors as a cause of various and serious
complaints.  Lancisi and Vieussens  considered  it  as constantly
causing palpitation;  Meckel,  as  rendering the pulse  habitually 
PERICARDITIS.
199
small; and Senac, as productive of frequent faintings.   Even M.
Corvisart himself has fallen  into some  mistakes  on this  head.
He admits three species of adhesions,—all of which I have just
described as  mere  varieties  or stages  of  the  same  affection.
These are,  1st, a demi-concrete  albuminous adhesion,*which is
the only one recognised  by him  as the  consequence of pericar-
ditis; 2nd, the very intimate or close cellular adhesion, deemed an
effect of gouty or rheumatic affections; and  3rd, the extended or
long  cellular  adhesion,  the cause  of which is not assigned  by
him.*  M. Corvisart is further of opinion that no person can live,
and preserve a good state of health, who is  affected with a com-
plete and close adhesion of the  pericardium to the heart, or of
the lungs to the pleura.
   I have, however, met  with many cases where this condition of
parts was found after  death, in which no disorder of the respira-
tion or circulation existed during life.  A case adduced by M.
Corvisart in support of his opinion (op. cit. p.  34) appears to
me rather conclusive against it, inasmuch as the  appearances on
dissection showed sufficient lesions in other organs to account  for
the symptoms referred by him to the adhesions  between the heart
and pericardium.
  . Sometimes, though rarely,  the inflammation is confined to a
part  only—sometimes a very small  part—of the  pericardium.
These partial inflammations are in proportion  to  the general, in
point of frequency, hardly as  one  to  ten.  Their anatomical
characters  are precisely  the  same,  only  that  the albuminous
 exudation is in them confined  to the  inflamed  part.  The serous
 effusion is sometimes as abundant as  in the  general  disease; more
 commonly, however  it is less.  The inflammation in  this  case
 almost always terminates in  being cured, by  the transformation
 of the pseudo-membranous exudation into  long'serous laminae;
 scarcely ever are these partial inflammations followed  by the in-
 timate adhesion of the parts.
    We frequently find on the surface of the heart  opaque  white
 patches, sometimes as large .as the  palm of the hand, more com-
 monly one  half or  one  third this size,  and  often very small.
 They are nearly of the  thickness of the nail, and  have a degree
 of consistence  equal to that of  the membranes composed of con-
 densed cellular substance, as, for instance, the exterior  membrane
 of the lymphatic glands.  They adhere so closely to the parts on
 which they lie, that it is difficult to ascertain, even by  dissection,

            * See Treatise on the Heart, &c, by M. Corvisart. 
200           DISEASES OF THE PERICARDIUM.
            whether they are situated above or beneaUji the  fine membrane
            covering the heart and great vessels.  M. Corvisart is of opinion
            that they are beneath it.   I have, however, ascertained the in-
            correctness of this opinion, as I have several times  been able to
            remove the patches, leaving the  serous membrane  of the pericar-
            dium still untouched.
              Are these patches the effect of-partial pericarditis and the con-
            sequent conversion of the effused lymph  into a  condensed mem-
            branous cellular tissue?   M. Corvisart considers them as produc-
            ed without previous  inflammation, and seated, as  I have already
            said, beneath the serous surface of the pericardium.  Both  these
            notions are, I think, inadmissible,  inasmuch as  there  exists no
            example of an albuminous exudation oil the adherent surface of
            a serous membrane, and  as facts  without  number prove  that
           pseudo-membranous  exudations  are always  the  produce of in-
           flammation.
             I have lately met with a case  which appears  to me  to  throw
           some  'light on the question of  the  origin of these spots.   In a
           man dead of peripneumony, I found a thin false  membrane, very
           firm and of a yellowish colour,  investing the right  auricle and a
           portion of the ventricle of the same side, all the  rest of  the peri-
           cardium being quite free,  only  containing in its  cavity two or
           three  ounces of a transparent and slightly yellow  serum.   Some
           parts of the false  membrane, particularly on the auricle, were of
           a whiter colour and firmer than the rest, and exhibited an appear-
           ance almost the same as she white  patches above described.
             Chronic  pericarditis is  always general, occupying the whole
 m         internal surface  of the serous  membrane.  This is commonly
/          much  redder than in the acute disease.  The redness is formed
           by the close approximation of minute  points,  which  look as if
           applied with a pencil.  Rarely the chronic disease is accompanied
           by a pseudo-membranous  exudation; and when  this exists, it is
           thin, soft, friable, and entirely resembling  a layer of very  thick
           pus.   In every case there  exists  a more  or less  copious effusion
           of a turbid, milky  fluid,  sometimes, having  quite  a  puriform
           character.   I am  led to believe that the  close  adhesion of the
           pericardium to the heart,  is  commonly the  consequence of the
           absorption of this fluid, and that  the adhesion by the long laminae
           is the product of the acute  disease.   In one case I found a close
           and general adhesion of the pericardium to. the  heart and  large
           vessels,  by means of a false fibro-cartilaginous membrane,  in
           every respect like those of  the pleura.
             From one case, cited by  M. Corvisart, I am led to believe, that 
HYDRO-PERICARDIUM.               201
there may occasionally arise, subsequently to chronic inflammation
of the pericardium, a tuberculous eruption similar to those  fre-
quently formed in the false  membranes of  the  pleura and perito-
neum.  " The portion of the  pericardium," he says, " which in-
vests the  heart,  was  of a greyish  colour, thickened,  unequal,
wrinkled, crisp, and containing granulations of which the summit
seemed ulcerated."   I am the rather led to consider these granu-
lations as tubercles, because in the same   subject  " both lungs,
although crepitous, were granular throughout."   (Op.  cit.  obs.
vii.)
  In many cases of pericarditis, especially  in the chronic disease,
the muscular substance of the heart has lost it* colour and become
whitish.   'I his loss of colour  is sometimes attended by a notable
degree of softening, and,  at other times, the consistence is natural.
Most writers have regarded this loss  of colour as a mark of the in-
flammation of the heart  itself, and most of  the  examples recorded
of Carditis  are merely cases of  inflammation of  the pericardium
accompanied by this loss of colour.  A great number of those col-
lected by M. Corvisart are of this kind.   For  my own  part I am
disposed to doubt the correctness of the opinion  that refers this loss
of colour to inflammation.  We cap never be sure of  the exist-
ence of inflammation in a muscular organ unless we find a deposi-
tion of pus among its fibres.
                       SECTION SECOND.

      Of Hydro-pericardium, or Water in the Pericardium.

  It is extremely common to find a greater or less quantity of se-
rum in the  pericardium;  most  frequently this does not exceed a
few ounces, and can rarely be considered  as  idiopathic.  Most
commonly it can only be regarded as taking place in articulo mor-
tis.   When there  exists a general dropsical diathesis, we occa-
sionally find some water in the pericardium, but, in general, it con-
tains less than the  other serous cavities.   In the idiopathic hydro-
pericardium, on the contrary, the pericardium is  commonly the
only membrane which contains  serous effusion.
  The effused serum is sometimes colourless, but more commonly
                             26 
 202           DISEASES OF THE PERICARDIUM.

 it is yellowish, brownish or reddish, although still perfectly limpid,
 and without any admixture of flakes of lymph: rarely it is sangui-
 nolent.   It  is  variable in amount.   Most frequently it does  not
 exceed  one or  two  pounds, but it has been found in much greater
 quantity than  this.   M.  Corvisart records an  instance wherein
 eight pounds were found.   This effusion is attended by no change
 in the heart or its coverings.  Some authors have, indeed, stated
 the heart to have been macerated (macere) in such cases; but  1
 am disposed to consider such statements as the result of imperfect
 observation and  incorrect description.  Very  frequently  before
 opening a pericardium partially filled with serum, I haye distinctly
 observed an accumulation of  air in  the caviy.    I  have seen this
 occupy  a space the size of the fist, and when as large as  this,  a
 distinct hissing sound is perceived in puncturing the pericardium.
 In  place of this continuous  mass of air, we  more commonly ob-
serve a  great quantity of  small air-bubbles on  the  surface  of the
liquid.  I am inclined to think that I have found air in the peri-
 cardium in cases where there was  no serum, but I am  not quite
 assured  of  the  correctness of my observation.   At all events, this
 cast of  simple  Pneumo-Pericardium is extremely rare, while the
 other variety, just described, is by no means so.
                       section third.

         Of Accidental Productions in the Pericardium.

   Various species of accidental productions have been found be-
tween the pericardium  properly so called, and the pleura; also,
between it and the internal and serous membrane; and, lastly, be-
tween the serous membrane and the heart.   In the Sepulchretum
of Bonetus and  other  collections of cases, we find  examples of
what appear  to be tubercles, cancerous tumours, or cysts, in the
different situations just  mentioned.   But the imperfect knowledge
of membranes before the time of Bichat, and the general confusion
of all accidental productions under the names  of Scirrhus, Carci-
noma, Atheroma, &c. renders it impossible to  ascertain  precisely
either the nature or site of such morbid  growths.  I have already
noticed the fatty productions, in the form of a cock's comb, deve- 
ACCIDENTAL PRODUCTIONS.
203
loped occasionally between the pleura and fibrous membrane of
the pericardium.   Twice or thrice I have found  tubercles in  the
same situation, in subjects which exhibited a great number of these
bodies in the lungs and  elsewhere.   I have also seen a tubercle
situated at the point of the origin of the pulmonary artery and  be-
neath the serous membrane of the pericardium.
   Once  only have I met with an instance of ossification between
the layers of the pericardium.   As this case was remarkable both
for its extent and the effects produced by it, I shall here briefly  de-
tail it.
   Case 45.  A man, aged 65 years, had led an intemperate life,
but had, nevertheless, enjoyed good  health until his fiftieth  year.
At this time he appears to have had an attack of pleurisy of short
duration, but which was  followed by  oedema of the lower extre-
mities and subsequently by  anasarca of other parts, and by dysp-
noea and breathlessness on  ascending  an elevation, or using any
degree of exercise.   When he came  into hospital, in the end of
spring, the dropsical symptoms continued and the lips were swollen
and violet.  The pulsations of the heart were unequal, irregular,
and  very distinct, though  perceptible over a very small extent of
the chest.  The  pulse was feeble, small, soft, unequal, intermit-
tent and irregular.  There was  no cough, but copious expectora-
tion.  The thorax sounded well superiorly, but badly on the lower
parts.
   The patient could lie in any posture; slept  well, even without
having his  head raised, and had no sudden startings from sleep.—
He died in the  course of a  few months, the  dropsical  swellings
and dyspnoea having much increased.  The brain, lungs, and ab-
dominal viscera were found in a sound state.   The heart was en-
larged, and adhered throughout to  the  pericardium, by means of
very close cellular attachments.  On first touching it, it seemed to
be  quite inclosed in  a  bony case, situated  beneath  the  fibrous
membrane  of the  pericardium; but on further examination this  in-
crustation was found to be incomplete.   Around the base of  the
ventricles there was a zone or band, partly bony and partly carti-
laginous, of from  one to two fingers' breadth, of unequal thickness,
flattened, yet somewhat rough on its surface.  This band projected
into the angle between the ventricles and auricles, and extended
along the interventricular septum on  both sides, to near the  apex
of the heart.  The whole of this production was contained be-
tween the fibrous membrane of the pericardium  and  the serous
membrane  which lines it  internally.  The auricles were enlarged 
204
DISEASES OF THE AORTA.
so that each might have contained a large egg.   One of the mitral
valves contained an ossified point of the size and shape of a
French bean.
                     CHAPTER III

           OF ANEURISM OF  THE AORTA.*


   In the following observations I shall adhere to the ancient dis-
tinction of  true and false Aneurisms,—the former comprehending
dilatation without rupture of  any  of the  arterial coats, the latter
with rupture of some of  these.
   True aneurism of the  ascending portion and arch  of the  aorta
is  very common.  The dilatation  usually extends from the  origin
of the artery to the point where it begins to descend.  This dila-
tation rarely proceeds so  far as to produce very serious symptoms,
the extreme point of dilatation of the artery not" being wider than
from two to three fingers' breadth.   The convexity of  the arch
and anterior  part of the  artery appear to yield  more  than the
other parts of the vessel.  When the  dilatation exists in  the de-
scending aorta, it assumes the form  of an ovoid tumour, gradually
terminating, at*each  extremity, in the undilated artery.   It  is not
uncommon to find  several dilatations of this kind  in the same
artery.  Sometimes  we find the whole tract of the  aorta dilated
to  double its natural  size.
   Dilatation  in the  arch  of the aorta,  in the degree above describ-
ed, is very common; but  this  is not  usually named aneurism unless
it  arrives at a considerably greater extent.   These sometimes are
very large.  M Corvisart records one double the size of the heart,
and I have seen them of the size of the head of a full-grown  foetus.'
When the true aneurism  acquires  a certain size, the inner coat
often is ruptured and a false aneurism ensues.   The true  aneurism
is  commonly accompanied with a  morbid  degeneration of the in-
ternal tunic of the artery.  It exhibits spots of a bright red, slight
cracks, and a great  number of small ossified points.   These fatter
are usually considered as contained in the  substance  of the inner

        * This chapter is  more abridged than the others.—Tram 
ANEURISM.
205
coat, but they are, in truth, situated  between it  and the middle
coat.
   The false aneurism of the aorta, consequent to the true, is rarer
than the simple dilatation of that artery; but it is much more com-
mon than that  greater  degree  of simple dilatation which alone
usually claims the name of aneurism.
   The false aneurism is most common in the ascending, and the
true in the descending aorta   I have never  met with  any other
species of false aneurism in the ascending aorta, or its  arch, but
that consequent to the true, or simple  dilatation of the part.   In
t\e descending aorta, however,  false  aneurism often takes place
without any previous dilatation.  The opinion at present current in
the Parisian schools, viz. that  in aneurism the internal  coat re-
mains entire and  protrudes, in the form of a hernia, through the
ruptured fibrinous tunic, is more untenable, as a  general position,
than that of Scarpa, who maintains the rupture of the two inter-
nal tunics in every  case of the  disease.  Both these opinions are
true in certain cases, but not in all.
   Aneurisms of the aorta produce various effects on the  adjacent
organs, according to their volume and position.  Simple dilatation,
 when in a moderate degree, hardly produces  any  effect, but the
 most inconsiderable false aneurisms may give rise  to very serious
 disorder.  The first and most common of these effects is compres-
 sion acting on the heart and lungs.  When the aneurism is in con-
 tact with the lungs, it most commonly merely compresses them; some-
 times, however, the substance of these organs gives way, and the
 aneurism, when it  bursts, pours its blood directly into the air-cells.
 Frequently the aneurism compresses the trachea, or one of the two
 bronchial trunks, flattens, and  eventually destroys  a part of them,
 and  death ensues by a species of haemoptysis from the rupture of
 the tumour.   The  same thing  occasionally happens with the oeso-
 phagus, but not so  frequently.   I have only met with three instan-
 ces of death from this cause.   The ordinary effect of these aneu-
 risms on the  heart, is to  displace it more or less, downwards or to
 one side.   Sometimes the aneurism bursts  into the  pericardium
  (see Morgagni and Scarpa); but I have never met with an exam-
  ple of this. A case is on record of an aneurism  of this kind burst-
 ing into the pulmonary artery.*  The left cavity of the pleura is,
  by far, the most frequent situation for the rupture  of these aneu-
  risms.   I have met with one case where the aneurism compressed
  and destroyed the thoracic duct; and M. Corvisart notices a fatal
f Bulletin de la Faculty de Med.  1819. 
206
DISEASES OF THE AORTA.
case of compression of the superior  vena cava  from  the  same
cause   The most  remarkable local effects of aneurisms of the
aorta, are  those on the  vertebral column.  They often destroy this
to a very great depth.   This destruction is entirely the work of in-
terstitial absorption, there never being  any mark  of caries.  On
the side next the vertebrae  the sac is  completely destroyed, and
the circulating blood is bounded by the naked bone.
   Aneurisms of the ascending aorta destroy, in like manner, the
sternum by their pressure, so that they  are  at  length covered
merely by the skin.   I  have met with two or three tumours of this
sort so large that they could  not  be completely covered by both
hands.  The aneurisms of the arch of the aorta, and of the arteria
innominata, sometimes project, in like manner, at the  top of the
sternum or above it, or under the cartilages of the first false ribs
of the right side.   It is not always the largest aneurisms that most
readily make their  way externally.  Sometimes those of the size
of an egg  produce this effect, whilst, occasionally, those of the size
of the head  of a full-grown foetus remain quite covered and are
even compressed by the sternum.
END OF PART FIRST
/ 
PART SECOND.
DIAGNOSIS. 
) 
ON THE
DIAGNOSIS
OS
DISEASES OF  THE CHEST.
INTRODUCTION.
However dangerous diseases  of  the  chest may be, they are,
nevertheless, more frequently curable than any other severe inter-
nal affection.  For this reason  medical men,  in all  ages, have
been desirous of obtaining a correct diagnosis of them.   Hitherto,
however, their  efforts have been  attended  by  little success,—a
circumstance which must necessarily result from their having con-
fined their attention to the observation and study of the deranged
functions only.  From thecontinued operation of the same cause,
we must even now confess, with Baglivi, that the diagnosis of the
diseases of this cavity is more obscure  than that of those of any
other  internal  organ.   Diseases of the  brain, not in  themselves
numerous, are  distinguished, for the most part, by constant and
striking symptoms; the soft and  yielding parietes of the .abdomen
allow us to examine, through the medium of touch, the organs of
that cavity; and thus to judge, in some measure, of the size, posi-
tion, and degree of sensibility of these, and, also, of the extraneous
bodies that may be formed in them.  On the other hand,  the dis- 
210
DISEASES  OF THE CHEST.
cases of  the thoracic  viscera  are  very numerous and diversified,
and  yet  have  almost all the same class  of  symptoms.   Of these
the  most common  and  prominent are  cough,  dyspnoea, and, in
some, expectoration.  These, of course,  vary in  different diseases;
but  their variations are by  no means  of that  determinate  kind
which can enable  us to consider them  as certain indications of
known variations in the diseases.   The consequence is, that the
most skilful physician who trusts  to the  pulse and  general symp-
toms, 4s  often deceived  in regard to the most common  and best
known complaints of  this cavity.  Nay,  I will go so far as to as-
sert, and without fear of contradiction from those who have  been
long accustomed to morbid dissections,—that, before the discovery
of Avenbrugger, one half of the acute cases of peripneumony and
pleurisy, and.almost all the chronic pleurisies, were mistaken  by
practitioners;  and that, in such instances as the superior tact of a
physician enabled him  to  suspect the  true  nature  of the disease,
his eonviction was rarely sufficiently strong  to prompt and  justify
the application of very powerful remedies.   The percussion of the
chest, according to  the method of Avenbrugger, is one of the  most
valuable  discoveries ever made in  medicine.   By means of it, se-
veral diseases, which had hitherto  been cognisable by general and
equivocal signs only, are brought within the immediate sphere of
our  perceptions, and  their diagnosis, consequently, rendered  both
easy and certain.
   We must still admit, however,  that the  method of percussion
is  far from being complete, or generally available.   It frequently
affords no indication in phthisis; and in  no case  does it enable us
to distinguish  this disease from chronic  peripneumony.  Even in
peripneumony it fails  us  in a great measure when  the inflamma-
tion  is confined to the centre  of the lung, or when  both lungs are
equally affected,  and  only in a slight degree.   It does not enable
us to distinguish the disease jnst mentioned  from pleurisy,  hydro-
thorax,  or any  other effusion into  the  cavity  of  the  chest.   It
completely fails us, or rather  certainly misleads us, in the disease
called Pneumo-Thorax.  It gives no indication  of  the diseases of
the heart until this organ is greatly enlarged; and it is often before
this  takes place  that the disease proves fatal.  It affords no assist-
ance in aneurisms of  the aorta and large vessels, until the nature
of the disease is appreciable by the sight, or  by  the touch.  In
many other respects, also, the indications afforded by percussion
are rendered equivocal by  peculiarities of formation, by the1 nice-
ties  required in its  performance, and by the circumstances under
which it is  performed.   It is more particularly in  diseases of the 
DIAGNOSIS.                     211
 heart that we regret  the  insufficiency of this method, and wish
 for something more precise.  The genefal symptoms of disease
 in this organ  greatly resemble those produced by many nervous
 complaints, and  by the diseases of other organs.   The results
 afforded by the application of the hand to the  part, with the view
 of judging from  the tactual sensations communicated, have been
 found  of some use,  in doubtful cases; but,  as a general  method,
 this is by far loo vague and uncertain to be of  much benefit.
   In these cases some physicians have attempted  to gain further
 information by the application of the ear to the precordial region;
 and, doubtless, such  a proceeding will increase the certainty of the
 diagnosis.  Even  this,  however, is very  insufficient; and  there
 are, besides, many reasons why it cannot be followed,  as a general
 guide, in practice. Nevertheless,  I had been in the habit  of using
 this  method  for a long time, in obscure cases, and where it was
 practicable; and it was the employment of it which led me to the
 discovery of one much better.
   In  1816, I was consulted by a young woman  labouring under
 general symptoms of diseased heart, and in whose case percussion
 and the application of the hand were of little  avail on account of
 the great  degree  of  fatness.   The  other method  just  mentioned
 being rendered inadmissible by the  age and sex of the patient, I
 happened to recollect a simple and  well-known fact in acoustics,
 and fancied, at the same time, that  it might be turned to some use
 on the present occasion.  The fact  I allude to is the augmented
 impression of sound when conveyed through certain solid bodies,
 —as when we hear the scratch of a pin at one end of a  piece of
 wood,  on  applying  our  ear  to the other.  Immediately, on this
 suggestion, I rolled a quire of paper into a sort of cylinder  and
 applied one end of it to the region of the heart and  the other to
 my ear, and was not a little surprised and  pleased, to find  that I
 could thereby perceive the  action of the heart in a manner much
 more clear and distinct than  I had  ever been able  to do by the
 immediate application of the ear.   From this moment I imagined
 that  the circumstance might  furnish means  for  enabling  us to
 ascertain the character, not only of the action of the heart, but of
 every species of sound produced by the motion of all the  thoracic
viscera.   With  this conviction,  I  forthwith  commenced at the
Hospital Necker a series  of observations, which has been continu-
ed to the present  time.   The result  has been, that I have been
enabled to discover a set of  new signs  of diseases of the chest,
for the most part certain, simple, and prominent, and calculated,
 perhaps, to render  the  diagnosis  of the  diseases of the lungs, 
212
DISEASES OF THE CHEST.
heart and pleura, as decided and circumstantial, as the indications
furnished  to the surgeon by the introduction of the finger or sound,
in the complaints wherein these are used.
   In  prosecuting my  enquiries  I  made trial  of instruments of
various composition and  construction.—The  general  result has
been  that bodies of a  moderate density, such as paper, wood, or
Indian cane, are" best suited for the conveyance  of the sound, and
consequently for my purpose.  This  result is perhaps contrary to
a law of physics;—it has, nevertheless, appeared to me one which
is invariable.
   I shall  now describe the instrument which I use at present, and
which has appeared  to me preferable to all  others.   It consists
simply of a cylinder of wood, perforated in its centre longitudinal-
ly, by a bore  three lines  in diameter, and formed  so as to come
apart in the middle, for the benefit  of being more  easily carried.
One  extremity of the cylinder  is hollowed out into the form of a
funnel to  the depth of  an inch  and  half, which  cavity can be ob-
literated at pleasure by a  piece of  wood so constructed as to fit it
exactly, with the exception of the central bore which is continued
through it, so as to render the  instrument  in all cases, a pervious
tube.   The complete instrument,—that is, with the  funnel-shaped
plug infixed,—is used in exploring the signs obtained through the
medium of the voice and the action of the heart; the other modi-
fication, or with the stopper removed, is for examining the sounds
communicated  by respiration   (See  Plate VIII.)   This instru-
ment  I commonly designate  simply the  Cylinder, sometimes the
Stethoscope.
   In  speaking of the different modes  of exploration I shall notice
the particular positions of the patient, and  also  of the  physician,
most favourable to  correct observation   At present I shall  only
observe that, on all occasions,  the  cylinder should be held in the
manner of a  pen,  and that the hand of the observer should be
placed very close to the body of  the patient to  insure the correct
application of the instrument.
   The end of  the  instrument  which is applied to the patient,—
that,  namely, which  contains  the  stopper or plug,—ought to be
slightly concave to insure  its greater  stability in application;  and
whrn there is much emaciation, it is sometimes  necessary to insert
between  the ribs a piece of lint or cotton, or  a  leaf of paper, on
which the instrument is to be  placed, as, otherwise, the results
might  be affected by the  imperfect  application of ihe  cylinder.
The same precaution  is necessary  in the examination of the cir-
culation in cases where the  sternum, at its  lower extremity, it 
                       DIAGNOSIS.                       213

drawn backwards, as  frequently happens with  shoemakers,  and
some other artisans.
   Some of the indications afforded by the stethoscope, or mediate
auscultation, are very easily acquired, so that it is sufficient to have
heard them once  to recognise  them  ever  after: such are those
which denote ulcers in (he lungs, hypertrophia of the heart when
existing in a great degree, fistulous communication  between  the
bronchia and cavity of the pleura, &c.   There are others, however,
which require much study and practice for their  effectual acquisi-
tion.
   The employment of this new method must not make us  forget
that of Avenbrugger; on the contrary, the latter  acquires quite a
fresh degree of value through the simultaneous employment of the
former, and becomes applicable in many cases, wherein its solitary
employments either useless or hurtful.  It is by this combination
of the two methods that we obtain certain indications of emphy-
sema of the lungs, pneumo-thorax, and of the existence of liquid
extravasations in  the cavity of the  pleura.   The  sanle remark
may be extended  to some other means, of  more partial applica-
tion, such, for example, as the Hippocratic succussion, the  mensu-
ration of the thorax, and immediate auscultation;  all of which me-
thods, often useless in themselves, become  of great value  when
combined with the  results procured   through  the medium of the
stethoscope.
   In conclusion, I would beg to observe, that it is only in an hos-
pital that we can  acquire, completely and certainly, the practice
and  habit of this  new art of observation; inasmuch  as it is neces-
sary to have occasionally verified,  by  means of examination after
death, the diagnostics established by  means  of  the cylinder,  in
order that we may acquire confidence in the  instrument  and in
our own observation, and that'we  maybe  convinced, by ocular
demonstration, of the correctness of  the indications obtained.  It
will be sufficient, however, to study any one disease in two or three
subjects, to enable us to recognise it with certainty; and the dis-
eases of the lungs and  heart are so common, that a  very brief at-
tendance on an hospital will put it in the power  of any one to ob-
tain all the knowledge necessary for his guidance in this important
class of affections   There are three classes of application of this
instrument, viz. as regards the Voice—the  Respiration—and  the
Circulation; all of which I shall here briefly notice as observable
in the healthy subject;  referring for the  varieties of these, as
modified by disease, and for the diagnostic indications afforded
by them, to the individual affections to be noticed hereafter. 
2U
DISEASES OF THE CHEST.
    I.   The Voice.  When a person  in  health  speaks or  sings,
 his voice excites in the whole parietes of the thorax a  sort  of vi-
 bration, which is easily perceived on  applying  the hand  to the
' chest.   This phenomenon is no longer observable  when, through
 disease, the lungs have ceased to be permeable to the air,  or are
 removed from  the contact of the parietes of the  chest by an effus-
 ed fluid.   This sign is of inferior value, since a great many causes
 occasion varieties in the intensity of the vibration,  or  completely
 destroy it.   For instance, it  is little sensible in fat persons, in those
 whose  integuments are considerably flaccid, and  in those who have
 a sharp and weak voice.  Anasarca of the chest  completely de-
 stroys it, even  when the lungs are quite sound.   In  any case it is
 only very perceptible at the  anterior and superior part of'the  chest,
 on the sides, and in the middle  of the  back.   From  these and
 other causes we can derive little practical benefit from attending
 to this  particular circumstance.
   On making  use of the cylinder with the view  of further investi-
 gating this phenomenon, I soon found, as indeed might have been
 expected, that  it  conveyed  the peculiar vibration much less dis-
 tinctly  than the bare hand.   I also ascertained that  the degree of
 intensity of the vibration varied in different points of the thorax.
 The places  where it is  most  distinct  are the axilla,  the  back—be-
 tween the spine and the edge of the  scapula,  and on the anterior
and superior part of the chest near the angle formed by the union
of the clavicle  with the sternum.  When we  apply the cylinder
to these points, the voice appears stronger and nearer to us; in the
others, on the contrary, particularly in the inferior  and posterior
parts of the thorax, it seems  weaker and more remote.
   II. Respiration.   On applying the cylinder,  with its  funnel-
shaped  cavity open, to the breast of a healthy person, we  hear,
during inspiration and expiration, a slight but  extremely distinct
murmur, answering to the entrance of  the air into, and  its  expul-
sion from, the air-cells  of the lungs.   This  murmur may be com-
pared to that produced by a pair of bellows whose valve makes no
noise, or, still better, to that emitted  by a person in a  deep  and
placid sleep, who makes now and then » profound inspiration.  We
perceive this sound almost equally distinct  in every part of the
chest, but more particularly in those points  where  the  lungs, in
their dilatation, approach nearest to the thoracic parietes, as, for
instance, the anterior-superior, thelateral, and the posterior-inferior
regions.  The hollow of the  axilla, and  the space  between  the
clavicle and  superior edge of  the trapezius muscle, exhibit the
phenomenon in its greatest intensity.   It is  equally perceptible on 
DIAGNOSIS.                     215
the larynx, on the exposed or cervical portion of the trachea, and,
in many persons, through the whole tract of this canal to the bot-
tom of the sternum; but on the trachea, and in  some degree at
the root of the bronchia, the respiratory murmur  has a  peculiar
character, which evidently indicates  the transmission of the air
through  a larger space than the air-cells.   In  this position, also,
it often seems as if the patient, in inspiring, inhales the air through
the tube of the stethoscope, and expels it by ihe same, during ex-
piration.
   To judge correctly of the state of  respiration  by  this method,
we must not rely on the results  of the first moments  of  examina-
tion.  The sort of  buzzing sensation often caused by the first ap-
plication of the instrument, the  fear, restraint, and agitation of the
patient, which mechanically lessen the force of respiration, the
frequently inconvenient posture  of the observer, and the great sen-
sation occasionally produced by the action of the heart,—are  all
causes which  may  at first prevent us  from  correctly appreciating,
or even  from  hearing at all,  the sound of inspiration and expira-
tion.   We must, therefore, allow some seconds to pass before we
attempt to form an  opinion.
   I need hardly observe that there must be no noise whatever in
the vicinity of the patient.  The  intervention of clothing, even
when of considerable thickness, does not  sensibly diminish the
sound of respiration; but we must  be  careful  that  there is no
friction between this and the instrument,  as this circumstance,
especially if the clothes  are of silk, or of a fine  hard stuff, may
mislead us by exciting a sensation analogous to that  produced by
respiration.   Fatness, even  when excessive,  and anasarca of the
chest, seem to have no notable effect in diminishing the peculiar
sound.   The sound is more distinct in proportion as the respiration
is more frequent.   A very deep inspiration made very slowly will
sometimes  be scarcely audible, while an  imperfect inspiration,
such, for instance, as hardly  at all elevates the chest,—provided it
be  made quickly, may  produce a very loud sound.   On this ac-
count, when examining a patient, more especially if we have had
but slight practice  with the instrument, we should desire the res-
piration to  be performed rather quickly.  This is, however, a very
unnecessary precaution in most diseases of the chfcst, as the  fre-
quent presence  of  dyspnoea necessarily renders  the respiration
quick.   The  same is true of fever, and the agitation caused  by
nervous  affections.
   Many other causes, and especially the age of the individual, alter
the intensity of the sound.  In children, respiration is very sono 
21(5
DISEASES  OF THE CHEST.
  rous, even  noisy, and can be heard easily even through very thick
  clothing.   In them  the close  and  forcible  application of  the
  instrument, to prevent the friction of the garments, is unnecessary,
  as any noise that might arise from this cause is  lost in the intensity
  of the other.   The respiration of children differs, also,  from that
  of adults in other respects besides its intensity.   It is impossible
  to describe this peculiarity, but it will easily be understood by com-
  parative trials.   It appears as if, in children, we  could distinctly
  hear the dilatation of all the air-cells to their full  extent; whilst,
  in  adults, these seem as if,  from their  stiffness,  they  could only
  bear a  partial  dilatation   This  difference of  sound is much less
  marked in expiration than inspiration.   The dilatation of the  chest
  in inspiration  is also greater in the child, and both  these peculiari-
  ties are more remarkable as the  child is young: they continue, in
  a greater or less degree, to the period of puberty or a little beyond
  it.
    The  sound  produced by respiration varies, also, very much in
  its intensity in  different adults.   In some men  it is scarcely per-
  ceptible unless they make a very deep inspiration, and even then,
  although sufficiently distinct, it is not one half so audible as iu the
 majority of  persons.   These  individuals have generally a rather
 slow respiration, and are  little subject  to dyspnoea, or  breathkss-
 ness, from  any cause.   Others, however, have  the  respiration
 very sensible even  during  a common inspiration, without being, on
 this  account, at all more subject  to  shortness of breath  than the
 former.  Some  few individuals, again, preserve through life a slate
 of respiration resembling that of children, and which I shall there-
 fore  denominate puerile, in  whatever age it may be perceptible.
 Such persons are almost all  women, or men of a nervous tempera-
 ment, and they preserve,  in some other  respects, the character of
 childhood.   Some  of these  cannot be  said to have any actual
 disease  of the lungs, but they soon get out of breath, even though
 lean, by exercise, and are very liable to catch cold.  Others of
 this class are affected with a chronic catarrh, attended by dyspnoea,
 a condition constituting one of those cases to which the  name of
Asthma is usually given.   With these exceptions, an adult cannot,
by  any  effort, give  to  his respiration the  sonorous character of
childhood; but  in* some morbid states,  the respiration  spontane-
ously acquires  it,  without being,  at  the time, performed more
forcibly than usual.   This is particularly  the case when one whole
lung, or  a considerable portion of both  lungs,  is rendered  imper-
meable  to air through disease, especially acute  disease.   !,i  the
sound portion of the lungs, in  these cases, the respiration is  per- 
DIAGNOSIS.                     2H
feclly  similar to that of children. The same thing  is observable
throughout the  whole extent of the lungs in  some cases of fever,
and in certain  nervous diseases
   At first we are tempted to believe  that the superior intensity of
the respiratory murmur in children may be owing to the tenuity of
the muscles covering the chest, and  to the superior suppleness of
the tissue of the lungs.   But  the first cause must have  scarcely
any effect in this way, since we find that, even in the fattest chil-
dren, and  in  those  most thickly clothed, the respiration  is much
more  distinct  than  in  the  leanest  adult examined uncovered  ;
whilst, of the adults  who  possess the puerile respiration, many  are
very robust and full  of  flesh.   Neither does the quieter  respira-
tion  of the adult depend on any  induration  or  loss of pliability
in the  pulmonary tissue,  since it sometimes accidentally returns to
the character it had in  infancy.  I am rather disposed to  believe
that the difference of result depends on the fact of children  re-
quiring a greater proportion, of  air than adults ; whether  this  ne-
cessity arises from the greater activity of their circulation,  or from
some difference in the chemical composition  of the  blood.
   The respiration  which is most audible to the ear, is  not  that
which produces the  greatest noise in the  interior of the chest.   I
do not here allude  to that species of respiration which is accom-
panied with a rattling or hissing, or  any other  unnatural sound,
but to that kind of respiration  which is simply loud, and which is
so frequent in dyspnoea.   This noise is merely the aggravation of
the natural sound made by many persons in sleep, and is caused by
the mode in which the air  impinges  upon the parts in the fauces.
We can imitate it at will.   I am acquainted with an asthmatic
patient, whose habitual respiration can be heard at the distance of
twenty feet, and whose respiration, as heard in the interior of the
chest, is, nevertheless, weaker than in the majority of men.  The
same  remark applies to the  noise  (snoring) emitted  by many
healthy persons during sleep; and, also, to the imitative sounds of
jugglers and ventriloquists,—all of  which  are  produced  in  the
throat and posterior nares, and are  quite  unconnected with  the
sound of respiration in the interior of the chest.
   When we can distinctly  perceive,  and  with a uniform intensity,
the respiratory  murmur in   every part of the chest, we  may be
assured  that there exists neither  effusion into  the  cavity of  the
pleura, nor any species  of engorgement in the  substance of the
lungs.   On the other hand, when  we find the respiration is not to
be distinguished in any particular point,  we may safely conclude
the corresponding portion of the lungs within is become imperme-
able to the air from  some cause or other.  This  sign is as easy to
                               2S 
2.18
DISEASES OF THE CHEST.
be perceived as the presence or absence of the sound, in the per-
cussion of Avenbrugger,  and affords precisely  the same indica-
tions.  With the exception of some peculiar  cases, in which the
simultaneous employment of the two different  methods  gives us
signs which are completely  pathognomic,—we may stale it as a
general fact, that the absence of the sound on percussion coincides
uniformly  with the absence of respiration,  as ascertained by the
stethoscope.
   As  appertaining to the action of respiration,  although not ob-
servable in the perfectly healthy  conditon of this function, I shall
here briefly allude to a phenomenon  which will be more particu-
larly described hereafter.   It is the peculiar  sound  conveyed by
the  cylinder,  when  the air,  during respiration,  is transmitted
through fluid matter of any kind in the lungs or bronchia.  From
its resemblance, both in its origin and character, to what is usually
called the rattles in dying  persons, and from  want of a better
word, I have  adopted  this  term to denote  it whenever it occurs.
Its character and varieties will be  described hereafter.
   Ill  The  Circulation.  In  the  introductory  chapter to  the
Diagnosis of the diseases of the heart, I  shall detail,  at consider-
able  length, the results  obtained  by the  cylinder, both  in  the
healthy and disordered condition of  that organ.   At present I al-
lude to them merely; and chiefly for the  sake of uniformity.
   The alternate contractions of the auricles and ventricles of the
heart give rise to sounds very  distinct, and of different  kinds, so
 as to enable us to study the actions of  that organ even  more ex-
 actly than by  the dissection of living bodies.  The truth of this
 seemingly paradoxical  assertion rests on  the fact, of the  ear judg-
 ing  much more correctly of the intervals of sound, than  the eye of
 the  intervals of motions corresponding to these..
   In ordinary  circumstances the stethoscope, applied between the
 cartilages of the fifth and sixth ribs,  at the end of the sternum, or,
 indeed, in any point where the pulsation of the heart is percepti-
 ble,—conveys to the ear a distinct sound.   This, in the healthy
 body, is double, and each beat of the arterial pulse corresponds to
 this double sound, in other  words, to two  sounds.  One of these
 is clear and rapid; and somewhat  resembles  the  sound  produced
 by the valve of a pair of bellows: this   corresponds to the systole
 of the auricles.   The other is more dull and prolonged,  coincid-
 ing with the beat of the pulse and  with the shock or impulse com-
 municated to the parietes  by the  motion of the  heart:—it indi-
 cates the contraction of the ventricles.   The sounds heard at the
 end of the sternum  are  produced by the action of the right side 
PHTHISIS PULMONALIS.
219
of the heart; those between the cartilages of the ribs by the left
cavities.   In the  state of health the sound  produced by the con-
tractions of  each side is the same.
               PHTHISIS PULMONALIS.

                        (Part I. Page 33.)

   In following up my observations on  the comparative resonance
 of the voice in several subjects, both healthy and diseased, I was
 struck by the discovery of a phenomenon entirely new to  me.  In
 the  case of a woman, affected  with a slight bilious fever, and a
 recent cough having the  character of a pulmonary catarrh, on ap-
 plying the cylinder below  the middle of the right clavicle, while
 she  was speaking,  her  voice seemed  to come  directly  from the
 chest, and to reach the ear through the central canal of the instru-
 ment. This peculiar phenomenon was confined to a space about an
 inch square, and was not  discoverable in any other part of the chest.
 Being ignorant of the cause of this singularity, I examined,  with
 the  view to its elucidation, the greater number of the patients in
 the  hospital, and I found it in about twenty.   Almost all these
 were consumptive cases in  an advanced stage of the disease.   In
 some the existence of tubercles  was still doubtful,  though there
 was  reason to  suspect them.  Two or  three, like the  woman
 above mentioned, had no symptom of this disease, and the degree
 of robustness of these seemed to put all  fears of it out of the ques-
 tion.  Notwithstanding this I began  immediately  to suspect that
 this  phenomenon might be occasioned by tuberculous excavations
 in the lungs.   The observation of the same thing in patients who
 had  no other  symptom of phthisis,  did not appear to me  conclu-
sive  against the correctness of my suspicion,  because I knew it to
be by no means unusual  to find in the lungs of persons  dead of
some acute disease,  and  who had never shown any sign of con-
sumption, tubercles not only softened but excavated, and forming
the very  case denominated  ulceration of the lungs.  The subse-
quent death, in the hospital, of the greater number of the indivi-
duals who had exhibited  this  phenomenon,  enabled me. to ascer-
tain the correctness of my supposition:  in every case I found ex- 
220
DIAGNOSIS.
cavations in  the lungs, of various sizes,  the  consequence of th?%
dissolution of tubercles, and all communicating with the bronchia
by openings of different diameters.
   I  found this peculiar phenomenon (which  I have denominated
Pectoriloquism) to be more perceptible according to the proximity
of the excavation  to the superficies of the lungs; and  that it was
most striking  when these adhered to the pleura in such a manner
as to render the thoracic parietes almost a part of the Walls of the
ulcerous excavation,—a case of very frequent  occurrence.
   This circumstance naturally led me to think, that pectoriloquism
is occasioned  by the superior vibration produced by the voice, in
parts having a comparatively more solid, and  wider extent of sur-
face; and 1 imagined  that, if this were so, the  same effect ought to
result from the application of the cylinder to the larynx or trachea
of a person in health.  My conjecture proved correct.   There is
a perfect identity  of  effect between pectoriloquism and the sound
of the  voice  as heard through the tube resting on the larynx; and
this  experiment offers an excellent mean for giving us an exact no-
tion  of the phenomenon, when we have not the proper  subjects for
observation.  Pectoriloquism becomes more striking when we close
the other ear  by the  hand.   We then  perceive, in the most evident
manner, that the  whole articulate voice of the  patient passes by
the cylinder.
  In the early stage of Phthisis, neither percussion of the chest,
nor auscultation in any of its forms, affords any means ofdetecting
the disease in  ordinary circumstances.   When, as sometimes  hap-
pens, especially in the superior lobes, the tubercles are congregat-
ed in great numbers in one spot, so as to form masses of consider-
able size,—in this case the respiration is inaudible, and percussion
elicits a dull sound.   This,  however,  must be  considered as a very
rare  case.
  As long as the expectoration retains either of the characters as-
cribed to the  first  stage of  the disease (see page 56), it is useless
to look  for the phenomenon of pectoriloquism, for the tubercles
being still unsoftened, it cannot exist.  But when the expectora-
tion  assumes the characters of the second stage (page 57, 58), if
we  have recourse  to tbe stethoscope at this period, we shall dis-
cover incipient pectoriloquism.  This will daily become more evi-
dent; and sometimes, even at the end  of a few  hours, will be com-
plete.   This  is especially the case where the yellow purulent ex-
pectoration has existed in great quantity from  the very moment of
its first appearance.
  In upwards of two hundred  instances of consumptive subjects, 
PHTHISIS PULMONALIS.
221
whose bodies I have examined after having ascertained, during
life, the condition of their lungs as  indicated by the cylinder, I
have not met with a single instance in which ulcerous excavations
did not exist in those points of the lung over which the phenome-
non of pectoriloquism had shown itself distinctly; and as in most
of these  cases I had  ascertained the existence of this in several
points at once, I have, in fact, several hundred of positive obser-
vations on this point, and not  a single negative one.
   On the other hand, I have not met with one case of pulmonary
excavations  .communicating  with  the  bronchia, in  any subject
whose chest I had completely examined, and during several days,
without  finding pectoriloquism.  This deception, however, it is
evident,  may readily occur if  we are  satisfied  with a single exam-
ination of a patient, or if we confine our examination to one point
of  the chest; because, as I have already remarked, the sputa con-
tained in the excavations may obstruct, for a time, the communi-
cation with the bronchia, and thus suspend pectoriloquism for se-
veral hours.   On this account, when  we have reason  to suspect an
attack of consumption, and do  not find  this phenomenon  on our
first trial, we ought to suspend our judgment until similar observa-
tions, repeated at different times, have confirmed or overturned the
first indication.   If, after repeated trials, we cannot discover pec-
toriloquism, we must infer either that the tubercles are  still im-
mature,  or, if softened,  that they do  not as yet communicate with
the bronchia, or, lastly,  that the disease  is not phthisis.
   Although the superior lobes of the lungs are the most common
seat of  tuberculous cavities,  still  we must not  content ourselves
with examining  these only, in cases  where we do not at first dis-
cover pectoriloquism.   It sometimes, though rarely, happens that
excavations exist in the  centre of the lungs, in their anterior, mid-
dle, or lateral parts, or even in their inferior edge, while the supe-
rior lobes are uninjured.
    In two or three cases only, in subjects which I had thoroughly,
 though but  for a few times, examined, and in which  there was no
pectoriloquism, have I found  on dissection excavations of greater
or less extent.  In one case of this sort 1 discovered a cavity large
 enough to contain a middling sized apple.  But  in this, and other
similar  cases, the cavities were almost completely  filled by soft
tuberculous matter, and communicated  with  the bronchia only by
 one or two openings at their inferior  and posterior parts, of so nar-
 row a caliber as almost to preclude the escape of the pus by them.
 Sometimes, also, in  cases wherein pectoriloquism had  been dis-
 tinct, in addition to the excavations which  afforded this sign, I 
22%
DIAGNOSIS.
 have  discovered, on  dissection,  other  cavities,  generally  small,
 though  sometimes large enough to contain an almond, which had
 no communication whatever with the bronchia.   These  were ge-
 nerally  filled with tuberculous matter softened to the consistence
 of pus.   Cases of this sort,  it is  obvious, are merely exceptions
 which confirm a general rule; since we know that pectoriloquism
 cannot show itself but in cases where there is a communication
 between the bronchia and a cavity, at least empty in part.
   I have detected pectoriloquism in subjects in whom, at the time,
 no other characteristic symptom of phihisis was  present; as was,
 indeed,  the case  with the first  patient in whom  1  recognised  it.
 In cases of this sort, whose progress 1 have been enabled to trace,
 I  have observed  the gradual  development of phthisical symptoms
 until they reached  that  point when their nature could be misun-
 derstood by no one.   From all this, I think we are entitled to con-
 clude, that pectoriloquism  is a true  pathognomonic sign of phthisis,
 and that it announces  the presence of this disease  sometimes  in an
 unequivocal manner, long before  any other symptom leads us to
 suspect its existence.  I may  add, that it is the only sign that can
 be regarded  as certain.
   Cough,  dyspnoea,  puriform sputa, heftic fever,  haemoptysis,
 emaciation,—in  short,  the  complete  reunion of symptoms  of
 which the frightful  picture has  been so  faithfully delineated by
 Aretajus,—may exist in cases, which we  see, nevertheless,  reco-
 ver, contrary to all expectation.^   We have  already  shown  that
 some of  these cases may probably be truly  cases of phihisis; but
 there can be no doubt that others  are examples of organic  affec-
 tions simulated by nervous or mere functional disorder.
   On  the  other  hand, we frequently  observe in cases of true
 tubercular  phthisis,  that  almost all  the  usual  symptoms of this
 disease are wanting.   Sometimes there is no cough whatever, or
 it  is suspended for months  together; and  hectic fever is, in  like
 manner^  scarcely perceptible, or altogether  absent, for as loug  a
 period.   Even emaciation, which has given its name  to  the  dis-
ease, is sometimes very trifling; and death may be occasioned by
the mere effect of the tubercular disorganization before it be per-
ceptible.   In many cases, again,  a colliquative  diarrhoea  and
hectic feVer  are the only symptoms, and,  consequently, render the
nature  of the disease very equivocal
   In  this respect,  then,  the  indications  of the stethoscope  will
supply  one of the desiderata of medical   science,  and will help
* «ee M. Bayle's cases, 48, 49, 50, 51, 52,53, 54. 
PHTHISIS PULMONALIS.               223
us to distinguish the cases which  are quite beyond  the  resources
of nature and art, from those which  still leave us  room to hope,
We have already examined (Part I. page 42) the  question  how
far the presence of pectoriloquism ought to be considered as de-
noting the existence of an inevitable cause of death.*
   It is in the superior lobes that tubercles generally begin to show
themselves, and consequently, it is in the parts of  the  chest an-
swering  to these  that  pectoriloquism is most frequently  found,—
namely,  the interior and superior  part, the  axilla, the space be-
tween  the clavicle and trapezius  muscle, and on the upper flat
parts of  the scapula,—this  bone and its muscles having  no  other
effect over the phenomenon than to render the sound duller.
   Pectoriloquism is certain or. uncertain.   It  is certain when  it
possesses the  characters described in page 219, and  wheresoever
we find  it with  these, even  although  momentarily,  we may  be
assured  that there exists, in the corresponding parts of  the lung,
an unnatural  excavation communicating with the bronchia.
   Pectoriloquism is uncertain  when  the  patient's,  voice appears
somewhat more acute and  slightly altered  like that of ventrilo-
quists, or when it resounds under the cylinder with more than  its
natural strength, without seeming to traverse the tube.   We have
a perfect notion of the uncertain  pectoriloquism on applying the
cylinder between  the inner  ed*g# of the  scapula  and  the  spine,
opposite the origin of the bronchia, in  a healthy  person that is
lean and has an  acute voice.  This  phenomenon naturally  exists
 in this point  in such subjects,  and,  indeed, more  or less  in  all
 persons, for  reasons  already  stated.  In  thin  narrow-chested
 children, these  points  even  give sometimes  perfect   pectorilo-
 quism.
   For this reason, we must, in many cases, draw  no  conclusion
 from uncertain  pectoriloquism, when it exists only  in   the  point
just mentioned, in the axilla, or near the junction of the clavicle and
 sternum   We must even  extend the same remark to  the  whole
 superior and anterior portion of the chest, when the  pectoriloquism
 is very  imperfect and exists equally in both sides.    When,  how-
 ever,  we find uncertain pectoriloquism  in  places below the  third
 or fourth rib, or  on one side only, there is strong  presumption of

   * We  shall see, in another place, that there is an analogous phenomenon
 [Hacgophonism] which may sometimes be confounded with pectoriloquism,
 but which by no means  affords the same indications; and there is one case
 of actual and perfect pectoriloquism, where the cause of the phenomenon
 is of a much less serious kind than consumption.  [Dilatation of the Bron^
 chia.] 
224
DIAGNOSIS.
the  existence of an  excavation; and if the same phenomenon
does not exist in the points above  mentioned, the presumption
amounts to a certainty;  and we must  conclude,  either that the
tuberculous cavity is seated very profoundly in the  lungs, or that
it is still filled, in a great measure,  by imperfectly  softened  mat-
ter..  If in any point of  the chest, the sound of the voice is much
stronger than in the opposite side,  more  especially  if it  is so in-
tense as to seem stronger and nearer than the  natural voice heard
by the ear, the indication isas certain  as if the voice  traversed
the tube, and we reckon, in'such case, the pectoriloquism  imper-
fect, not uncertain.  Pectoriloquism is  more  distinct  in propor-
tion as the voice of the person is sharp.   This is most frequently
the case with women and children.   It is, therefore, in  them we
must be most on our guard against that variety ot the phenomenon
which I have named uncertain.   In  persons,  on the other  hand,
with a very deep'voice,  pectoriloquism is often  uncertain  when
there exist excavations in the state  most favourable for its pro-
duction.  In such cases, the voice, much agitated,  and as it were
trembling, does not enter the tube, but resounds at its extremity
with a  force double  or  triple  that  natural  to  it.   The patient
seems to speak through a speaking trumpet, quite close to the ob-
server,  and  not, as in the case of perfect pectoriloquism, through
a tube into his ear.  This variety of the phenomenon, especially
if  it exists on one side of the chest only, affords an indication  no
less certain than perfect  pectoriloquism.   This is more particular-
ly  the case, if we stop the other ear,  and find a very great differ-
ence of sound between the place in question,  and the other parts
of the chest.
   When the pulmonary  excavations are extremely  large  we find
distinct pectoriloquism changed into this variety, even in persons
not possessing a deep toned  voice.   This fact  enable us,  in some
cases, to trace  the  progress of the  increase and development
of tubercles.  In cases of the most perfect pectoriloquism, some-
times the voice, in place of passing  uninterruptedly through  the
cylinder, is intermittent.  This circumstance does not, in  any
respect, affect the indication.  Sometimes perfect pectoriloquism
ceases for a time, evidently  (as we learn from the  accompanying
rattle) by the  obstruction of the  excavations, or their openings,
by  the accumulation of the sputa.  On  this account  we must
never pronounce a patient to be  non- pectoriloquous from a single
trial-
   Commonly,  in  cases  of pectoriloquism, the voice,  as  heard
through the tube, is somewhat  smothered  like  that of  ventrilo-
i 
PHTHISIS PULMONALIS.               225
quists.  Like theirs, also, the articulation of some words is very
distinct, and of others  very obscure and dull.  Sometimes it is
weaker than the natural voice, but commonly it is louder.  Some-
times it seems as conveyed by a trumpet;  and at others,  as if
spoken  directly in the ear, without any intermedium, and so loud
as to be very disagreeable.   Sometimes  it resounds as if convey-
ed by a brass tube, and is accompanied by  a  very characteristic
sort of  bleating (chevrottement), which  will be described hereaf-
ter  under  the  name of Hagophonism.*   This must not be con-
founded with pectoriloquism  properly so  called. Sometimes every
word  is followed  by a  sort of tinkling, like  that  of  a small bell
or glass, which dies away in  the  tube at a variable  altitude.   I
shall  more particularly notice hereafter this sound also, which I
have  named metallic tinkling (tinlement metallique).   In some
cases  each word is accompanied by a sound  resembling the forci-
ble expiration of the breath in blowing out a candle;  and we  can
hardly believe that some one is not blowing strongly into our  ear
through the tube of the cylinder.
  The most complete extinction of the voice does not affect pec-
toriloquism;  it  being often very distinct in  persous  whose voice
cannot be heard at the distance of three or four feet.  A moderate-
sized  and  regular-shaped excavation  appears  to give rise to .the
phenomenon more decidedly than a very large or irregular  one.
  We may form some idea of the nature of the contents  of an  ex-
cavation from  the particular  characters of the pectoriloquism.
When the  cavities are   quite empty, the voice  is heard clear  and
without any extraneous  sound.  When, on the contrary, they con-
tain a certain portion of soft matter, the voice  is accompanied  by
a sort of guggling noise which renders the  articulation  less dis-
tinct.
  In the last stage of Phthisis, that is  to  say, after the formation
of tuberculous excavations, the auscultation  of the respiration also
affords some useful indications.  In these cases the sound of res-
piration continues very  audible over the site of the excavations;
but instead of being attended by the usual crepitous noise,  it here
resembles simply the sound of wind, as of  a pair  of bellows, or
like that observed on applying the cylinder to the trachea, but still
more  distinct.   In these circumstances percussion on  the parts of-
ten elicits a dull sound,  owing to the engorgement surrounding the
excavation; and these two  circumstances,—namely,—the existence
of a  spot yielding very  forcibly the sound of respiration without

                   * See  Diagnosis of Pleurisy.
                              29 
226
DIAGNOSIS.
crepitus, in the centre of a portion  of the chest which sounds
badly,—may be considered as pathognomonic of this state of parts.
In certain cases, the sound of respiration over the site of tubercu-
lous cavities is accompanied by the sensation  as if the patient  in
inspiration inhaled the air  from the tube of the stethoscope and
exhaled it during expiration.   This  is  observable on   applying
the instrument to  the trachea and  larynx  of a person  in health.
   One species of that variety of respiration,  also, which I have
denominated the rattle, affords some signs almost as characteristic
of the disease as  pectoriloquism itself.   The species  here meant
is  that which I have named the mucous or guggling rattle.  It  is
produced in the present case by the transmission of air through
softened tuberculous matter; in many other cases it arises from the
accumulation of sputa or blood in the bronchia or trachea: it is the
dead rattles of the vulgar.  This  is the only species  of the  rattle
that can be heard by the unassisted ear, and it can be so only when
its seat is  in the trachea  or larger bronchial tubes.  The cylinder
enables us to hear it when it exists in any part of the lungs.
   The mucous rattle points out the existence of tuberculous exca-
vations when it is found exactly circumscribed  and confined to par-
ticular parts of the chest.  It sometimes precedes  evident pecto-
riloquism  by several days or even weeks. Both simple respiration
and cough produce this species of rattle in tuberculous excavations
half-filled  with softened  tuberculous matter.   When  this is  very
liquid we  often can distinctly  recognise the fluctuation of a liquid,
in place of the rattle.   The noise in  such cases is sometimes ex-
ceedingly like that produced by the escape of  water  from a bottle
held with its  mouth  directly downwards.  Sometimes, but  very
rarely, the patient himself is sensible  of the motion occasioned  by
the passage of the air  in the excavation, which he commonly ex-
presses by saying that he feels the matter expectorated come from
that particular point.
  In exploring the phenomena of pectoriloquism, if the patient is
in bed we ought to  make him lie on bis back, and at both sides of
the  bed successively, while we  examine the anterior parts  of the
chest.   In examining the lateral parts of the chest,  and the axilla,
we  must make the patient to lean from us; and while examining
the  upper part of the shoulder he must lean towards us.  In examin-
ing  the back, we  seat him in his bed with bis back towards us, his 
PERIPNEUMONY.                   227
body  a little bent forwards and his arms crossed.   If the patient
is seated in a chair, it is best to kneel on one knee while examining
the anterior parts of the chest.   In every case it is  advisable  to
make him turn his face away from us while examining him.
                  PERIPNEUMONY.

                       (Part I. Page 59.)

  Peripneumony is  one of the longest known diseases: its diag-
nostic symptoms are  not, however, on  this account,  unequivocal.
Impeded respiration, deep pain in the side affected,  incapacity of
lying on the opposite one, fever,  cough, viscid  sputa, sometimes
mixed with  blood, the urine of a deep red,—are the principal
symptoms assigned to this disease by authors.  There is, however,
not one of these but may be  absent in the most violent cases,
while, on the other  hand,  they are almost all  common to many
other diseases.
   In a great many   cases  of peripneumony there is no  pain.
Dyspnoea is, in  like manner,  sometimes very slight, and  is fre~
quently unperceived  by the patient when it is visible to the medi-
cal attendants.   Some  patients cannot lie  on the affected side,
though  the  contrary is much more commonly the  case.  The
cough is sometimes slight and infrequent; and in the  chronic va-
riety of the  disease especially, (whether this is  the original affec-
tion or succeeds the  acute stage,)  it  is sometimes so very incon-
siderable  as scarcely to deserve' the name, and its  existence  is
denied by the patient.   Even  fever, the invariable  attendant  of
inflammatory affections, at  least at their origin,  is sometimes to-
tally wanting in this disease after the few first days.
   The only one of the general symptoms  that can certainly  be
depended on is the tenacious sputa noticed in the First Part (page
63).  But  even this  is not always  well-marked;  and, indeed,
seldom is so after the first days of the disease.
  .From all  this it follows, that the  physicians, who confine them-
 selves, in diseases  of the chest, to the examination of general
 symptoms, must often mistake  chronic peripneumony, and even 
228
DIAGNOSIS.
sometimes the acute disease;  particularly if they do not see the
patient  till after the first days  of the complaint, or in those cases
where the peripneumonic  affection  supervenes in the course of
another disease
   The  percussion of the chest, according to the method of Aven-
brugger, is a much surer means  of ascertaining this  disease, in
all its stages, than the examination of the external symptoms only.
The little time and trouble required  by.it, and the certainty  of its
results, would exclude the necessity of any other mode of explo-
ration,, if it  were  applicable  in all  cases; but we have  already
seen (page 210) that this is not the case.
   The exploration by the cylinder has not  this  disadvantage: it
indicates  the pulmonary  inflammation in every possible  case,  and
points out, moreover, the degree of  it, with much greater preci-
sion than percussion.   In the first  degree of peripneumony, the
respiratory murmur is still  heard  in the part, affected, whether
percussion affords any sensible alteration of sound or not; and it is,
further, accompanied  by  that species of  rattle to which I give the
name of crepitous rattle,  afld which is  the pathognomonic sign of
this first degree of peripneumony.   This species of rattle resem-
bles the crepitation  of solid salts in a heated vessel, or  it  may be
said to be very analogous to  the noise emitted by the healthy lungs
when compressed in the  hand,—only  stronger.  The only other
diseases in which this species  of rattle is found, are oedema of the
lungs and haemoptysis.   The second and third varieties of perip-
neumony  are distinguished by  the total absence  of the  respiratory
murmur.   On the patient  making a deep inspiration we see  and
feel the motion of the thoracic  parietes, but we  hear  no sound
whatever.   Sometimes, however, in  place of the natural sound of
respiration we  hear the  mucous rattle.  This  is particularly the
case when a pulmonary catarrh  is conjoined with the  peripneu-
mony,  or  when the viscid mucous  sputa, of the early stage  are
changed, towards its latter stage/into a thicker  and more opaque
expectoratiou.*   We commonly observe, also, in all the varieties
of the disease, but especially in the  two  first, thatthe  respiration
acquires the character which we have named puerile (page 216)
in the parts of the lung which have  remained sound.
   When  peripneumony terminates   favourably,  the  cylinder  be-
comes a sure measure of the  progress of the cure.  Before  per-
cussion  can inform us of any diminution of the pulmonary engorge-
ment, the cylinder enables us to  distinguish a  slight murmur

        * For an account of this species of Rattle see Page 226 
PEMPNEUMONY.
229
during expiration.   This is  first  observable in one  point, and
always in the superior portion of the side affected, gaining ground
daily,  both in  degree and extent, until the  period of complete
resolution   If in this state the patient  makes a deep  inspiration,
we often can perceive, towards its termination, a sort  of crepita-
tion like that produced by blowing air  into the cellular substance
of meat, as practised  in the  shambles,  or like the sudden disten-
tion of a dry bladder.   The  percussion of the chest gives a much
tardier  indication  of  the resolution  of the  inflammation;  and,
moreover,  does not point out the progressive  amendment, like
the cylinder.   This is a matter of great  importance  both  in  a
moral and  therapeutic point of view, and cannot be properly met
by attention to  the general symptoms merely.  It  often happens
that persons affected  with, peripneumony, after the use of  anti-
phlojE^tics, appear almost cured for a few days: the fever and pain
go off, the  cough becomes less frequent,  and the expectoration
trifling; the strength  and appetite return;  but  we learn by the
cylinder and percussion  that the pulmonary engorgement remains
quite undiminished.   Accordingly,  in  such cases,  we find that
after a deceitful convalescence of  a few days, or even weeks, the
strength  again  fails, and a fresh inflammation,  or merely general
exhaustion, with cerebral congestion and dyspnoea, carries off the
patient.   In a  still  more numerous class of cases,  peripneumony
retains the character of  an acute  disease only during four or five
days, while the organic lesion  of the  lung is not completely re-
moved til]  after several weeks.
   There are many other cases wherein  the method of auscultation
is applicable, when  that of percussion fails.   The following are a
few of the circumstances which render percussion either partially
or  generally useless as a diagnostic: 1st, it is inapplicable to that
portion of the thorax  occupied  by the  liver, and also, in a great
degree, to  the  opposite portion containing the distended stomach-
2nd, it is  useless  in  many cases of great fatness; 3rd, in  most
rickety subjects; 4th, in some few cases it is  rendered useless by
some unknown peculiarity  of constitution;  5th, by the artificial
application of  a blister to the part; and 6th, when both lungs are
inflamed in  corresponding points, or when they are violently af-
fected, and throughout a great extent.  In this last case death al-
most always supervenes  before the pulmonary engorgement be so
far advanced as to be indicated by any peculiarity of sound on per-
cussion.
   In this case the cylinder is of great  use.  Besides the species
of slight crepitus that  accompanies respiration in the first degree 
230
DIAGNOSIS.
 of  peripneumony, and the  comparative intensity of the natural
 respiratory murmur in the sound portions of the lungs, this instru-
 ment furnishes another symptom quite  characteristic in  the  pre-
 sent case.  It is this—although the respiration is still heard in the
 inflamed parts, we perceive  that it is in force very much  less  than
 it ought to be, considering its frequency, and the  great degree of
 enlargement of the thorax in inspiration  which then conspicuously
 exists.  In these cases the cylinder is of the greatest advantage,
 inasmuch as the double peripneumony (that is, of both lungs) is one
 of the most insidious diseases, and  may be easily confounded  with
 an attack of asthma or nervous dyspnoea, especially when  it super-
 venes, as it frequently  does,  during a fever or disease of the heart.
 In such a case, an opportune bleeding (which is  rarely indicated
 by the general symptoms) will often save the patient.
  To conclude,—in every case, even where percussion is employ-
 ed with most advantage, auscultation affords indications more  con-
 vincing still.   Nevertheless, the method  by percussion ought never
to be omitted in  peripneumony.  In this case I may observe  that
the  method of auscultation is more  simple, requiring only two  pre-
cautions—namely,  to cause the patient to breathe a little more fre-
 quently, and to keep the cylinder exactly applied on the chest.
          GANGRENE  OF  THE LUNGS.


                       (Part I. Page 64.)


  The general symptoms of this affection have been already no-
ticed in Part First (page 66).  When the disease has produced ex-
cavations in the substance of the lung, these  give rise to pectorilo-
quism  equally with those of phthisis.   When these cavities com-
municate at the  same time  with the  bronchia and cavity of the
pleura, and have thereby excited an attack  of pleurisy accompa-
nied by pneumo-thorax,  (see page 141), the modification  of the
respiratory sound, denominated the metallic tinkling, is further ob-
servable. 
HAEMOPTYSIS                    231
HEMOPTYSIS.
                       (Part I. Page 69.)


  The  principal symptoms of this disease are the following:—
great oppression, cough  attended by much irritation of tire larynx,
and sometimes by very acute pain in the chest;—expectoration of
bright and frothy blood, quite  pure or merely intermixed with sa-
liva, or some  bronchial or guttural mucus;—pulse jfrequent, full,
and with a particular kind of vibration, even when soft and weak,
as it frequently is after a day or two.   Of all these symptoms the
spitting of blood is the most constant and most severe.   This is
commonly very  copious, returning by  fits, with  cough, oppression,
anxiety, intense  redness or extreme paleness of face, and coldness
of the  extremities.   When the hemorrhage is  very great it comes
on sometimes with a very moderate degree of cough, and is ac-
companied by a convulsive elevation  of the diaphragm  like that
which  takes place in vomiting.   This accounts fqr the expression
■—vomiting of blood, which is used by most persons who have suf-
fered a violent haemoptysis.
   The  haemoptysical engorgement is usually of too small extent to
be recognisable  by percussion; and, besides, it frequently has its
seat in  those portions of the lung which  are beyond the reach of
this means of diagnosis.
   The  stethoscope affords two signs  indicative of this  affection,
viz: 1st, the absence of respiration in a portion of the lung of small
extent, and 2nd, a mucous rattle.  In that variety of the disease
where the blood is furnished by the bronchial  membrane, there is
the latter indication without the former.   Should  this distinction
be not  very clear (as will be the  case when the engorgement is of
small extent), it will always be wise to act as if the affection were
certainly the  more severe of the two. 
232                      DIAGNOSIS.
              PULMONARY CATARRH.


                        (Part I. Page 70.)


   In the First Part I have stated  that the general symptoms of pul-
monary catarrh, especially cough and expectoration, afford no cer-
tain means of discriminating it from  other diseases of the lungs.
Mediate auscultation, however, either by itself, or conjointly with
percussion, furnishes us with several certain indications, as well of
its existence, as its severity.  The chief of these is furnished  by
that modification of the respiratory sound which I  have named the
rattle;  and I shall take this opportunity of describing this pheno-
menon more  particularly than I  have hitherto done.   The pecu-
liar sounds classed under this denomination are very various; and
although they are,  in general, very striking in their characters, it
is, nevertheless, very difficult to communicate a correct notion  of
them to such as have never heard them.   However, from what I
have already said respecting  them, and what  I shall  now say, I
hope any one will be able to distinguish the different  kinds  on
trial, as they can be much more easily  recognised than described.
   There are four  principal  kinds of this phenomenon:  1st, the
humid  or  crepitous; 2nd, the mucous or guggling; 3rd,  the dry
sonorous; and 4th, the dry sibilous or  hissing  rattle.   The two
first of these have  been  already described (pages 2^6 and 228).
   The dry sonorous rattle is more variable in  its  character than
the two former.  In this the sound, more or less  deep,  is  some-
times extremely loud,  resembling, at different times,  the snoring
of a person asleep, the bass note of a musical instrument, or the
cooing   of  the wood-pigeon.   This  last sound is sometimes  so
exactly imitated that one is tempted to  think  one of  these birds
is concealed about the patient's bed.  This variety is usually very
partial  in  its extent.   I have  often found its  site in  pulmonary
fistulas, at other times in the bronchial  tubes preternaturally dila-
ted.  We must not confound this species of rattle with common
snoring, which, as we have  already shown,  has  its  seat  in the
fauces, and is quite inaudible in the chest. 
PULMONARY CATARRH.
233
   It is not easy to determine the cause of  this phenomenon.  The
character of the sound does not indicate the presence of any liquid,
and the examination, after death, of persons exhibiting  it,  con-
firms  the indication.   I am led by my  dissections to  believe that
it  is produced by the partial obstruction or  narrowing of a part
of the tract of a bronchial tube; whether  this takes place  from
the pressure of a tumour, or of a portion  of the lung condensed
by inflammation, or  by the obstruction  produced by a portion  of
tenacious mucus, or  by the partial thickening of  the internal coat'
of a bronchial ramification.
   The dry sibilous or  hissing rattle is also  varied in its character.
Sometimes it  is like a prolonged  whisper  of various  intonation;
sometimes it is  very momentary,  and  resembles the chirping  of
birds, the sound emitted by suddenly separating two portions  of
smooth oiled  stone,  or by the  motion  of  a small valve.   These
different kinds often exist together in different parts of  the lungs,
or successively in the  same part.
   The peculiar nature of the sound, and the  appearances on dis-
section, prove the sibilous rattle to be owing to minute portions of
very viscid mucus obstructing,  more or less completely, the small
bronchial ramifications.
   Besides the peculiar sound indicated  by  the various species  of
rattle, there  is also to be noticed a slight sense  of vibration com-
municated to the cylinder when the seat of the phenomenon  hap-
pens to be in  the point immediately beneath it, but  not otherwise.
When this vibratory sensation can  be  discovered in no  point of
the chest, we  mayconclude the  rattle  has its seat in the central
parts  of  the lungs.   Some of the species of rattle,  especially the
mucous and crepitous, cannot be distinguished at the distance  of
one or two inches from their site. The other kinds may frequently
be distinguished through  the  whole  extent of the chest,  and,
thus,  are often combined with the others.  The different varieties
of this phenomenon  frequently convey to the ear a sensation, as if
it  was accompanied by the  successive formation and rupture  of
bubbles of various sizes, like those made by children from soapy
water.   Many of the  various images  suggested  by the  different
sensations are very distinct,  and  may be described  as permanent
varieties  of the  phenomenon.   I shall   not, however, enter upon
this at present.
   The indications afforded  in  disease, by the exploration of the
various species  of rattle,  are  less  numerous,  and  of much less
importance than those  furnished by the voice, and  by respiration
in  its  simple state.
                              30 
234
DIAGNOSIS.
  The above observations  respecting the rattle apply to this  phe-
nomenon as observed in the chest,  and as tHe cause exists in the
ramifications of the bronchia.   The same thing is observable over
the  trachea in certain cases, as in catarrh and haemoptysis.   This
is the only species that can be heard with the naked ear; but the
cylinder detects it often when inaudible to the ear.
  In the commencement of pulmonary catarrh, when there merely
exists a slight  coryza, almost  without  cough, and  accompanied
6nly by a  sligh' irritation in the throat, the  cylinder announces  a
rattle which  is often  very loud.  This  is  usually of  a sonorous
but dull character, and  sometimes  hissing.  Its site is indicated
by the sort of vibratory sensation  formerly  noticed.  When very
loud, we can hear it at  a distance from its site; but here it is more
feeble, and unaccompanied by  the vibratory movement.
  I am led to believe that the rattle is more grave  and sonorous,
in'proportion as the mucous membrane is much swollen, and the
secretion  of mucus is small.   In  proportion  as  the  disease ad-
vances and* the mucous  secretion  increases, the  rattle gradually
assumes the character of guggling or mucous formerly  described.
  When  the  pulmonary catarrh is partial, as is usually the  case,
the rattle is confined  to the part affected.   The danger of the
disease, and the severity of the general symptoms, are always
proportioned to the extent  of the local affection.   When the rat-
tle is heard over the  whole of one lung,  or  in the greater part of
both, the case is always  severe.  If the disease is acute, it is then
attended by a  violent  fever; if  chronic, there are orthopnoea and
prostration of strength,—and these symptoms are more severe in
proportion as  the  patient is advanced  in life.   When  the  rattle
extends over the  whole of both  lungs  (which  is  only the  case
when  there is violent fever), the  disease is almost always  fatal,
except when the patient is very young.
   One of <he" most remarkable phenomena  in the pulmonary ca-
tarrh, is the occasional suspension of respiration in the affected part.
This circumstance,  which may be considered as pathognomonic
of the disease, often  supervenes all at once, and  passes off  in the
same manner, after coughing  or expectoration.   Its cause is ob-
viously the obstruction  of a bronchial tube by the contained mu-
cus.   In  such cases, sometimes the respiration is not entirely lostrf
but only so far lessened  as to be barely audible.
   This suspension of respiration must not mislead  the observer  to
confound  this with other diseases.   In the present  affection, per-
cussion of the chest produces  a distinct sound,—a circumstance
sufncient to distinguish  it  from peripneumony, and pleurisy with 
PULMONARY CATARRH.                235
effusion into the chest.   In pneumo-thorax and emphysema of the
lungs, the same absence of the sound of respiration and the dis-
tinct sound  on  percussion exist, as in these cases of catarrh.  But
in the former disease (pneumo- thorax), all the other symptoms are
so different, that there can  be no risk  of confounding the two
affections.   In  the latter disease (emphysema), the very same in-
dications are furnished by auscultation and percussion,  as in  the
pulmonary catarrh; but, in this case, sure  means of discrimina-
tion  are furnished by the general symptoms.   Pulmonary catarrh,
of sufficient  severity to produce suspension of respiration in  a
large part of the chest, is a severe acute disease, accompanied by
fever, strong and  frequent  cough,  and  copious expectoration;
while emphysema is a chronic affection, whose almost only symp-
tom  is the impeded respiration.
   Chronic Catarrh.  In the  former part of this work  (page 77)
I  have adverted to  the difficulty of distinguishing this disease
from phthisis pulmonalis.   In  fact  the most perfect  similitude
exists between  the two diseases, in as far as  regards the expec-
toration, the emaciation, and all the other general  symptoms.
   Percussion gives  no assistance in the diagnosis;  since, in most
cases, the chest sounds  quite well in  consumptive patients.   The
indications afforded  by the stethoscope are much more  to be de-
pended on.   In such  cases, if,  upon properly  examining  a pa-
tient, (viz. at different times, and for a  certain length of time,)
we find  neither  pectoriloquism, nor the guggling produced by
softened tubercles (see page 226);  nor the tracheal respiration  of
tuberculous  excavations (see page  225); nor the permanent ab-
sence of respiration in certain places (from  tuberculous  engorge-
ments of  some extent, see page  220);—and if the respiration is
perceptible over the whole  chest, we  have  a strong presumption
that  the disease is merely chronic  catarrh;  and if the  same  re-
sults uniformly present  themselves after  an  attendance of some
time  (say two  or three" months),  our presumption is  converted
into  certainty.
   With  regard to  the  diagnosis  of the  different varieties  of
catarrh, I shall only  here  observe, that in  chronic catarrh the
rattle is rarely continuous, and  still more rarely  general over the
chest; and that, further, the sound  of respiration is scarcely ever
suspended as in the acute disease.
   In the pituitous catarrh the rattle is usually extremely sibilous
and  sonorous,  frequently resembling the  chirping of birds, the
sound of a bass string,  and  sometimes the  cooing of the  wood-
pigeon in a slight degree. 
236
DIAGNOSIS.
  The pathognomonic signs of the Dry Catarrh are the same as
those of emphysema of the  lungs  (see  Emphysema),  a disease
which its existence for a short time necessarily produces.
  Often in cases of chronic catarrh the respiration  acquires  the
character of puerile.  In  such cases the dyspnoea is greater than
usual, and the disease is usually called Asthma.  In many cases,
however, of dyspnoea, which might  properly  be called nervous
(nervous asthma), I have  observed the respiration quite natural; in
others, I have observed it with the puerile character.
DILATATION OF THE  BRONCHIA,
                       (Part I. Page 79.)


  From the time that I had ascertained the dependence of the
phenomenon of pectoriloquism on the reverberation of the voice,
in an excavation situated amid the pulmonary  tissue, and that the
same thing was observable on the larynx and trachea, I  had no
doubt but  the lesion  in  question  would give the  same  result.
Owing to  the  infrequency of this affection of the lungs,  I have
only as yet verified my conjecture in  a single case.  A  woman,
aged 50, died of a disease unconnected with the thoracic viscera.
She had been for several years affected with an habitual  expec-
toration, and had before her death  exhibited the  phenomenon  of
pectoriloquism, in a very evident manner, about the  third rib on
the  right side.  On examination,, we  found  in  the part  of  lung
corresponding to this point, two bronchial tubes dilated to  three
times their natural size, and one of them terminating in a cul-de-
sac  sufficient  to contain a small filbert.
  We may regard it as certain, that, in the case of partial  or  gen-
eral dilatation of the bronchia, pectoriloquism will  be found  to
correspond to the extent  of the organic affection.   1 am  also
confident that in such case, the character of the  voice,  and the
sound of respiration, will be such as to indicate that the  pheno-
menon does not arise from  an ulcerous cavity; but as  I have not
yet  had an opportunity of verifying this conjecture,  I shall not
here dwell upon the subject. 
EMPHYSEMA OF THE LUNGS.             237
EMPHYSEMA  OF THE  LUNGS.
                        (Part I. Page 82.)


  The general symptoms of this affection  are  rather  equivocal.
Dyspnoea being its most striking  feature, it is one of the diseases
usually confounded under the name of asthma.  In it the respira-
tion is habitually impeded, but is  aggravated by occasional pa-
roxysms  which are quite irregular  in  their return  and duration.
Like dyspnoea  from  any other cause, it is further increased by the
usual causes, such as indigestion, mental emotion, elevated  situa-
tion, violent exercise,  especially that of  mounting,  &c.   It  is
unaccompanied by any  fever, and the  pulse is, for  the  most part,
regular.   When the affection exists in a  high  degree, the skin
assumes a dirty aspect, with a bluish tint in some places, especial-
ly the lips.   In all the cases I have seen there  was a  slight de-
gree of habitual cough, with a very  slight mucous  expectoration.
The complaint often exists  from childhood, and  does not  seem
materially to abridge the duration of life.   Like other dyspnoeas
it frequently, in the end, gives  rise to  hypertrophia or dilatation
of the heart.
  When this disease occupies only one side, or exists much more
in one lung  than the other, this side is  evidently enlarged, and the
intercostal spaces wider.   It also yields a more distinct sound on
percussion.   When  both  sides are equally  affected,  the  chest
yields a very distinct sound throughout, and presents a more round-
ed outline,  both before  and behind,  than is natural in the sound
state of that cavity.
  The pathognomonic sign of this disease is furnished  by a com-
parison of the indications  derived from percussion and ausculta-
tion.  The  respiratory  murmur is inaudible over the greater part
of the chest, and is  very feeble in  the  parts where it is audible:
at the same time a very distinct sound is produced  by  percussion.
If the disease is not very severe, the  sound of the  respiration  is
still  audible, but in a much less degree than the sound on percus-
sion would lead us to expect.  There is also heard, in  the affect-
ed parts, an occasional slight sibilous rattle. 
233
DIAGNOSIS.
   This single circumstance—of the absence of the  noise of res-
piration in a chest, which sounds well on percussion,—is sufficient
to distinguish  emphysema of the  lungs from  any other disease of
the chest except  pulmonary catarrh and pneumo-thorax.   We
have already made some remarks on the distinction  between  the
former disease and empysema;  and may repeat,  that the general
symptoms are sufficient to enable  any one to discriminate  them.
The means of distinguishing emphysema from pneumo-thorax will
be noticed under the account of the latter disease.
   It is difficult to account for the  absence of the sound of respi-
ration, in a disease  which consists essentially in dilatation of  the
air-cells, and in which, consequently, there exists more air than is
usual  in the lungs.  The fact is,  probably, accounted for by  the
temporary obstruction of the bronchia by  the increased mucous
secretion which usually accompanies this disease, and by the par-
tial compression of  the air-cells by those dilated.  This supposi-
tion is corroborated by the fact, that persons affected with this dis-
ease have their breath much oppressed, in  the first instance, when
they chance to catch cold; while the respiration  improves  imme-
diately after  the expectoration  commences,  and even  becomes
better than  before the catarrhal  affection.
(EDEMA OF THE LUNGS.
                       (Part I. Page 92.)


  The symptoms of this affection are extremely equivocal. Imped-
ed respiration, slight cough, and a  watery expectoration are the
only signs of it.  Percussion affords no useful indication.   The
stethoscope furnishes two  means of diagnosis,  but even these are
less satisfactory than in  most other diseases of the lungs.  These
are,  1st, the much less degree of distinctness of the respiratory
murmur than might be expected from the efforts used in this action,
and from the great dilatation of the  chest with  which it is accom-
panied;  and, 2nd, a slight crepitous rattle like that in the first
degree of peripneumony, but fainter.  Indeed,  the cylinder  is not 
ACCIDENTAL PRODUCTIONS.
239
sufficient of itself, without reference to the general symptoms,  to
distinguish the last mentioned disease from oedema.
  There is another case in which it is almost impossible to ascertain
the existence of cedema of  the  lungs, and that is, where  it  is
complicated with emphysema of  that organ.   The indications  of
the stethoscope will, in this case,  merely point to the  emphysema;
while, should the patient die, the  examination of the body is likely
to lead us into an error on the other side, the emphysematous con-
dition of the lung being obscured by  the serous infiltration of the
air-cells.*
  The same difficulty of ascertaining the true character of the lung
exists, in a still greater degree, in the case of peripneumony super-
vening to the emphysema.
  With  regard to this last  complication, I may here remark,
though  somewhat out  of place,  that, on the  living subject, the
cylinder and percussion in the first degree of peripneumonic affec-
tion, will only recognise the  emphysema; and, in the  second  or
third  varieties, will only  recognise  the peripneumonic  affection.
This is true of the complication when seen only after  it is formed;
if the patient had been seen previously to the  supervention of the
peripneumony, percussion  of  the chest would  have demonstrated
the existence of the emphysema and the invasion of the peripneu-
mony.
ACCIDENTAL  PRODUCTIONS
                      (Part I. Page 99.)


  Whatever be the nature of these bodies, the symptoms attend-
ing them are almost always  the same, and consist, for the most
part, only of a degpee of dyspnoea proportioned  to the s|ze of
tumour; and cough, varying in degree and in the extent and nature
of the accompanying expectoration   The  most  deleterious pro-
ductions, even, such as the medullary tumour, sometimes attain a
considerable size, and produce death  by  suffocation without pre-

  * In this case  we must pass a ligature round a portion of the lung and
dry it, when the true character of the part  will be evident. 
 ^40                      DIAGNOSIS.

 viously giving rise to marked derangement of functions/ Tubercles,
 more than any of the others, produce general effects on the system.
 Yet, even in the case of them, these effects rarely supervene until
 long after their formation, and, indeed, not until after the period
 of their solution.
   When an  accidental production has attained* a  large  size, for
 example that of an egg, the  cylinder will indicate  its presence by
 the absence of respiration in the part.   But when the tumours are
 small, and  the lung sound  in  the intervals,  the  respiration, as
 indicated by the cylinder, is not at all affected.  I have often  ob-
 served the respiration  equally distinct on both sides of the chest,
 in persons in  whom it was  found,  after death, that one lung was
 sound, or merely  containing a few very small tubercles; and  the
 other filled  with tubercles;  from the size of a millet-seed to that
 of a filbert, and in such quantity as to  give to  this lung double or
 triple the  weight of a  healthy  one.   When,  in such cases,  the
 intermediate portions of lung are  engorged with  any species of
 matter, respiration of course ceases in them; and percussion yields
 a dull sound.
   In  the case of cyst noticed in page  101, and in  the hydatid
 described in case 27, page  103, the cylinder must have  detected
 their existence, and in the latter perhaps,  might have led to, and
justified  the  performance of, an operation for the relief of  the
 patient.   At all events the employment of the cylinder must afford
 more chance of ascertaining the character of such affections, than
 any other means we yet possess.
   Osseous Concretions.   The cylinder gives no assistance in  as-
 certaining the existence of these.
   Melanosis.   When  melanotic tumours soften  so as  to leave a
 cavity, they will give rise to pectoriloquism; and when this matter
 impregnates a  portion of the lung, to the extent noticed  in  page
 111, the cylinder  will indicate the impermeability of the lung to
 air, but will not enable  us to discriminate the affection from perip-
 neumony.
   Medullary Tumour.   During the greater part of the existence
of this  species of tumour in the lungs, there js no sensible degree
of fever, and death arrives without any perceptible alteration of
the pulse.  Emaciation  may be very long in taking place, but it
always  does  so, and is rapid in  its progress, towards  the termi-
nation of the disease.   The cylinder will point  out their presence
as that of other tumours, when they are of a certain size. 
PLEURISY.                      241
PLEURISY
                       (Part I. Page 122.)


   A well-marked acute pleurisy is, for the most part, easily re-
cognised.  The stitch in the side, dyspnoea, fever, and dry cough,
or cough accompanied only by glairy and almost colourless sputa,
are often sufficient to afford a  moral  assurance of its existence,
and to do away all necessity of  other more precise means of diag-
nosis.  But it is not uncommon to meet with pleurisies, even acute,
in which many of these symptoms are wanting; whilst many chro-
nic pleurisies are often so indistinctly  characterised,  and accom-
panied by so many functional anomalies, that it is frequently not
till after  several weeks, or even  months, that  the true nature of
the disease comes to be suspected.
   Percussion points out the disease with much more certainty.
As soon  as the effusion takes place, the resonance  of the chest
fails over the whole of its site.   This  failure,  indeed, may  arise
equally from peripneumony:  but the nature of the general symp-
toms, more particularly the character of the  expectoration, and
the absence or  presence of the stitch of the side, will tend to  fix
the distinction.
   Mediate  auscultation furnishes  us  with  much  more certain
means of discriminating these two diseases, and enables us to as-
certain with  precision, not  merely the existence of the effusion,
but its quantity.   The signs by  which the cylinder  effects this,
are,  1st,  the  total absence, or great diminution, of the respiratory
murmur; and,  2nd, the appearance, disappearance, and return of
the sound which I have named Hcegophonism.
   When, as is often the case, the pleuritic effusion is very copious
from  its  very  commencement,  the  sound of respiration  is  then
totally absent through the whole of the side  affected, except in a
space of  three fingers' breadth along the vertebral column.  This
complete disappearance of respiration after the existence of disease
for a few hours, is quite pathognomonic of pleurisy with copious
effusion.
   In peripneumony, the disappearance of the  respiration is gra
                            31 
242
DIAGNOSIS.
dual, and is perceived to be unequal in different parts of the chest,
being often not lost in the upper part till after some days or weeks;
it is, further,  preceded for twenty-four or thirty-six  hours by  a
crepitous rattle (see page 228)  quite characteristic    In pleurisy,
on the contrary, the loss  of the  respiratory  murmur is sudden,
equable, uniform, and  so  complete, that.no effort of inspiration
can render  it perceptible.   The  continuance of the  respiration
along the spinal column is an equally  constant sign.   This exists
equally in the chronic disease, attended with  the most copious ef-
fusion.   It is  explained  by  the compression of the lungs back-
wards towards their roots.*
  These copious and sudden effusions occur chiefly in  old persons,
or in adults of weak and cachectic habits.  The sudden cessation
of the respiration in such cases, must,  therefore, be considered as
affording a very b;>d prognostic; as we may be  assured that the
conversion of the false membranes into  cellular substance,  and
the absorption of the effusion, will take place either not at all, or
imperfectly, and the disease  will soon pass into the chronic state.
In  children,  and  persons  of  strong constitution,  the  effusion
scarcely ever  takes  place so rapidly and suddenly;  and the respi-
ration  does not finally disappear till after one or more days.  When
the effusion is considerable the  respiration  becomes puerile in the
sound  side.
   When the effusion begins  to diminish, by absorption, this is first
observable by the augmented intensity of the respiratory murmur
along the side of the spine, where it had never quite  disappeared.
Shortly after, it is perceptible in the anterior superior part of the
chest,  and top of the shoulder,  and  in a few days it returns in the
other parts  of the chest.   Wherever  there are adhesions between
the  lungs and pleura,  of  any considerable extent, the respiration
continues audible over them in a greater or less degree throughout
the whole period of the effusion; and the commencement of the
absorption  is perceived  by the augmented  intensity of sound  in
these places.
   The return  of the. respiratory sound  is much  more  slow  in
pleurisy than  peripneumony.   Sometimes it is weeks, and  even
months, afterthe reappearance of it near  the clavicle, before it is
perceptible  in  the  inferior parts  of the chest; and, often, for

  * In some rare cases the respiration continues to be audible.immediately
under the clavicle, owing to close adhesions existing in that part, between
the lungs and pleura. 
PLEURISY,
243
 months after the convalescence of a patient, it is only one-half so
 distinct in the affected side as in the sound one.
   To these signs 1  have to  add another, already noticed, and
 which appears quite  characteristic of this  disease  when  accom-
 panied by a middling degree  of effusion:—I mean Hxgophonism,
 or  Caprine Pectoriloquism   This phenomenon  has a  great analo-
 gy to pectoriloquism, and I for a long time confounded it with the
 latter, considering it  as a modification depending on  some pecu-
 liarity of shape or situation of the tuberculous excavations.   It is,
 however, quite distinct from pectoriloquism, and depends on quite
 a different cause, as has just  been stated.   Haegophonism resem-
 bles pectoriloquism in consisting, like it, of a strong resonance of
 the voice under  the  cylinder.  Very rarely,  however,  in  haego-
 phonism does the voice seem  to enter the tube,  and scarcely ever
 does it completely traverse it, as in perfect pectoriloquism.   The
 voice seems, further,  to be more  acute,  and as it were  argentine,
 than the natural voice of the  individual, and exhibits the  illusion
 as if some one were  speaking within the  cavity of the chest.  It
 has, moreover, another character so  constant as to  lead  me  to
 derive from it  the appellation of the  phenomenon,—I mean a
 trembling or bleating sound like the  voice  of a goat, a character
 which becomes the more striking as the key of  it approaches that
 of this animal's voice.   It also sometimes  resembles the sound of
 the human  voice transmitted through a cleft reed, or  the  nasal
 intonations  of the juggler speaking  in  the character of  Punch.
 This species of bleating is most commonly combined with the ar-
 ticulation of the words, as heard  within the  chest; sometimes it
 seems  to be contemporaneous with the articulation, but not arising
 from the same point; and sometimes it seems rather  to succeed,
 than accompany the pronunciation of the words.*
  I am of opinion that this  phenomenon only exists  in cases  of
 pleurisy (acute or chronic) attended  by  a pretty  large effusion into
 the pleura; or in cases  of other liquids effused in the same  pro-
 portion.   It has uniformly appeared to me that  haegophonism has
 decreased gradually with the  absorption of the  effused fluid   In
 acute pleurisies I  have found  it sometimes  to continue only a few
 days; while, in the chronic disease, I have known it  to continue,
 with variable intensity, for several  months.  I have  further ob-

  * To hear this sound properly we must apply the cylinder strongly to the
patient's chest, and place the ear  gently on the other end.  If the latter 13
 forcibly applied, the bleating sound is diminished one  half, and  the pheno
 •^'.non approaches nearer to common pectoriloquism. 
244
DIAGNOSIS.
served that when the effusion has become very abundant,—espe-
cially when so great as to cause evident dilatation of the chest,—
this phenomenon has ceased; and I have never met with it in  old
cases of Empyema, in which the lungs  were compressed towards
the mediastinum.  In cases where it was absent, it has sometimes
appeared, on the absorption (as it seemed to me) of a certain por-
tion of  the effusion.
   Haegophonism further differs from  pectoriloquism in being  ex-
tended over a considerable space. Most commonly it is perceived,
at the same time, in  the  whole  space between  the  scapula  and
spine, around the inferior  angle Of the former bone, and in a zone
three fingers broad, stretching from the  middle of the scapula to
the sternum.  I  consider this phenomenon to be owing to the na-
tural resonance of the voice in  the bronchial tubes rendered more
distinct by the compression of the  pulmonary tissue,  and by its
transmission through the medium of a  thin layer of fluid.  The
respiration is always very perceptible  in the points where haegopho-
nism exists.
   1  think there are only two  cases of Pleurisy in  which  this
phenomenon will not be observed:   These  are, (1)  where a very
rapid and copious effusion has suddenly  compressed  the lung
against  the mediastinum; and  (2) where a former attack of the
same disease has firmly attached the posterior parts of the lung to
the pleura.
   From the preceding observations I  think we are entitled to
conclude that haegophonism is a  favourable sign in pleurisy, as it
seems  uniformly to indicate a moderate  degree  of effusion.   Its
continuance for some time is a favourable omen, as showing that
the effusion  does not increase; if it continues as long as the fever,
or longer, we may be assured  that the  disease will  not become
chronifc, as this never happens  except when the  effusion is  ex-
tremely abundant.
   I am  of opinion that simple peripneumony is never accompanied
by this sign; but it does not prevent  it from  being perceptible^
when there is pleuritic  effusion, even  though it has arrived at the
degree of hepatization.
   Haegophonism, like pectoriloquism, is sometimes suspended  for
a longer or shorter time, reappearing after the patient has coughed
or expectorated.   The cause of this  suspension is, doubtless,  the
same in both, namely, the temporary obstruction of the bronchia
by the sputa.  In the site  of this phenomenon  the  respiration is
frequently found to  be  of the kind  already  described where  the
patient seems to inspire through the tube of the cylinder. 
PLEURISY.
245
   Contraction of the Chest.   Those kinds of pleurisy which ter-
 minate by the production of false pembranes of a fibro-cartilagi-
 nous character, are often extremely obscure, being very variable in
 their symptoms, and very irregular  in  their progress.   Very fre-
 quently there is nothing  in  their commencement which  resembles
 the  acute disease, and it is to them especially that the term latent
 Pleurisy can be  applied.  The stitch  of the side  is  infrequent
 and transient, and often so  slight as not to be mentioned by the
 patient unless questioned respecting it.   Sometimes  the  dyspnoea
 is very slight, and the cough is infrequent and dry; at other times,
 especially in asthmatic  patients, and  those  subject to  catarrhal
 seizures, there is well marked dyspnoea, and a plentiful expectora-
 tion. In these last, however, the symptoms rather indicate catarrh
 or asthma, than pleurisy.  In some cases the  symptoms are quite
 anomalous, and entirely  mislead our attention from the chest.  In
 all such doubtful cases mediate auscultation and  percussion  offer
 the  only means for detecting the true nature of the disease, by the
 absence of the usual sound on percussion, and the absence of the
 respiratory murmur every where except at the root of the lungs.*
   In the less severe cases of  this nature, and  when  the contrac-
 tion of the chest is not very considerable, after the complete  con-
 version of the false membranes into cartilage, the murmur of res-
 piration returns in a slight degree in the affected side, but still con-
 tinues less than in  the sound one.   This circumstance  points  out
 the  period of this conversion, and consequently the final  cure  of
 this  variety of pleurisy.  In the patient, from whom  Plates VI.
*and  VII. were designed, it was not until two years and half, to
 reckon from  the  invasion of the disease, or  a year  and  half,  to
 reckon from  the period of his convalescence, that respiration began
 to be perceptible in the upper parts of  the chest.  Sometimes the
 respiration returns  completely in* the superior  parts of the chest,
 while it is'entirely absent in the inferior.
   Circumscribed Pleurisy.  The absence of respiration in the af-
 fected part is the only sign  by  which the cylinder can indicate the
 circumscribed pleurisy; consequently it  cannot distinguish it from
 an extensive tumour  in the  lungs, or from chronic peripneumony.
 The difficulty, however,  will, in general, be removed by attending
 to the history and general symptoms of  the disease.
   As the Hippocratic Succussion of the chest affords  no indication
 of the simple pleurisy, I  shall not notice it in this place.  We shall

  * For an account of Mensuration of the Chest as a diagnostic sign in certain
 cases of both the acute and chronic pleurisy, see Part First. 
246
DIAGNOSIS.
afterwards find it described, and its importance proved, when we
come  to treat of the diagnosis,  of those  liquid effusions  into the
chest which are complicated with gaseous  fluids.—See Pneumo-
thorax.
                  HYDROTHORAX.

                     (Part I. Page 151.)

  The chief and almost sole symptom of this disease is impeded
respiration.   Percussion elicit? the dull sound, and the cylinder
detects the absence of respiration over the whole chest,  except at
the root of the lungs. I should expect that haegophonism must also
be sometimes present.  The nature of the general symptoms and
the progress  of the disease can alone  distinguish it from chronic
pleurisy.
                 HjEMA-THORAX.

                     (Part I. Page 155.)

  The cylinder and percussion afford the same indications in this
case as in the effusion of pleurisy.
         ACCIDENTAL  PRODUCTIONS.

                     (Part I. Page 156.)

  Extensive tumours may be distinguished from the effusion of
pleurisy and  hydrothorax by the  very  gradual  and  progressive 
PNEUMO-THORAX.                  241
diminution of the sound of respiration in the former; and from
peripneumony, by the  absence of* the crepitous  rattle  which  we
have  mentioned  as pathognomonic of this  affection  in its first
degree.
   Intestinal Hernia in the thorax will be readily distinguished, not
merely by the absence of  respiration in the site of the tumour, but
by the existence of borborygmi in a  situation superior to the region
of the stomach.
                 PNEUMO-THORAX.

                       (Part I. Page 159.)

  The general symptoms of  this affection are very obscure. Per-
cussion, by itself, tends but little to remove the obscurity, or even
misleads us.   When the gaseous effusion is very considerable, the
diseased side yields a more distinct sound than the sound one, and
may thus induce us to apprehend disease in the latter.  Dilatation
of the chest is, also, little to  be  depended on  as a diagnostic sign;
its existence together with an increase of sound on percussion, will
be apt to lead us to  fancy that the lesser volume  of the other  is
owing to a contraction of the latter.   In proof of the uncertainty
of all these signs I may mention, that out of several  cases  that
occurred,  during my attendance  at the clinical lectures of M. Cor-
visart, not one was recognised before death.
  The certain diagnosis of this  affection is afforded  by the com-
parison  of the results of percussion  and mediate  auscultation.
Whenever we find one side of the chest sounding more distinctly
than the other, and, at the  same time,  perceive the  respiration
veuy well in the least sonorous side and not at all on the other,—
we may be assured that there exists pneumo-thorax on the latter.
We may be equally sure of  our diagnosis when both sides  are
alike sonorous, and  even although the  affected side  were less
sonorous than the sound one. This latter case  occurs when  the
pneumo-thorax supervenes to pleuritic effusion, or any other fluid
extravasation.  Here, before the supervention of  the pneumo-
thorax, the affected side yielded  a perfectly  dull sound, and  the
respiration was either entirely  absent, or was heard  very  indis-
tinctly.   As soon as the gas begins to accumulate,  the resonance 
248                      DIAGNOSIS.

of the chest returns, in some degree, in the situation occupied by
the air, without, however, being as distinct as in the sound side.
Day by day, the extent and  intensity of this  resonance  increase,
without any return of the  sound of respiration; and if there had
previously be,en any remains of the respiratory murmur,  even this
now totally vanishes.
   There is only one circumstance which can render the  diagnosis
difficult in such cases: this is, the case of the lung being attach-
ed to the side by  means of a very short cellular  tissue;  in  the.
point of  adhesion  the  respiration will  be still audible.   It  is
hardly necessary to observe, that, in pneumo-thorax, as in pleurisy
and hydrothorax, some degree of  respiration will be still  percepti-
ble in  that part of the  back corresponding  to the  roots of  the
lungs.
  The only other disease which presents any  signs  analogous  to
the above is emphysema of the lungs.   The differences,  however,
between the two diseases  are so striking that none  but a very
inattentive observer could be  mistaken:   These  differences  are
chiefly the following: In pneumo-thorax,  the  absence of the  re-
spiratory  sound is complete, except in the  point between  the
scapula and spine  corresponding to  the  roots of the  lungs; in
emphysema, the'respiratory sound is never completely inaudible;
in the latter there  is a slight  rattle, and  never in the former:
pneumo-thorax comes on rapidly, and cannot continue  long with-
out giving  rise to  dangerous symptoms, or  even  proving  fatal;
emphysema comes on slowly  and is never so severe as to confine
the patient to bed or incapacitate him for his ordinary occupations.
I never saw a patient with pneumo-thorax that was not in bed.
  These indications exist  in  every case of pneumo-thorax; but
when it is accompanied by an effusion of fluid, there  is  observed
an absence  both of  resonance on percussion, and of respiration,
in the parts  occupied by the fluid; and  an absence of the res-
piration only, in the  parts occupied by the  gaseous  accumula-
tion.
  The precise  diagnosis of pneumo-thorax, and its existing in a
simple state or  complicated with liquid effusion, is not a merely
speculative subject.   It is extremely probable, as Hewson* and
Rullierf have  imagined, that  the simple pneumo-thorax  is the
case which offers  most  chance of success  to the  operation of
empyema,  or rather,  of  simple puncture of the thorax.   This
opinion is strengthened  by the  assertion of  Riolan,  that he  had

  * Med. Obs. & Inq. vol. 3.  .      -j- Diet, des Sc. Med. Art. Empyemp 
PNEUMO-THORAX.
249
met with several cases wherein air  alone had escaped from the
chest on its being punctured.*
  The stethoscope furnishes still another and very important  sign
for the diagnosis of this affection, which has been more than once
alluded to already, and which I shall now explain more particu-
larly;—I allude to the phenomenon  which I have  named Metal-
lic Tinkling.
  This phenomenon consists of a  peculiar sound  which bears a
striking resemblance to that emitted  by a cup  of metal, glass,  or
porcelain, when gently struck with a pin, or into  which a grain
of sand is dropped.   This sound does not at  all depend on the
nature of the materials  of which the stethoscope is composed:
it is  perceived during respiration, speaking,  and coughing; but is
much more perceptible during  the  two  latter than  the  former.
The reverse of  this is, however,  sometimes the case.   It is,  in
general, heard  in a  most striking  manner,  during  cough;  and
when in any degree  doubtful, this action ought to be performed?
It may exist either with or without pectoriloquism.
  This phenomenon  only exists in  that variety of the  pneumo-
thorax  complicated  with  empyema,  and which communicates
with the bronchia by means of a fistulous opening, as has been de-
scribed in Part First; and it may be considered as the pathogno-
monic sign of  this  triple lesion.   This peculiar  sound seems
caused  by the agitation of  the air confined between the surface of
the puriform fluid and the solid parietes.   The sound  is in general
distinct in  proportion to  the  size of the fistula  communicating
with  the bronchia;  and,  also, in proportion  to  the volume of gas
contained in the cavity of the chest.
  When the tinkling originates in a  large tuberculous excavation
in the lung, half-filled by purulent matter, it is less  intense, and
its vibrations are confined to a small space: it,  also, seems  to
penetrate  the tube of the  cylinder, and  is conjoined  with  pecto-
riloquism.   All these peculiarities will distinguish this case  from
pneumo-thorax, setting aside the little resemblance that exists be-
tween the general symptoms of the two  complaints.    I have  only
observed the metallic tinkling  four  times in tuberculous  excava-
tions.
   There exists  still another means of ascertaining the existence,
during life, of  the pneumo-thorax complicated with   purulent ef-
fusion, which I have also several times alluded to in the first  part
of this work—I mean  the exciting the sound of fluctuation  by

                         * Enchirid. Anat.
                              32 
250
DIAGNOSIS.
 the succussion of the  chest.  This  method was practised by
 Hippocrates, or his disciples, and is  described  by the  author of
 the treatise DeMorbis  in the following words:   "After  having
 placed the patient in  a  solid  chair that will not vacillate, cause
 his bands to be extended by an assistant, and  hen shake him by
 the shoulder, in order that you may hear on which side the disease
 will occasion  noise."   Although  this  method is described  in  a
 work  not  unanimously attributed to Hippocrates, there can  be
 little douht of its having been known to him.   Several passages
 in the  Hippocratic writings either speak of  it formally,  or allude
 to it;  and it is uniformly represented  as a  certain  test of empy-
 ema.   The incorrectness  of this representation, doubtless, has
 been the cause of the practice being abandoned by practical men,
 and never had recourse to  even by the commentators of Hippo-
 crates.   The authors  of treatises  of Surgery have, indeed, men-
 tioned  it,  but doubtfully,  and rather out of respect for Hippo-
 crates  than for any other reason.  I  am unacquainted with any
 author who  says he  himself had tried the  method  in  question.
 A few mention the phenomenon as having been  observed in cer-
v tain cases during the spontaneous movement of the chest.   Mor-
 gagni observed this once, and has  collected  four other  instances
 of the same  fact mentioned  by preceding  authors (Epist. xvi.}.
 A similar case is mentioned by Ambrose  Pare.*  None of these
 observers appear to have tried if artificial commotion of the chest,
 in  these cases,  would  produce the phenomenon; and  Morgagni
 and Fanton even attempt to prove that the practice can  be of no
 benefit as a means of diagnosis.
    This opinion is, indeed,  correct as  far as it regards the  simple
 liquid  extravasation, as in hydrothorax, and empyema  uncompli-
 cated  with pneumo-thorax   In this  complication, however, the
 fluctua'ion of the liquid is distinctly heard on shaking the  patient
 in the  manner of Hippocrates.   Sometimes, also, but much  more
 rarely, the motion of  the patfent  in bed, or  in walking,  gives rise
 to it, so  as to be heard  both by him and the bystanders.
    M>rgagni has expressed  an opinion that  this succussion might
 be dangerous.  This, however, is totally unfounded.  When pro-
 perly used, it is not more fatiguing to the  patient than the percus-
 sion of the chest, or the examination of the  abdomen  by compres-
 sing its contents.  To enable us to hear the sound it  is  not neces-
 sary to shake the body  much; all that is required being merely to
 shake  the shoulder  pretty quickly and to  stop  all  at once.  In
* CEuvres, liv. viii. ch. x. 
PNEUMO-THORAX.
251
several of the cases detailed in Part First,  this means was suc-
cessfully used as a test of this  peculiar complication of disease.
(See  Cases 34, 36,  37,  38).   In some instances  the sound  of
fluctuation will be  perceived by the cylinder when inaudible by
the unassisted ear. 
252                   0F THE HEART.
OF  THE HEART.
 OF THE ACTION OF THE HEART IN GENERAL, IN HEALTH
                       AND DISEASE.


  Before entering upon the diagnostic signs furnished by the
stethoscope in particular diseases of the heart, it will be necessary
to examine the general results afforded by it, as well in the sound
as diseased state of that organ.   I shall do this under  four prin-
cipal heads, viz. 1st, the extent of the heart's action,  as ascer-
tained by the cylinder; 2nd, the.shock or impulse  communicated;
3rd, the nature and intensity of the sound; and, 4th, the rythm of
its actions.


        /.   Of the extent of  the Pulsation of the  Heart.

  This must be  considered in two points of view:—first, the sen-
sation conveyed by the instrument when applied  to the region of
the heart;  and, secondly, the  parts of the chest  (other than this
region) in which its action can  be perceived.
   1. In the natural condition of the organ,  the heart,  examined
between the cartilages of the fifth and sixth ribs, and at the lower end
of the sternum,  communicates, by its motions, a sensation as if it
corresponded evidently with a small point of the thoracic parietes,
not  larger than  that occupied by the end of the stethoscope.
Sometimes, it appears as if it were placed deep in the mediasti-
nal cavity, leaving a vacant space between it and the sternum: in
this case its movements,  even  when  pretty  energetic,  appear to
communicate no vibratory impulse to the neighbouring parts.  In
other cases, again, the heart seems entirely to fill  the cavity of the
mediastinum, and to extend much beyond the point on  which the
instrument rests;  and, in this  case, its contractions, even  when 
EXTENT OF PULSATION.
253
slow  and noiseless, seem to elevate,  to  a considerable extent,
the thoracic parietes before them,  and to displace  the  adjacent
viscera within.   This difference of sensation seems, in a  word, to
convey the impression of the action of a smaller or a larger heart;
and,  generally speaking,  this  indication  is  sufficiently  correct,
when the organ is examined in  the state of quietude which  results
simply from repose of body.
   2.  The second point is  of more practical  importance.   In a
healthy person, of moderate fulness, and whose heart is well propor-
tioned, the pulsation of this organ is only perceived in the cardiac
region, that is, in the space comprised  between  the cartilages of
the fifth and seventh  ribs, and under the lower end of the sternum.
The motions of the left cavities of the heart are  chiefly  percepti-
ble in the former position, those of the right cavities in the latter.
This is so much the case, that,  in disease  of one  side of  the heart
only, the pulsation in these two situations gives quite different re-
sults.   When  the  sternum is short,  the pulsations extend to the
epigastrium.   In very fat subjects,  the  pulsation  of  whose hearts
is quite imperceptible to the mere touch, the space in which it can
be detected  by the cylinder is  sometimes  not more than an inch
square.   In thin persons, in  the  narrow-chested,  and, also, in
children, the pulsation is more  extended;  being  perceptible over
 the lower third,  or even  three-fourths, of  the sternum, and some-
 times even over  the  whole of this bone; also  at the superior part
 of the left side,  as high as the clavicle,  and sometimes,  though
 feebly, under the right clavicle.
   When the pulsations are confined to the places above  mention-
 ed, in subjects  of the kind noticed, and when they are much
 weaker below the clavicles than in the region of the heart, we
 may conclude  that this viscus is well proportioned.
    When the pulsations of the  heart become more extended, they
 are heard successively in the following places:—1st, the whole
 left side of  the  chest, from the axilla to  the stomach;  2nd, the
 whole of the right side; 3rd, the posterior part of the left side of
 the chest; and, 4th,  the  posterior part of the right side.  This last
 is rare.  In these cases  the intensity of the sound is progressively
 less  in the succession mentioned.   This succession  has  appeared
 to be constant, and may be taken as an index of  the extent of pul-
 sation.  For  instance, if this be perceptible on the right side, we
 may be assured that  it will be  equally so over the whole  sternum
 under both  clavicles, and over  the left side; but  we are  not sure
 that it will  be so on the back.  But if it be perceptible on the back 
254
OF THE HEART,
 on the right side, we may calculate on its being still more audible
 in ev^ry other part of the chest.
    Several circumstances unconnected with the state of the heart
 may derange the order above mentioned, and augment  the extent
 of the pulsation.   This latter effect is produced by a hepatized or
 compressed  lung, and also by a part containing tuberculous excava-
 tions. In every case the heart gives two distinct  pulsations for one
 beat of the arterial  pulse.   In my examinations of several  hundred
 individuals,  I have only met with one in whom the pulsation of the
 subclavian arteries could be heard by the stethoscope;  and I may
 state it is an almost universal fact, that neither the pulsation of this
 artery, nor of the aorta, can be mistaken for that of the heart.
   When the pulsation of the heart is heard over a greater extent
 than what is above stated  to be the range of a well proportioned
 organ, the individual rarely enjoys good health.   If he  has  not
 formal dyspnoea, he has, at least, shorter breath  than usual, is put
 more easily out of breath, and  is more subject to palpitation. This
 state, however,  which  is that  of many  asthmatics, may  remain
 stationary many years, and does not always prevent the  attainment
 of an advanced age.
   With regard to the relation between the state of  the  heart  and
 the extent of its pulsation, I think it  may be  taken as  a  general
 fact, that the extent of  pulsation is in the direct  ratio of the thin-
 ness and weakness of the heart, and  consequently, inversely as its
 thickness and strength.  The size of the organ must also  be con-
 sidered as affecting the extent of its pulsation.
   In explanation of what has been just stated, we  may presume,
 when the pulsation extends over all the places above  mentioned,
 that the  heart is increased beyond the natural size,  and that  this
 increase is owing to the dilatation  of one or both ventricles.  This
presumption  will be strengthened, if  the pulsation  is as great un-
der the clavicles or in the axilla, as in the region of the heart.  If
the pulsation is perceived neither in the  back nor right side, but
only in the other points mentioned, and if its intensity is  nearly
equal in  all these, we may  conclude that the  ventricles  are mode-
rately dilated, and that the parietes of the heart are naturally thin.
On the contrary, when there is very strong pulsation in  the region
of the heart, and none or very little under the  clavicle, we may
be assured (if the patient has other general symptoms of diseased
heart) that the disease is hypertrophia of the ventricles.   If the
patient has never experienced any marked disorder of the circula-
tory organs, we may be certain that the parietes of the left  ventri- 
IMPULSE ON THE EAR                Z6b
cle are  much thickened, though still not sufficient  to  constitute
disease.
   Generally speaking, then, it may be taken  for  granted  that a
great extent of pulsation is a mark of thin  parietes of the heart,
more particularly of the ventricles; and that a confined range of
pulsation coincides with an increased thickness  of these.  Some
accidental causes may augment for a time the  extent of the heart's
pulsation, such as nervous agitation, fever, palpitation, haemoptysis,
and, in  general, whatever increases the frequency of the pulse.


II. Of the Impulse communicated to the Ear by  the Action of the
                             Heart.

   In investigating this we must be careful not to confound with the
action of the heart, the rise of the thoracic parietes during inspi-
ration.   This caution is more particularly necessary when the res-
piration is very short and frequent.
   The  degree  of impulse communicated by  the  cylinder to the
ear, is,  in general, inversely as the extent of the pulsation of the
heart, and directly as  the thickness of the walls of the ventricles.
In a person whose organs of circulation are well proportioned, this
impulse is very little perceptible, often quite imperceptible, espe-
cially if the individual is rather fat.  When  the  parietes of the
heart are unnaturally thick, the impulse  is usually so great  as very
sensibly to elevate the head of the observer, and sometimes to give
a  disagreeable shock to the ear.  The more intense the hypertro-
phia, the longer time the impulse is perceptible.   When the dis-
ease exists in a high degree, we feel as if  the heart, in dilating,
first comes  in contact  with the thoracic parietes in one point  only,
and then with its whole surface, and that  it contracts and falls back
all at once.   The impulse  of the heart is only felt during the sys-
tole of  the  ventricles; or if, in some rare cases,  an analogous phe-
nomenon accompanies the contraction of  the auricles, this is easily
distinguished from the former.   I,n fact,  when the  systole of the
auricles is attended by any sensible action, this is perceived to have
its seat much  deeper; and most commonly it  consists merely of a
sort of  vibration.  In any case, it is very  little marked as compar-
ed with the sensation produced by the contraction of the ventricles,
 when these are of a good degree of  thickness..
   When the parietes of the heart  are thinner than usual,  no im-
pulse is communicated,  even when  the  pulsation is the greatest;
and, in this case, the  alternate  contraction of  its cavities is only 
256
OF THE HEART.
distinguished  by the  sound these produce.   A  strong  impulse,
therefore, must be regarded as  the chief sign of hypertrophia; and
the absence of all impulse as the characteristic  of dilatation  of
the heart.  The correctness and  constancy  of this result have
been confirmed to me  by many examples.
   The  impulse of the heart's action is usually perceptible only
over the region of the  heart, or, at most,  over the inferior half of
the sternum.  When  very great, it extends to the  epigastrium in
cases where the sternum  is short.   In  simple hypertrophia it is
usually  perceived  in  no other part; but  when this is conjoined
with a certain degree of dilatation, it is sometimes distinctly per-
ceived under the  clavicles,  and in the right side  of the chest.
The impulse of the heart's  action  is, of course, diminished by
whatever debilitates the general strength of the system.


     ///. Of the Sound produced by the Action of the Heart.

   The   alternate  contraction  of the different parts  of the  heart
produces a  peculiar sound,  of which  the individual  is  himself
sensible during  palpitation  and in  fever.   In certain states  of
disease  it can be heard at some distance from the patient; but this
is a very rare case.  The sound  is the only phenomenon  usually
observable in any other part  of the  chest  beside  Ihe  precordial;
the impulse of  its action being confined, as already observed,  to
that part.
   The  sound produced by  the  action of the heart is great  in pro-
portion  as the parietes of the ventricles are thin and their impulse
feeble:  consequently,  it cannot be attributed to the  percussion  of
this organ against the  side.   In a moderate  degree  of hypertro-
phia, the contraction  of the ventricles yields only a dull  sound,
like the murmur of inspiration, and  the  auricle, in like  manner,
a much  less noise than in the natural  state.   In a high degree  of
hypertrophia, the contraction of the ventricles produces merely a
shock without any sound, and the sound of the auricles is scarcely
audible.  On the other hand,  when  the ventricular parietes  are
thin, the noise  produced by their  contraction is clear and  loud,
approaching to that of the auricles;  and if there  be a  marked
dilatation of the ventricles, the sound becomes very similar, and
almost  as strong as that of the auricles.
   In the state of health the sound of the contractions of the heart
is no where heard so  strongly  as in the region  of the  heart.   In 
RYTHM OF PULSATION.                257
certain states of disease it may be  heard more  distinctly in other
places.
  The softening of the substance of the heart deadens the sound
of its contractions; as does also any impediment of the circulation,
whether caused by too much blood, or by an obstacle in the auri-
culo-ventricular orifices   This latter state,  further, gives rise to a
dull  rustling  sound, very like  the noise of bellows,  or (when
stronger) like  that produced by the action of a file on wood. The
particular orifice  affected is, in  this case, indicated  by the  place
and time  in  which  the sound is observed.  When the orifice is
on the left side, we  can sometimes feel with the hand a sort of
vibratory sensation like that produced  b\  the  purring of a cat.
In this case, the noise produced by the  contraction of  the  cavity
having the obstructed orifice is not only duller, but  much  more
prolonged than inMhe" natural state.
        IV.  Of the Rythm of the Pulsations of the Heart.

   By rythm I understand the order of the  contractions of differ-
 ent parts of the heart, and their relative  duration and succession,
 as detected by the  cylinder.   Before entering on  this subject I
 think it necessary to notice the relative  proportions  of the heart
 to the  body of the  individual,  and of the  different parts of the
 heart to  each other, in a state of health,  and in a well propor-
 tioned subject.
   The  heart, including  the  auricles,  ought to be of  a size equal
 to the closed  hand of the subject, or only  a little less or  greater
 than  it.  The walls of  the left ventricle ought to be of  a thick-
 ness somewhat more than double that of the right.   The  texture
 of the left ventricle, firmer and more  compact than  that of the
 muscles, ought to keep it from collapsing when laid open.   The
 right ventricle ought to be a little larger than the left,  with colum-
 nae carneae of greater size, and ought to collapse  on being  cut
 into.   In a heart so proportioned, the alternate contractions of the
 ventricles  and auricles,  as  examined  by the  cylinder,  and  the
 pulse as examined by the finger, afford the following results:—
  At the moment of the arterial pulse, the ear is slightly elevated
 by an isochronous motion  of the heart, which is accompanied by
 a somewhat dull, though distinct sound.  This is the  contraction
of the ventricles.   Immediately after, and  without any interval,
 a noise resembling that of a valve, or a whip, or the lapping of a
dog, announces the contraction of the  auricles.   (I  make  use of
                              33 
258
OF THE HEART.
these trivial expressions  because* they appear to me to express,
better than any description, the nature of the sound in question.)
This  noise  is accompanied by no  motion perceptible by the ear,
and is separated by.no  interval of repose from  the  duller sound
and motion  indicative  of  the contraction of. the  ventricles, which
it seems, as it were, to interrupt abruptly.   The duration of this
sound, and consequently the period of contraction of the auricles,
is less than that of the ventricles,—an incontestible fact  of which
Haller entertained doubts.  Immediately after  the systole  of  the
auricles there is a very short, yet  well-marked interval of repose,
subsequently to which  we feel  the  ventricles swell anew, with  the
dull sound and gradual  progression which characterise their action;
then follows the quick  and sonorous  contraction  of the  auricles,
and again  the renewed  but  momentary immobility of  the heart.
This state of quietude  after  the contraction  of 4he  auricles does
not appear to have  been  known to Haller  as a natural  condition.
The relative duration of  the contractions of the auricles and ven-
tricles, appears to me to be as  follows:  Dividing the whole into
four parts, a fourth (or third) belongs to the systole of the auricles,
a fourth (or somewhat less) to the state of quiescence, and two-
fourths to the systole of  the ventricles.—These observations  are
most conveniently made when the  pulse is slow.
   From the  foregoing observations it appears that  the  heart, far
from being in a state  of. constant action,  as is usually supposed,
presents alternations of action and repose,  the sum  of which does .
not differ from those of many other muscles, more  especially the
diaphragm and intercostal muscles.  From the  proportions above
stated it  follows that  in   twenty-four  hours the ventricles have
twelve, and the auricles eighteen  hours of  quiescence. In persons
whose  pulse is habitually below 50, the repose of the ventricles
 is more  than sixteen hours in  the  four-and-twenty.
   Hypertrophia of the ventricles, when  in  a  moderate degree,
 presents, in some respects, an exaggeration of the natural rythm
of  the heart's actions.  The contraction of the ventricles becomes
 less noisy, and more readily distinguishable from that of the auri-
 cles.   After the latter, the interval of quiescence is well-marked,
 and contrasts very sensibly with the  sound that precedes, and the
 motion which follows it.  But in hypertrophia  carried to a very
 nigh degree the  rythm of the  heart is  singularly changed.
    In this case,  the contraction  of the ventricles is greatly pro-
 longed.  This at  first is  perceived as a  profound  and obscure
 motion, which gradually  augments, elevates the applied ear,  and
 then terminates  in producing the impulse or shock.   This con- 
RYTHM OF PULSATION.               259
 traction is unaccompanied by any noise, or, if this exists,  it is
 merely a sort of murmur like that of respiration.
   The contraction of the auricles is extremely short, and  almost,
 or altogether, without sound; and in some cases the systole of the
 ventricles seems scarcely over  before they begin to swell afresh.
   In  extreme cases there  is  no sound  distinguishable but the
 murmur above mentioned, and we merely recognise an  elevation
 of the heart corresponding to each  beat  of the pulse.   In  these
 cases  the increased brevity of the auricular contraction  is not the
 consequence of their diminished contractibility  merely,  but, also,
 of their contraction commencing before that of  the ventricles has
 entirely ceased.
   When the walls of the left ventricle are naturally thin, or have
 become so  from dilatation,  the rythm  of the  heart's  actions  is
 quite different.   In this case, the interval of repose after the con-
 traction of the auricles is no longer perceptible.  The contraction
 of the ventricles is more sonorous,  more  resembling that of the
 auricles,  and more approaching the latter in duration.   In this
 condition of the heart, there is, as already observed, a less degree
 of impulse during the contraction of the ventricles,  and a  greater
 extent in the pulsation of the heart.   This condition of the organ
 of circulation is congenital in many cases.   It does  not necessa-
 rily abridge  life, but is usually conjoined with  a delicate  consti-
 tution.
   Actual dilatation of the heart produces  merely an increase of
 all the characters which indicate a heart with thin parietes.  The
 contraction of the ventricles becomes as short  and  noisy as that
 of the auricles;  the  pulse,  consequently, becomes very  frequent;
 and  the isochronism of the arterial pulse and the contraction of
 the ventricles  becomes quite indistinguishable.  In addition to
 these signs  we must add—the  absence  of any  sensible  impulse;
 the extension of the heart's pulsation  over  the  whole or  greater
 part  of the chest; and the existence of this in as  great force under
the clavicles and the  axilla as  in the region  of the  heart itself.
This last  character, particularly, may be regarded  as pathogno-
 monic, if the patient is not phthisical and pectoriloquous  in th<;
places mentioned.
* 
260
OF THE HEAR!
                V.  Of Palpitation of the Heart.

   By palpitation of the  heart is meant, in the common language
of medicine, every beating of the heart which is sensible and un-
pleasant to the individual, and, at the same  time,  more  frequent
than natural.   When this affection  is  studied  by the aid  of the
cylinder, we find that there are many varieties of it, all of which
appear  to  have  merely this one character  in common, viz. that
the individual is sensible of the heart's action.  Frequently, also,
the patient hears the  pulsation, especially when in the horizontal
posiure.   In the upright position, the contraction of the ventricles
only is heard; while, when  lying on the  side, the  individual is
sensible of a pulsation of his ear double  that  of  the pulse, viz.
the alternate contraction of both the ventricles and auricles.   In
many cases th^re is merely an increased  frequency of pulsation,
although the patient imagines, from his sensations, that there is
a.rso great increase of force.  This species'  of palpitation is most
common in dilatation  of the ventricles, and lasts  the longest  of
any.  I have known  it continue eight days;  the pulse remain-
ing, through  the whole  of this time,  extremely small  and  weak,
and between lf>0 and  180.
   Another variety consists in an increase both of frequency and
force  of pulsation   This is what arises in  healthy persons from
great exertion or from moral  causes;  it also accompanies slight
degrees of hypertrophia. In simple hypertrophia in a high degree,
the ventricles are found to contract with great force, and to elevate
the thoracic parietes in an extent and  to a  height  much greater
than natural.   The noise, however, produced by their contraction
is much duller and more indistinct than usual;  the  extent  of tho-
rax over which the  pulsation is  perceptible  is  not increased; and,
notwithstanding the increase of  the heart's  power to double  or
triple its ordinary force, the pulse is, almost  always, two or three
times more feeble and smaller than in the natural condition of the
circulation.   In  hypertrophia with dilatation, the impulse, noise,
and extent of the heart's action, are usually  equally increased.
V 
INTERMISSION OF PULSATION.            261
           VI.   Of Irregularity of the HearVs Action.

  Irregularity  in the pulsation of the heart may exist  without
palpitation   In old persons this is often  met  with  without any
perceptible  alteration  of the general health.  The irregularity
which occurs in palpitation consists usually in mere variations in
the  frequency of the heart's pulsation.  Sometimes this variation
is almost consiantly recurring; at other times it is at longer inter-
vals, and consists  only of  a  few  contractions longer or shorter
than the rest.   These irregularites occur most frequently  in cases
of dilatation.
  In hypertrophia, and  during  the  existence of palpitation,  the
contractions of the ventricles are so quick, and so much prolong-
ed, that those of the auricles cannot be perceived.  It sometimes,
though  very rarely, happens during palpitation, that each contrac-
tion of  the ventricles  is followed by  several  successive contract
tions of the auricles,  so quick as only  to  equal in point of time
one ordinary contraction.   Sometimes  these contractions  are two
or four, .but most frequently three.


        VII.   Intermission of the Pulsation of the Heart.

  By intermissioji, we usually understand a sudden and momen-
tary suspension of the pulse, during which the artery is no longer
perceptible beneath the finger.   The duration of the  intermission
is very  variable, and  may serve to divide this affection  into well-
marked  varieties.  Sometimes  the intermission  is  shorter than
one arterial pulsation; sometimes it is equal; and  sometimes it is
longer.
  The  first kind of intermission is the most common;  it is fre-
quent in old age, even during health.   At  other  periods of life,
it is only observed in certain  diseased  states of the  heart,  parti-
cularly  hypertrophia.    By means of the  stethoscope we ascertain
that this species of intermission  always succeeds the contraction
of the auricles.  It, therefore, only differs /rom the  natural qui-
escence after this contraction, in the irregularity of its recurrence.
The duration and  recurrence of  this species of suspension of  the 
262
OF THE HEART.
 heart's action are  very  variable.   This,  the real  intermission,
 must be distinguished from the false intermission, already noticed,
 produced by  the variation  of  the duration and  strength of the
 heart's contractions.   This can easily be  done  by the  cylinder.
 The species of intermission  which consists in the  absence of one
 complete pulsation, returning sometimes with an exact periodicity
 at longer or  shorter  intervals,  constitutes  the  sign  deemed by
 Solano indicative of the approach  of critical  diarrhoea.   The
 third variety is  accompanied by  a  state of fulness of the artery
 during its continuance.                              t
   Many considerations,  some of  which have  been stated, prove
 that the mere examination of the  pulse is insufficient to inform us
 of the true state of the circulation;  and must  often lead us  into
 error.—To  notice only the indications afforded by it as to blood-
 letting, to prognosis  in all  diseases, and to diagnosis in several:—
   We have seen, that, in peripneumony and pleurisy, the absence
 of fever and  a  perfectly  natural state  of the pulse,  frequently
 accompany an incurable  disease.   In diseases of  the  heart, the
 pulse is often  feeble, sometimes  even  almost  imperceptible^ al-
 though the heart's contraction, that  especially of the  left ventri-
 cle, is much more energetic than natural.   In apoplexy, on the
 contrary, we often meet  with a very  strong  pulse  in  persons in
 whom  the  impulse of the  heart's action  is  scarcely  observable.
These two opposite facts may easily be  verified by  the use of
 the cylinder;  I have myself  done so, perhaps more than a thou-
 sand times,  within the last three years.   They appear  quite in-
 explicable, unless we admit  the  arteries  to  possess  a  power of
 action independent of that of the  heart.
   It would seem to be proved, also, by many other facts, that the
 different systems  subservient to  the  circulation,  although neces-
 sarily and reciprocally dependent, have still, in other  respects, a
 particular or individual existence, which, in certain states of  dis-
 ease and in  certain  individuals, is more marked and isolated than
in ordinary  cases  and circumstances.  This view of the case is
supported by the  observations of  practitioners,  in  all ages, of the
 different effects of bleeding, according as  it  is  general  or local,
venous or arterial, depletive or derivative.   The same is shown by
the great  benefit of  a natural hemorrhage of a few ounces only,
 and the ineflicacy of  copious venesection  in the same case;  and
by the trifling degree of exhaustion produced sometimes by very
profuse hemorrhage,  campared with the great collapse occasioned
by the  bleeding of a  few leeches in the same person.  These
facts prove, I  think, that the capillary circulation is in  some  sort 
INTERMISSION OF  PULSATION.
263
independent of the general.   The influence of the latter on the
former  seems very inconsiderable indeed in certain  hemorrhages
from the uterus, bowels,  nose or  lungs, which are  found to be
very little affected by the most copious venesection.
   The mere state of the  pulse,  then, is far from  indicating the
State of the circulation in general; it does  not even  certainly in-
dicate its condition in the whole heart,  as  it merely  corresponds
with the contraction of the left ventricle, which may be regular
at the tune when that of the auricles and right ventricle  is irre-
gular.   In like manner, the state of the pulse  fails to be a  sure
guide as to the expediency of blood-letting.  Every one knows
that in certain cases, for instance in  apoplexy,  peripneumony,
pleurisy, and inflammatory affections of  the  abdomen, the weak-
ness and smallness of the pulse  do  not always  contra-indicate
venesection;  on the contrary, that the artery, in such cases, re-
covers its force and fulness after the  loss of blood.   The recog-
nition of this  kind of pulse  (fictitiS  debilis) is one  of the  most
important and difficult  points  in  the  treatment of the acute dis-
eases, as an error in respect of it may be fatal.  In  cases of this
sort, the stethoscope affords a  rule much   surer than  the pulse.
Whenever  the contraction of the ventricles is energetic  we  may
bleed without fear,—the pulse will rise; but if the  contractions
of the heart are feeble, although the pulse  still retains  a certain
degree of strength, we must  be cautious respecting  the  employ-
ment of  venesection.  When the pulse  is  very strong,  and the
contractions of the heart moderately strong (as is  frequently the
case in apoplexy), we may still bleed  with  advantage as long as
there  is not a marked diminution in the  noise and  impulse of the
heart's actions.  But when both the pulse and the  heart  are  fee-
ble, we  must not open a vein, whatever  be  the  name  or  the  seat
of the disease, as such practice must  infallibly destroy  the  few
resources still left to nature.   The most we can do, in such a case
if there  be any local congestion, is, to try, by the application of a
few  leeches,  if the  patient can  bear  the subtraction of blood
from the capillaries.
   The certainly and facility with which the cylinder  indicates the
propriety of blood-letting  in such cases as those above mentioned
(which  have been hitherto considered  among the most difficult in
practical medicine,) appears to me  to be  the greatest  advantage
to be derived from  the employment of this instrument.
   After  what has  been said,  and after its general   uncertainty
avowed by the most experienced practitioners, it may seem sur-
prising that the practice of feeling the pulse has been so generally 
264
DIAGNOSIS.
followed in all  ages.   The reason  of the  practice is, however,
sufficiently obvious: it is of  easy performance, and gives little in-
convenience either to the physician or patient; the cleverest, it is
true, can derive from it but  a few  indications and  uncertain  con-
jectures; but the most ignorant  can, without exposing themselves,
deduce from it all sorts  of indications.   lis very uncertainty gives
it a preference with persons of  inferior qualifications, over means
quite certain in their nature,  and which enable the non-professional
observer to judge of the skill of the physician by the correctness
of his diagnosis and  prognosis.
  The facts above stated relative to the discordance existing be-
tween the pulsation of the heart and of the  arteries,—more espe-
cially as to strength, are contrary to. the more general opinion  of
modern physiologists, who consider the  action of  the arteries  as
entirely dependent on that of the heart.  Bichat himself has fallen
into this error.*
     OF SYMPTOMS COMMON TO  ALL THE DIS-
                 EASES OF THE  HEART.

  These are—an habitually short and difficult respiration;  pal-
pitations and oppression constantly produced by the  action of as-
cending, by quick walking, by emotions of mind,—or without any
perceptible cause; frightful dreams, and sleep frequently disturbed
by sudden starts; a cachectic paleness and a tendency to anasarca,
which, indeed, comes on after the disease has persisted some time.
To  these symptoms  is frequently  added the angina pectoris,—a
nervous affection characterised by a sense of oppression, constric-
tion and onpression in the  region of the heart, and  a pain or numb-
ness of the arm, more commonly of the left, sometimes of both at
once.  When the disease has reached a high degree it  is recognised
at a single  glance.   The patient, unable to bear the horizontal
posture,  remains  night and  day  seated in his bed, with the  face
more or  less swollen, sometimes  very  pale, but more  commonly of
a deep violet  tint, either  over the  whole or only on the  cheeks.
The lips are swollen  and  prominent, of a deeper  violet than the

              * Anat. Gener. Ire part. torn. II. page 371. 
DISEASES OF THE HEART.
265
rest of the face, or of this hue when it is quite pale.  The whole
body is more or less anasarcous.  The  congestion and  lentor of
the capillary circulation are further shown by affections of the in-
ternal  organs;  for instance—haemoptysis, pains of the stomach,
vomiting, apoplexy (which frequently terminates such affections),
and most of all, dyspnoea, which last symptom has  been  the cause
of confounding  such  diseases (with many others) under the name
of Asthma.  Emphysema of the  lungs likewise bears much resem-
blance to some  varieties of disease of the heart, but the following
marks  will distinguish them  from each other.
   In disease of the heart, the patient, although with the respiration
habitually short, does not usually experience the feeling of oppres-
sion and dyspnoea, except  when walking rather quick,  or using
much exertion, or, more particularly, when ascending an elevation.
   On the other hand,  the individuals affected  with  emphysema,
become oppressed  on the breath when  they  are quite still:  and
these attacks recur without any known cause,  or from a slight
change  of  the  weather.   Moderate  exercise seems  often- to  re-
lieve  them, if  the disease has not reached a great degree of in-
tensity.
   In diseases of the  heart the general circulation is not always so
much affected  as  the capillary.  Sometimes  the pulse  is almost
natural, but is often irregular.—At all events, it is evident that none
of the  general symptoms already mentioned suffice to characterise
disease of the heart;  and that for a certain diagnosis we must recur
to mediate auscultation.   It is necessary here to remark that the
study of the physiological  conditions of the  heart, by  means of
the cylinder, requires much  more time  and  application than  that
of the voice and respiration.   In hospital practice, also, owing to
our general ignorance of the anterior history of patients, we  are
liable to be led into error  by its use, without proper care.   For
example, we may, in some  cases, consider a  patient  as labouring
under  hypertrophia or dilatation of the  heart, when he is merely
affected with nervous palpitations.  Another, and more  insidious
cause of mistake, arises in diseases  which diminish the  extent of
respiration; for instance, peripneumony, emphysema,  and more
particularly chronic  pleurisy.  In cases of this kind I  have some-
limes found the heart enormously dilated and thickened after death,
although,  during life, its contractions had been perfectly natural
in respect of sound,  impulse and rythm.  It would seem as if the
diminished capaciiy of the lungs produced a diminished action of
the heart. The  fact here alluded to was observable  in cases 6, 19,
                            34 
266
DIAGNOSIS.
21, and 23.  Cases of this kind are, however, rare,  even in an
hospital; in private practice, the previous history of the disease will
generally prevent us from being misled.
    HYPERTROPHIA OF THE  LEFT VENTRICLE.

                       (Part I. Page 165.)

  It is to this variety of the disease, especially, that the symptoms
attributed by M. Corvisart to active aneurism of the heart, must be
referred.  These  are,—a strong full pulse, strong and obvious pul-
sation of the heart, absence or diminution of the sound afforded by
percussion on the region of the  heart, and a  tint of complexion
rather red than violet. None of these symptoms,'however, are con-
stant; and it is not uncommon to  find the  disease in  persons who
have none of  them.   The  pulse, in particular, is  very deceptive,
being almost as frequently weak as strong,  in such cases.
  The cylinder furnishes  signs  which  are much more  constant
and positive.   The contraction  of  the left ventricle, examined
between the cartilages  of  the fifth and sixth  ribs, gives a very
strong impulse, and is accompanied by a duller sound than natural;
it is more prolonged  in portion as the thickening is more consider-
able.   The contraction of  the auricle is very short, productive of
little sound, and, consequently,  scarcely  perceptible in  extreme
cases.   The pulsation of the heart is confined to a small extent,
being, in general, scarcely perceptible under the left clavicle, or
at the top of the sternum; sometimes if is confined  to the  point
between the cartilages of the fifth and seventh ribs. In this disease
the patient experiences, more  constantly than in any other, the
sensation  of the action of the heart;  but he is less subject to
violent attacks of palpitation, except from accidental causes, such
as  moral affections  and violent  bodily  exertion.  In this  case,
during the palpitations, irregularity and intermission of  the pulse
are uncommon: there is rather increase  of the  power of the ventri-
cles than of the noise produced by their action. 
HYPERTROPHIA OF THE VENTRICLES.        267
    HYPERTROPHIA  OF THE RIGHT VENTRICLE.

                       (Part I. Page 165.)

   According to M. Corvisart, the symptoms are the same as when
 the disease is on the other side, only that the respiration is more
 oppressed, and the colour of the face is deeper.  Lancisi has men-
 tioned the swelling  of the external jugular veins, with a pulsation
 analogous to that of an artery, as a  sign  of the aneurism of the
 right ventricle.  M. Corvisart has rejected this symptom, because,
 he says, " it has been found in cases where the  left side of the
 heart was dilated, and because the pulsation may be  confounded
 with  that of  the carotids."  In this opinion I differ from M. Cor-
 visart.   I have uniformly found this symptom in every case of this
 kind, of any degree of severity; and I have never met with it  in
 hypertrophia of the left ventricle unless there existed,  at the same
 time, a similar  affection of the right   I think a very little atten-
 tion must distinguish this pulsation from that of the  carotids.   I
 would, therefore, be disposed to regard this symptom as one which
 ought to lead us to  suspect the existence of the thickening of the
 right ventricle.
   The contractions of the heart, as explored by the cylinder, give
 the same results nearly, whether the hypertrophia  be on the right
 or left side; only, in the former case, the shock of the  heart's ac-
 tion is greater at the bottom  of the sternum than between the car-
tilages of the ribs,  which is the reverse  of what  happens when
the disease is in the left side of the organ. In most men, in health,
 the heart is heard equally in both these places; and I am disposed
to believe, when heard better below the sternum, we may suspect
an  incipient  hypertrophia or  dilatation  of the right ventricle.
 When both ventricles are affected, the symptoms of both  coexist,
 only those of the right side are almost always more marked. 
368                     DIAGNOSIS,
      DILATATION OF THE LEFT VENTRICLE.


                      (Part I. Page 167.)

   The symptoms of this affection, according to M.  Corvisart, are
■—" a soft and weak pulse, and feeble palpitations:—the hand ap-
plied to the region of  the heart feels as if a soft  body elevated
the ribs, and did not strike these with a sharp and distinct stroke."
   The only certain  sign of the existence of this disease  is that
given by the stethoscope, viz. the clear and sonorous contractions
of the heart between the cartilages of the fifth and  seventh  ribs.
The degree of-distinctness of the sound, and its extent over the
chest, are  the measure of the dilatation: thus,—when  the  sound
of the contraction of the ventricle is as clear as that of the  con-
traction of the auricle, and if it is, at the  same time, perceptible
on the right side of  the back, the dilatation is extreme.
     DILATATION OF THE RIGHT VENTRICLE.

                      (Part I. Page 167.)

  According to M.  Corvisart the stale of the pulse and the pul-
sation of the  heart, are very nearly  the  same as in dilatation of
the  left ventricle, only that the action of the heart is heard some-
what better towards the bottom of the sternum than in the region
of the  heart.  More  certain  symptoms  he  considers  to be—a
greater degree of oppression, more  marked serous diathesis, more
frequent  haemoptysis, and a more livid state of the countenance,
■—than in the affection of the left ventricle.  With regard to the
swollen state  of the jugulars without pulsation, which M. Corvi-
sart considers of little  importance,  I am disposed to look upon  it
as the most constant and characteristic  of the equivocal signs of
this affection.  The only constant and truly pathognomonic symp- 
             DILATATION OF THE VENTRICLES.         269

torn, however, is the loud sound of the  heart perceived at the bot-
tom of the sternum,  anil between  the  cartilages of the fifth and
seventh ribs of the right side.  The degree of dilatation is mea-
sured by the extent of the action of the heart over the chest.  The
palpitations  which accompany this affection  consist, principally,
in an increase of the  frequency  and sound of the contractions,
while, at the same time, the impulse of the hearts action is fre-
quently feebler than in the ordinary state of the patient.
    DILATATION WITH HYPERTROPHIA  OF THE
                      VENTRICLES.

                      (Part I. Page 167.)

  In this case there is a combination of the symptoms of the two
affections.  The contractions of the ventricles  yield at the same
time a strong impulse and a very marked sound, and they are felt
widely over the chest.  When palpitation is present, the hand ap-
plied  to  the  region of the heart is forcibly  raised.   Even in the
absence of palpitation, if we observe the patient, we find his head,
limbs, and  even his bed-clothes shaken at each contraction of the
heart.  The beating of the arteries is often visible. 
270
DIAGNOSIS.
DILATATION OF ONE OF THE VENTRICLES WITH
          HYPERTROPHIA  OF THE OTHER.

                     (Part I. Page 168.)

  The signs of this  complication  are—a mixture of those com-
mon to each  affection,  with predominance of those  belonging to
the  one of greater intensity.  They are to be discovered by com-
paring the two sides of the heart together.  In this case, however,
the  indications of the cylinder must be taken in conjunction with
those of the  general symptoms  of disease, else  we shall be led
into error.
          DILATATION OF THE AURICLES.

                     (Part I. Page 168.)

  The symptoms of this affection are  obscure: M. Corvisart does
not  distinguish them from those of the corresponding ventricle.
I have not myself had yet sufficient experience of the use of the
stethoscope in this affection,  to  speak confidently on  the subject.
I think, however, there can be little doubt that the  signs afforded
by it must be confounded with those  arising from  the disease of
the  ventricles, or of the valves, of which the auricular affection is
the  consequence.
  Of partial dilatation of the heart, and of the induration of its
substance, 1 have nothing to say in this place. 
CARDITIS.
271
SOFTENING OF THE  HEART.
                       (Part I. Page 171.)

  Cases of total softening of the heart are usually accompanied
by a certain  degree  of  cachexy, even  when  the  individuals  are
otherwise in tolerable health.  When such subjects are attacked
with dilatation or hypertrophia  of the  heart, as almost always
happens, they do not present the usual swollen and livid state of
the face observable in other cases of  this sort.
  When softening exists  along with dilatation of the ventricles,
the sound produced by the contraction of these cavities,  although
loud, is yet dull,  and without the clearness which attends  com-
mon dilatation.   When it is complicated with hypertrophia,  the
sound of the contraction of the ventricles  is so  obtuse as to be
nearly  inaudible;  and in extreme cases, the impulse of the heart
is attended by no noise whatever.
                       CARDITIS.

                      (Part I. Page 177.)

  In the present state of our knowledge it is impossible to ascer-
tain the existence of either an abscess or ulcer of the heart. 
272
DIAGNOSIS.
 CARTILAGINOUS AND BONY INDURATION OF THE
               VALVES OF THE  HEART.

                       (Part I. Page 180.)


   The symptoms of ossification of the mitral  valve are somewhat
 different from  those  attending  the same affection  of the sigmoid.
 According to M. Corvisart the principal sign of the former lesion
 is " a peculiar  rustling  sensation,  perceived on the application of
 the hand to  the region of  the heart."   I  have often  noticed this
 symptom, which is very readily  recognised after being once per-
 ceived, although it is difficult to  give a description  of  it   The
 nearest idea I can give  of it is by comparing it to the purring of
 a cat  when  pleased.  The  same sort  of quality  is said, by M.
 Corvisart, to exist in the  pulse,  which, he adds, is weak, but with-
 out hardness or fulness.   To these symptoms may be added those
 characteristics of hypertrophia  and dilatation of  the left  auricle
 and whole right side of  the heart, which usually follow the affec-
 tion of the valve.
   I must confess that I have never perceived the peculiar charac-
 ter of the pulse described  by M. Corvisart;  and  that  I have fre-
 quently found wanting the  peculiar vibration in the region of the
 heart in cases of undoubted disease of the valves.  I  believe the
 latter sensation  is only perceptible by the hand when the contrac-
 tion of the  orifice is very  considerable.  In ossification of the
 sigmoid valves, several signs deduced from the state of the circu-
 lation are given by M Corvisart, but the whole  may be reduced
 to the purring sensation  above  mentioned.
   Since I have used the cylinder I have only met  with three cases
 of ossification  of the mitral valve accompanied  by the purring
 sensation; and only four  cases of the same affection of the sigmoid
 in a slight degree, and unattended by the purring.   In comparing
 these, however, with the  numerous cases I had before studied, I
 th'ujik I can give the following  results, if not correct, as, at least,
 approaching to correctness.
   Ossification of the mitral  and sigmoid valves does not  produce
 irregularity of the circulation, and  cannot  therefore be suspected
from the state  of the pulse, or by the application of the hand to 
PERICARDITIS.
273
 the region of the  heart, unless it is so considerable as materially
 to lessen  the orifices of the left ventricle   In ossification of the
 mitral valve, in a middling degree, the sound which attends the
 contraction of the auricle  becomes much  more prolonged, more
 dull,  and  with  something  in its tone  which reminds one of the
 rasping of a file on wood,  and  sometimes of a bellows  smartly
 compressed.   This sounjJ is well-marked when the purring is not
 perceptible to the  hand,  but it is much  more distinct when this is
 perceptible, and is, indeed, proportional to its intensity.
   The ossification of the sigmoid valves of the aorta is shewn by
the existence of this sound  during the  contraction of the ventricle;
but this does not exist in slight  degrees  of the  affection, nor in a
similar condition of the mitral.
   In  these cases, as in dilatation and  hypertrophia, the  alternate
examination of the heart under the.sternum and between the car-
tilages of the fifth and seventh ribs, as  well as  the state  of the
external jugulars, will always enable us to decide in which side of
the heart the disease exists.
PERICARDITIS
(Part I. Page 197.)
   1. Acute Pericarditis.  There are few diseases  attended  by
more variable symptoms, or of more difficult diagnosis, than this.
Sometimes it  appears with all  the symptoms of a very violent
disease of the chest; at other times it proves fatal without leading
us, in the least, to suspect its  existence.  Again,  we  find cases
marked by all the symptoms usually attributed by nosologists to
this disease, and in the subjects of which,  after death, we discover
no traces of its  existence.   The  same difficulty is acknowledged,
or at least encountered, by most practitioners.  Corvisart attributes
the difficulty to  the circumstance of  pericarditis being almost
" always complicated with pleurisy, peripneumony, or some other
disease of the chest, which masks its peculiar  symptoms." These
                          35 
274
DIAGNOSIS.
  complications,  which are very common,  must, unquestionably,
  have this effect where  they exist; I must, however,  confess, that
  the most completely latent affections of this kind that I have met
  with, were in subjects whose thoracic viscera were, in every other
  respect, quite sound, and  who had died  of disease  of  the  abdo-
  men.   These facts seem to prove that  inflammation  of the peri-
  cardium  is  sometimes a local affection of little  violence, and of
  very inconsiderable influence on the general system or even on the
  circulation; while, in other cases, it is accompanied by an acute
  fever, and by such violent disorder of almost all  the  functions,  as
  to compromise the life of the  patient.
    M. Corvisart is likewise of opinion that it is when the  disease
  is very acute, that the symptoms are very obscure.  " Its invasion,"
  he says," is sudden, its progress rapid, its termination almost instan-
  taneous."   When it exists in  a-less violent degree, but still acute,
  he thinks that it can be  recognised by the  following symptoms:
  viz. sense of heat in the  region of the heart; great  difficulty of
  respiration; greater colour of the left cheek than the  right; pulse
  at first frequent, hard, and rarely irregular,—becoming about the
  third or fourth day, small,  hard, contracted and  often  irregular;
  great anxiety, slight palpitations; partial faintings; peculiar change
  of features; and (towards the close of the disease) total or  partial
  cessation of the local pain.
   These symptoms are certainly sometimes present in  pericarditis-
 but each, or all of them may be absent,  and some  of them  are
 very rare.   I have never  observed  the increased colour  of the
 cheek, have rarely heard complaints of local heat or pain, and, in
 place of the progressive  increase of irregularity in the pulse '(as
 described by M. Corvisart), I have uniformly found  this irregu-
 larly intermitting, wiry, and almost insensible, from the very com-
 mencement of the disease.
   I  must admit that the stethoscope scarcely furnishes  us with any
 more certain  signs of this disease.   The following appear  to me
 to be the most common symptoms of the  inflammation of the peri-
 cardium, when not latent: the contraction of the ventricles yields a
 greater shock, and sometimes a  more marked sound,  than  usual,
 and, at intervals, feebler and  shorter pulsations  are  perceived'
 which correspond with intermissions of the pulse,  the smallness
 of which contrasts remarkably with the  strength  of  the heart's
 pulsation.  When  these symptoms  come on suddenly  in a person
 who had never  been affected with disease of the heart,  there is
great  probability of their being the consequence of this  disease.
In addition, it is further common  for  the  patient  to have  much 
HYDRO-PERICARDIUM.
275
dyspnoea and very great anxiety; and to suffer syncope on taking a
few steps, or on moving suddenly in his bed.
   2.  Chronic Pericarditis.  The signs of this variety are still more
uncertain than  those of the acute disease.   I have attended seve-
ral cases which I considered, throughout  their whole course, as
chronic inflammations of the pericardium, but  which  almost  all
were  cured.  In two or three cases only have I been able to  verify
the correctness  of my diagnosis by examination after death; whilst
very frequently I have  found the pericardium full of pus and in a
true state of chronic inflammation, without having been  at all led
to suspect such an affection.  In the cases which have occurred
within the last  three years, I have found the symptoms to be pre-
cisely the same  as in the acute disease, only less violent.   From
one to two years has elapsed before a cure has  taken  place; and
when this has been effected  the action of  the heart and pulse  has
become natural and regular.
HYDRO-PERICARDIUM.
                      (Part I.  Page 201.)


  Authors vary respecting the symptoms of this affection.  Lan-
cisi states the principal to be.a sensation of an enormous weight in
the region of the heart.   Reimann and Saxonia assure us that the
patient feels his heart swimming in water.  Senac says he has seen
the fluctuation of the fluid between the third, fourth and fifth ribs.
M. Corvisart says he has perceived this fluctuation by the touch,
and adds the following as marks of the affection:—sense of weight
in the region of the heart; inferior resonance on  percussion; pul-
sation of the heart irregular and obscure, and felt  over  a  large
space and with variable intensity in the same and different points
of this space; pulse small, frequent and irregular; threatened suf-
focation on lying in the horizontal posture; frequent syncope, but
rarely palpitation; cedema.   To these symptoms I may  apply the
same remarks as to those of pericarditis: they may exist, in greater
or less number, with or without hydro-pericardium. I am unable 
276
DIAGNOSIS.
to say, from experience, how far, and in what respect, the cylinder
will assist the diagnosis of this disease.
              ANEURISM OF THE  AORTA.

                       (Part I. Page 204.)


   There are few diseases so insidious as this.   It cannot be cer-
tainly  known till it shows  itself externally.   It can hardly  be
suspected,  even when it  compresses  some  important organ and
greatly  deranges its functions.   When  it  produces  neither  of
these effects, the first indication of its existence is often the death
of the individual as instantaneously as  if by a pistol-bullet. I have
known men cutoff in this manner, who were believed to be in the
most perfect health, and who had not  complained of the  slightest
indisposition.   We  must,  therefore, admit that aneurism of the
aorta has no symptoms peculiar to ij:; all those noticed by authors,
and  especially by M.  Corvisart, being indicative  merely of the
change or compression of adjoining organs.   This will be evident
by the  enumeration of the principal of these;  viz. oppression  on
the chest,—dissimilarity of the pulse in both arms,—a whizzing
or rushing at the top of the sternum, perceptible by the hand,—ob-
scure sound on percussion,—rattling in the  throat, and dragging
downwards  of  the  larynx,  when  the  tumour compresses the
trachea, &c.   After what  has been said of the symptoms of other
diseases of* the chest, I need not remark how very equivocal  all
these are.   In the present state of  our knowledge there certainly
exists no certain means of ascertaining the existence of this disease
until it shows itself externally.  And hitherto,  my experience has
been insufficient to enable me*to say how far  this difficulty is likely
to be removed by the use of the stethoscope.  Since my  employ-
ment of this instrument I have met only with  a dozen  cases  of
what I  conceived to  be aneurisms of the aorta.  Most  of  these
left the hospital after obtaining relief  by  blood-letting and proper
diet.   In two instances of moderate dilatation of the arch, I was
enabled to verify by  dissection my previous  diagnosis afforded  by
the cylinder; and in a third,  which showed itself externally, I was 
ANEURISM OF THE AORTA.
277
enabled to verify still  further the  diagnostic indications.   In this
last case, I found  the  pulsations of the tumour perfectly isochro-
nous  with the  pulse  at the wrist; they gave, at the same time, a
much greater impulse  and louder sound than the mere contraction   ^
of the ventricles; and the contraction of the auricles was not  at
all perceptible.   This pulsation, which I shall  call simple, in op-
position to that of the  heart, which is double (including the alter-
nate contraction of aurichsand ventricles), was distinctly percep-
tible  between the right scapula  and the  spine.   In some  cases,
this simple pulsation and greater impulse may indicate the disease,
but I  must confess that I have myself been deceived in three cases
notwithstanding these indications.  I would,  therefore,  say that
even  this simple  pulsation will  not assist  us  in  distinguishing
aneurisms of the  arch or  ascending  aorta  from dilatation of the
ventricles.
  Another sign, however, will still remain, though less marked than
the simple pulsation above mentioned: it is this; If we  find under
the sternum, or below the right clavicle, the impulse of the circu-
latory organ  isochronous with the pulse,  and perceptibly greater
than that  of the ventricles examined in the region of the heart, we
have reason to suspect dilatation of the ascending aorta, or arch,—
the more  so, as it is extremely rare to feel the impulse of the organ
of circulation beyond the  region of the heart, even in cases of the
most marked hypertrophia.
  The whole of  my experience on this subject leads me to the
following  conclusions:  1st, in several cases  aneurisms of the ascend-
ing aorta  can be ascertained  by the cylinder; 2nd, in other cases,
it requires the greatest attention to distinguish their pulsation from
that of the heart ; 3rd, aneurisms  of the pectoral aorta can be re-
cognised,  more especially  when they have produced injury of the
vertebral  ; and 4th, all of them will be often'mistaken," because
nothing will lead to the examination of  the chest,  and  because
ihere  will often be no  sign whatever  of ill-health.
END OF PART SECOND, 
 
APPENDIX,
CONTAINING SOME CASES NOT TRANSLATED IN THE  BODY
   OF THE WORK, AND FULLER DETAILS OF SOME THAT
             HAVE BEEN TOO MUCH ABRIDGED.
Case.  (No. xxxvi. of the Author, not translated in the body of
the work).  Phthisis Pulmonalis.—Tuberculous cavity partly
converted into fistula, producing the metallic  tinkling.  A woman,
50 years of age, who had been affected with cough and expectora-
tion for several years, and which  had  got much  worse  within a
few months past, came to the Hospital on the 13th April, having,
for the first time, been obliged to desist from her ordinary occupa-
tion.   She looked  much older than she was, and was very  thin.
The pulse was  quick, skin slightly  hot, and the expectoration.
which was in  moderate quantity, consisted of thick yellow  sputa
intermixed with much transparent ropy mucus.
   The stethoscope applied  to the  anterior and upper part of the
right side, and to the right  axilla, detected distinct pectoriloquism;
and, in the same places, when the patient  coughed or spoke, and
still more during respiration, there was heard a tinkling, like  that
of a small bell which has just stopped ringing, or of a gnat buz-
zing within a  porcelain vase. A mucous rattle, or strong guggling,
existed in the same points; and all these phenomena were distinctly
perceptible over the whole space from the top of the  shoulder to
the fourth rib,—being, only, more distinct anteriorly and  under the
axilla than behind.   The  murmur of  respiration was sufficiently
distinct over the greater part of the  chest, except at  the roots of
the right lung and the top of the  left.  The Hippocratic succus-
sion afforded no result.  From these various signs I made the  fol-
lowing diagnosis:  Vast tuberculous cavity occupying the whole of 
280
APPENDIX.
 the superior lobe of the right lung, and containing a small quantity
 of fluid; tubercles, especially at the, top of the left  and root of the
 right lung. Four days after her entry  this woman was discharged,
 for irregularity.   She came into the hospital again in the  end  of
 May, affected with precisely the same symptoms.  She died sud-
 denly on the 6th of June.
   Dissection twenty-four hours after death.  On  penetrating with
 the scalpel between the fourth and fifth  ribs of  the  right side a
 small quantity of air escaped.*  The  lungs on this side were flat-
 tened from within outwards towards the ribs, and adhered through-
 out to the pleura of the ribs, mediastinum and diaphragm.  Above
 the sixth rib the adhesion was  very close.  The upper half of this
 lung was occupied by a vast tuberculous  cavity,  which contained
 about two spoonfuls of a  purulent fluid.   The parietes of this ex-
 cavation (except on the lower side)  consisted of condensed pul-
 monary tissue, surrounded by a thin layer of a fibrous texture like
 the lateral ligaments of the joints, which was intimately connect-
 ed with the pleura  of the ribs  and lungs.  The cavity was large
 enough to contain the hand of the largest  man, and branched  out
 into many anfractuosities.   This cavity was crossed at one point
 by a band of flaccid pulmonary tissue, pretty healthy,  and covered
 by the lining membrane of (he excavation.  Here  and there, blood-
 vessels of the size of  a crow-quill ramified on the interior of this,
 some adherent and  others "partially detached, some quite obliterat-
 ed, others  only  partially.   A  semi-cartilaginous membrane, ex-
 tremely uneven  and of  very variable thickness,  lined  the  cavity
 throughout; and  this was the only boundary, on the inferior part,
 between  it and a branch of the pulmonary artery large enough to
 admit the little finger.   The anterior part of  this excavation ter-
 minated  in alongish cul-de-sac, which was lined by a membrane
 entirely cartilaginous, and much thicker than that of the other parts
 of it.   In cutting this part of the lung from above downwards, we
 could trace this cartilaginous lining under the form  of a lamina of
 cartilage, for more than an inch  into  the substance of the  lung,
 beyond the walls of the excavation.  This was no  doubt the re-
maining cicatrization of a cavity which had communicated with
that which existed at present. Some bronchial tubes that stretched
towards this lamina terminated in culs de sac  before reaching it,
still, however, retaining a  considerable caliber, and having their
mucous   membrane  very  red   and  thickened     Several  other

  * This must have come from the excavation which will be immediately
noticed, as the cavity of the pleura was obliterated. 
CASES.
281
  branches of the bronchia opened into the existing cavity, with their
  terminations quite smooth and polished.
    The anterior portion of the superior and  middle lobes,  which
  had not been implicated in  this destruction, was  still crepitous,
  and contained,  in different  parts, small  groups of tubercles in
  different stages, as did also the lower lobe.
    On puncturing the left side of the chest there was  an escape
  of gas, which must have  come from  the cavity of the pleura.
  There was no effusion in this side of the chest,  and the greater
  part of the lung was unattached, except at its very upper  point.
  This was strongly attached to the costal pleura by  a very  thick,
  whitish, fibrous  membrane.  This  covered a sort of cartilaginous
  cicatrice in the  lung, of two or three lines  in  thickness, which
  surmounted  an  irregular cavity of the size  of a pigeon's egg.
  The walls of this were formed by condensed pulmonary substance
  and  inclosed  a small calcareous concretion.   The remaining parts
 of this lung were pretty sound, only containing some tubercles.
    Case.  (No.  xxxvii. of the Author, not translated in the body
 of the work).   Phthisis  Pulmonalis.—Tuberculous excavation
 producing the metallic tinkling.  A  women, aged 40, came  into
 the Hospital 29th January, having been affected with cough for
 five months, and which had increased since her confinement, three
 months ago.   At this time the respiration was short  and quick,
 and difficult;  the chest resounded pretty well  in  the back and left
 side  before,—but  better on  the right  side; there was distinct
 pectoriloquism near the junction'of the sternum  and left clavicle
 and the same phenomenon, but  less distinct,  on the same, side
 where the arm joined the chest; the sound of the ventricles  was
 dull,  and the heart gave hardly  any impulse.  Two days after, by
 means  of the  cylinder, we  distinguished a sound  resembling
 fluctuation, in the left side,  when the  patient coughed, and the
 metallic tinkling  when she  spoke.   Succussion of the trunk  did
 not produce  the  sound of fluctuation.   From these results  the
 following diagnostic was given:  very large tuberculous excavation
 in the middle of the  left lung,  containing a small quantity of very
 liquid tuberculous  matter.  The patient died five days after this.
   Dissection twenty-four hours ajter death. In the right lung, through
 its whole extent,  there were innumerable tubercles of a yellow-
 ish white colour,  and varying  in size  from  that of a hemp-seed
 to a cherry-stone, and even a large filbert.   These last were  evi-
 dently formed  by  the reunion of several  smaller  ones.  and.  for
the most part,  were more  or less* softened.  Besides  these there
 were, in other parts, several cavities, the largest of which  would 
282
APPENDIX,
have contained a hazel-nut,, completely filled by pus, thicker than
that of an abscess, and lined by a  double membrane,  the  inner
layer of which was white, soft, and little adherent to  the other;
the outer  was of a cartilaginous character and  semitransparent,
and incomplete in certain points.   The left lung adhered closely
to the pleura of the ribs  and pericardium.  On  its anterior and
lateral part it contained,  near its surface, three cavities, one above
the other, and communicating by  two large openings.   The up-
per, of the size of a pigeon's egg,  occupied  the  top of the lung,
and corresponded to the junction of the clavicle and sternum; the
second might have contained a pullet's egg, and the lowest, which
reached within an inch of the base of the lung,  was of the size
of a  walnut.   These excavations were  lined by two membranes,
like those in the right lung, contained a  liquid pus, and commu-
nicated with  several  bronchial tubes.  This  lung contained also
some smaller cavities and tubercles, and exhibited marks of in-
flammation in several places.
   Case 1.  Page 44. (No.  i. of  the Author).   Phthisis  Pul-
monalis.   Ulcers  of the lungs cured by  transformation  into semi-
cartilaginous fistulae,   A woman, aged  68, had  been  for several
years affected with much cough and  expectoration; accompanied
by habitual shortness of  breath, greatly  aggravated by the  least
exercise.   In other respects she was pretty well, and was able to
discharge the laborious duties of a  servant.  She  was sufficiently
stout and had good appetite; but her lips and cheeks were of a
violet red colour.   On the last day of December  she  was seized
with fever,  very severe  dyspnoea,  and  cough attended  by  very
viscid frothy sputa,  of a  pale green  colour and semi-opaque.   She
 was  bled, and  thereby  obtained  some  relief.  Four  days  after
 this attack she was removed to the  hospital,  and presented the
 following  symptoms on being  examined  by  the  stethoscope:—
 Respiration  was barely  perceptible (and was  accompanied  by a
 well-marked rattle in the  inferior  and   left part of the chest)  to
 the height of about  the fourth rib.   Percussion elicited a dull
 sound over  the same  extent, especially on the back.  The pulsa-
 tion  of the  heart gave no shock,  but was  perceptible over the
 whole anterior and lateral part of  the chest, and  slightly on the
 left side of the back.   The contraction  of the auricles and ven-
 tricles  produced a  considerable  sound, and  nearly  equally so.
 The external jugulars were  swollen.  The dyspnoea  and expec-
 toration  were  as stated  above.   Qn  these  data  the following
 diagnostic  was given:  Peripneumony of the inferior part of the
 left lung: slight dilatation of the ventricles. 
cases.                       283
   Fresh bleedings gave temporary relief; but on  the  eighth day
 the fever increased and  was  attended  by  stupor and delirium.
 At this time respiration was much more perceptible on the  upper
 part of the left side than any where else; and naturally led us to
 suspect  the existence of pectoriloquism there;  but  the patient
 was loo weak to have this tried, and died the following day.
   Dissection twenty-four hours after death.   The lungs adhered to
 the costal pleura, nearly through their whole  extent, by means of
 well  organized cellular  substance,  evidently of ancient  date.
 The right lung  was crepitous  and very sound,  exclusive of the
 upper lobe, which contained an excavation of the size of a  large
 filbert.  This was lined by a thin smooth,  equable  membrane,
 pearl-grey,  and of a  semi-cartilaginous nature.   Several  bron-
 chial tubes opened into this, extremely dilated, so as, at first sight,
 to look like appendices of the  cavity.   The mucous hembrane  of
 some of these tubes was very pale, and that of others  red, but
 not swollen.  The top of the  left  lung contained a similar cavity,
 only larger and more  irregularly shaped.   It  was  lined  by a
 similar membrane, which was  continuous  with the mucous coat
 of a great  number of bronchial  tubes  (large as  a  crow-quijl)
 which opened into it.   It contained  merely  a  small  portion  of
 nearly colourless  serosity.  The  substance of the lungs  around
 these  cavities  was sound  and crepitous; except  in  the places
 where some of the projecting  angles came  nearly  in contact,  in
 which cases the- intervening substance appeared like a  compound
 of fibro-cartilage and black pulmonary matter.  There were no
 tubercles whatever in  the lungs; but the whole  of the inferior
 lobes, and the lower portion of the superior,  had  a consistence
 equal to  that of liver, which,  when cut, exhibited a  granulated
 surface, and poured out a purulent fluid intermixed with blood.
  The heart was somewhat larger than  natural,  and  was  filled
 with coagula.   The right ventricle, in particular,  was evidently
 enlarged, and both of these were thin, especially the right.
  Case  3, Page 45.  (No. iii. of the Author).   Phthisis  Pul-
 monalis.  Ulcer converted into semi-cartilaginous fistula.  A wo-
 man, aged 42, had been long subject to much cough,  and  dysp-
noea,  varied  by  temporary aggravations, especially  by certain
states of the weather.  These  symptoms, which she called Asth-
ma, had not incapacitated her for labour,  until the last fifteen days,
at the end of which time she came into  hospital.   At this  time
she could not at all lie  down,—the respiration  was very short and
difficult,  the lips  violet, and  there was anasarca of  the lower
limbs.   The chest yielded, on percussion^ a pretty good sound 
284
APPENDIX.
throughout, though, perhaps, somewhat less than natural.   Imme
diately below the clavicle on each side, the cylinder discovered a
well marked rattle.  The thoracic parietes  were'much and for-
cibly elevated at each inspiration. The cough  was very frequent,
and followed by expectoration of opaque yellow sputa.  Pectorilo-
quism was net  discoverable.  The pulse was frequent, small, and
regular; the external jugulars were swelled and distinctly pulsative;
the pulsations  of  the  heart (examined by the stethoscope)  were
deep, regular,  little sonorous, and without  impulse to the  ear.
From this examination I thought myself justified in considering
the heart as sound, notwithstanding the contrary indication afford-
ed by the general   symptoms;  and  accordingly gave my diagnos-
tic—Phthisis without* disease of the heart.   A  few days after, the
contraction of the  ventricles gave some impulse, a symptom which,
taken  along with  the  pulsation  of the jugulars,  gave reason  to
suspect slight  hypertrophia  of the right ventricle. The symptoms,
especially the  anasarca, got gradually worse;  and she died on the
19th of February.  The day before her death evident pectorilo-
quism was discovered in the anterior third of the fourth intercos-
tal space, on the right side, a point which had not been examined
before.
   Dissection.  The heart was of a natural size.   The  right ven-
tricle was perhaps a little  thicker  than natural; and  there  wa&
an ecchymosed spot, the size of the nail, on the inner  surface  of
the pericardium.   There  was about a pint of serum in the left
side of the chest, and the lung was  attached to the  costal  pleura,
at its top, by short cellular  adhesions.  In this point  there  were
 several radiated linear impressions depressed in  the point of their
 union.   These impressions correspond to three or four laminae of
 condensed cellular substance traversing the substance of the lung.
 In the  same  place there  was a dozen of tubercles  in different
 stages, and one small excavation of the size of a filbert*, lined  by
 a soft membrane, and filled by softened tuberculous matter.   The
 rest of this lung was crepitous and gorged with blood.
    The right lung adhered  firmly, throughout its whole extent,  to
 the costal pleura.  Immediately opposite  the fourth  intercostal
 space, and at  the  depth  of half an  inch,  there was a cavity the
 size of a walnut.  It was lined by a semi-cartilaginous membrane,
 of the kind  so often  already described,  and  contained  a  small
 portion of a yellowish pus.  A bronchial  tube opened into this on
 the  inferior  side, of the  size of a crow-quill,  but partially ob
 structed by a small  chalky  concretion which  lay  loose  in  it.
 There were seven or eight similar concretions in  other parts of 
CASES.
285
 the lung, two of which,  situated immediately under  the  pleura,
 were of the size of prune-stones.  The  lungs  were in other re-
 spects sound.
   Case 4, Page 45. (No. iv. of the Author).   Phthisis Pulmo-
 nalis— cured by the conversion of an ulcerous excavation into a fis-
 tula.  A lady, aged 48, of a good constitution and  healthy, with
 the exception of a local disease, until her thirtieth year, when she
 became  subject  to  very severe  pulmonary catarrhs, several  of
 which confined her to bed for two or three months, and produced
 considerable  emaciation.   Subsequently to one of  these  attacks
 she had  a diarrhoea, which was at length checked with great diffi-
 culty, but her bowels continued lax for several years. After being
 long without an attack of catarrh, and  in very good  health,  she
 was, in the beginning of 1817, attacked with a  distressing cough,
 attended by a slight  watery viscid and colourless expectoration.  I
 saw her in July, at which time she  was  considerably emaciated,
 and, though still able to attend to her occupation,  weak  and lan-
 guid.  The pulse and skin were  not uniformly febrile.  Respira-
 tion was very perceptible over the whole chest,  but less distinctly
 at the  top of the right lung.   From this, and the  nature  of the
 expectoration, I consider her as having tubercles in an early stage,
 and applied  leeches, &c.  The  symptoms  continued nearly the
 same throughout the summer  and part of the winter.   In the end of
 February,  1818, the cough  became suddenly loose,  and the pa-
 tient began to have  thick  yellow puriform expectoration.  This
 state of  the  sputa  lasted a month, when  the  cough  in a °reat
 measure left her and became nearly dry.  I did not see the  patient
 during this attack, which she looked upon as a cold; but I  visited
 her in the  beginning of April, and  upon examining her  chest I
 found most distinct pectoriloquism at the anterior and upper part
 of the right side.   I was convinced  by this that the supposed
 catarrh had been the discharge of the softened tuberculous matter.
 The sound of respiration was good over the whole chest; and even
 in the  vicinity of the pectoriloquous spot; the pulse was not fre-
 quent and the beat moderate. On this account I entertained hopes
 of her recovery, and  prescribed ass's  milk.  The cough and ex-
 pectoration progressively lessened, the flesh and strength returned;
 and, in the beginning of July my patient had regained every ap-
 pearance of the most perfect health, although the  pectoriloquism
still  continued most  distinct, beneath the  anterior  part  of the
second rib on the right side, in  a space of about an inch square.
  During the succeeding winter this lady had an  attack of catarrh.
but it lasted only fifteen days, and was not severe.   In other re- 
286
APPENDIX.
 spects she bore the winter well, and  she continues (1819) in
 good health, though still pectoriloquous in the same degree.  Her
 pulse is rather slow, and she has little cough and  less expectora-
 tion.
   Case 6, Page 48.   (No. vi. of the Author). Phthisis Pulmo-
 nalis.   Ancient cicatrice in the lungs in a patient dead of pleurisy
 and peritonitis.  A man, aged 65, came into hospital on the 29th
 of  November, affected with slight pulmonary symptoms,  chiefly
 marked by dyspnoea,  to which  he had been  long  subject, and
 which  he considered as Asthma.  Percussion  afforded no result,
 owing to  the excessive  fatness of the  individual; only the chest
 appeared  to sound somewhat less below the right clavicle.  Res-
 piration was inaudible over the whole  of the  right side, but was
 very sonorous on  the  le'ft.   From these results I considered this
 person  as affected  with a latent peripneumony of the right lung.
   Five days after this, there  was observed slight cedema of  the
 right side of the  chest; and on applying  the stethoscope to  the
 back, respiration was somewhat perceptible along the edge of  the
 spine on the right  side, though less so than on  the  left.   There
 was very  little cough, and scarcely any  expectoration.   These
 symptoms indicating pleurisy rather than peripneumony, necessa-
 rily modified our  diagnostics.   After a few days  the  oppression
 became less, and we  began to hear the  sound  of respiration, in a
 slight degree, below the right  clavicle; and  haegophonism (see
 page 243) was perceptible mthe same  spot for a few days.   On
 the eleventh the chest sounded still better in this point, and respi-
 ration became distinct  as in the opposite side, but was not percep-
 tible lower than the third rib.   It was, also,  sufficiently distinct
 between the spine  and scapula.   At this time the patient expecto-
 rated some opaque, yellow, puriform sputa.   The symptoms con-
 tinued much the same  until the middle of February, when he died,
 apparently from an attack of peritonitis.
  Dissection twenty-four hours after death.   The cavity of the
 right pleura contained about a pint of yellow and somewhat turbid
 serum.  The lung of the same side adhered to the diaphragm and
 posterior part of the chest  by a  strong, short  and well-organized
 cellular tissue.   On the anterior surface of the lung,  there was a
false membrane about the size  of the palm of the hand, soft,
opaque, yellowish, of a consistence inferior  to that of half-concrete
 albumen,  and appearing, at first sight, like the matter of thick
puriform sputa.   This patch was traversed by  numerous blood-
vessels, and adhered to the costal pleura by a lamina of greater
consistence,  also very  vascular, and  approaching more to the 
CASES.                        287
texture  of cellular substance.   Above and behind  another  firm
albuminous crust, yellow  and vascular, attached the lungs to the
pleura.
   The  substance  of the lung  was sufficiently  crepitous in  the
upper portions, although somewhat injected with a bloody'serum.
Its lower  portions were  more compact,  of a deeper red,  and, in
spots, somewhat granular on incision; it was also gorged with fluid,
and less creptious  than the upper portions.
   The left lung adhered to the pleura, at its summit, by means of
old cellular attachments.  In  this point there was an  irregular
depression, in the centre of which  lay a small ossification.  From
this point  could be traced into the substance of the lung a band  of
very white cellular tissue, very dense, yet scarcely amounting to
the consistence of a membrane.   This band  was about an  inch
long, six  lines broad, and three or four thick.  Its while  colour
formed  a  striking contrast with  the  natural pulmonary  tissue.
Some bronchial tubes of the size of a crow-quill, or  larger, ter-
minated and  became lost  in this  band.  An accidental circum-
stance prevented me from examining this substance more minutely.
The pulmonary substance was crepitous  throughout, and  there
were no tubercles in either lung.   The pericardium  contained a
few  ounces of limpid serum, and the heart was larger than the
hand of the individual.  The parietes of the left ventricle were
about eight lines thick at the origin of the columnae, and six  lines
at the base, and were very firm; the cavity of the ventricle was very
small.*   The right ventricle seemed small, but its parietes were
of natural thickness.   The peritoneal  coat of the  intestines was
inflamed.
   Case  7, Page  48.   (No.  vii. of the original).  Phthisis
Pulmonalis.   Ancient fibro-cartilaginous cicatrice  of the lung, in
a person dead of Peripneumony. A man, aged 62, had been affect-
ed five years with an  habitual cough,  but was otherwise  of a
good constitution.   On the 4th of April 1818, he  was suddenly
seized with acute  pain  in the  lower part of the left chest, which
soon extended over nearly the whole side, attended by difficult and
painful respiration, and inability to lie on  the affected side.   He
came into hospital on the 8th, and exhibited the following symp-
toms:—general paleness,  left cheek slightly coloured, lips bluish,
external jugulars swelled, pulse  weak and frequent, breathing short,

  * This well-marked case  of hypertrophia had  not been suspected,  al-
though the heart had been examined several times by the stethoscope, owing
to the existence of the disease in the lungs, which masked the symptoms.—
See Page 265. 
2bb
APPENDIX.
 loud and painful, and with the mouth extended, cough not very fre-
 quent and by fits, expectoration scanty, very viscid, frothy, semi-
 transparent,  and intermixed with some yellow and opaque sputa
   Percussion yielded a very good sound on the right side, but not
 so good on the left.   Respiration  (by the cylinder)  was quite in-
 audible in almost the whole  extent of the left side,  whilst on the
 right  it was  strong,  and attended  by a rattle and sort of hissing
 sound.   The pulsations of the heart were regular.   The contrac-
 tion of the auricles was sonorous  and heard distinctly below the
 clavicles.
   The paleness of this man, and the cough to which he had been
 so long subject, leading to the suspicion of tubercles, we examin-
 ed the chest  in several points with the view of discovering pecto-
 riloquism, but did not find it.   From these results the following
 diagnostic was (provisionally) made:  Pleura-peripneumony of the
left side.—Tubercles'? Slight dilatation of the hearth  This man
 died the  following night.
   Dissection thirty-six hours after death.   The left cavity of the
 chest  was larger than the right.  The right lung adhered, through-
 out, to the pleura by means of anGient attachments.   On the  top
of the right lung there was a fibro-cartilaginous mass three lines
 in thickness in its centre, which formed, in this point, the medium
of adhesion to the  ribs.   The  substance  of the  lung was very
crepitous  anteriorly, but little.posteriorly,  in  which  part it was
flaccid and  much injected by very fluid blood.   This  lung was
also marbled by a great number of spots formed by black pulmo-
nary matter.   [The  morbid appearances in the lungs indicating
the cure  of tuberculous excavations in this  case  are detailed in
the treatise,  pages 48  and  49.]   In its anterior quarter the  left
lung was crepitous, but the  remaining part was of the consistence
of liver, and  exhibited  the characters of lung in this degree of
 inflammation (see page 60).   The base of this lung adhered to
the diaphragm by its whole  border; and in its centre  there was a
patch of concrete lymph of the consistence of white of egg.   It
was easily separated from the pleura of the lungs, which appeared
redder than natural.
  The inner surface of the pericardium, where this membrane is
attached  to the diaphragm, was of an intense punctuated  red  for
the space of a square  inch.   The pericardium contained about
two ounces of a very bloody serum,  and two or  three flakes of
half-concrete lymph.  The heart was larger than the  hand of  the
subject, and exhibited on its anterior  surface a white spot of a 
CASES.
289
  cellular character, of the  size of the nail.   The  right ventricle
  was larger than natural, of the usual thickness, but yellowish and
  of a flaccid  texture.  The left  ventricle  was evidently dilated,
  and it was only four or five  lines thick; its texture was soft and
  pale like ihe right.
    Case  14, Page 68.  (No. xvi. in the original).   Gangrene of
  the Lungs. Pleurisy and pneumo-thorax consequent to the bursting
  of a gangrenous abscess of the lungs.  A labourer, aged 42, subject
  for  six years to occasional attacks of severe  pains of the chest, &c.
  for  which he had  been several times in  the  hospital,  began to
  have  cough, with copious and  extremely fetid expectoration, in
  the beginning  of April  1818;  which  symptoms continuing,  he
  came into the hospital Necker on the 30th  of May following   At
  this time he exhibited the  following symptoms: moderate  degree
  of fatness; decubitus practicable  on either  side,  but  more  easily
  on the left; cough frequent, and usually by fits; expectoration co-
  pious,  yellow and  opaque;  respiration very distinctly audible on'
  the  right side, much less on the left,  and accompanied with a mu-
 cous rattle;.resonance  on  percussion  somewhat lesson  the  left
 side both before and  behind.  Action of the heart natural.   After
 the examination the following diagnosis was given:  Slight chronic
 peripneumony, occupying the centre of the left lung.
   On the 7th June, the  respiration was still very distinct on  the
 right side, but on the left it was quite inaudible except at the  top
 of the  chest, where,  however, it was much weaker than formerly,
 —and  at the roots of the lung, where it  was much  more.distinct
 than formerly.  The left side sounded still worse on percussion
 than at first.  These results induced  me to  add  to my former diag-
 nostic:—the peripneumony has begun to resolve towards the root  of
 the lung; but there has supervened a pleurisy,  with sero-purulent effu-
 sion, of the left side. On the 12th  the respiration was very slightly
 perceptible below the left clavicle; and on the 16th it could scarce-
 ly be at all distinguished over the  whole anterior and superior half
 of this  side of the chest; but  the  resonance, on  percussion, had
 again become very distinct  over this space.   From  this  last sign
 I added to the diagnostic—Pneumo-thorax.  There was now much
cough, and the expectoration was  copious, opaque and ropy.   On
 the 17th the  pain, which had left him since April, returned  very-
 severe, between the fifth  and sixth ribs of the left side.   On the
 1st July the sound of respiration was quite  extinct  over  the left
side.   3rd. Resonance of the chest equal on both sides; respira-
tion very distinct on the right, not at all on the left side, either be-
fore or behind, except at the roots of the lung, and perhaps a little
                              37 
290
APPENDIX.  '
under the clavicle.   The pain and coiigh being more violent, he
expectorated in the  space of a few minutes half a, pint of yellow
opaque purulent sputa.   This kind of expectoration continued for
some days, with increase of pain and dyspnoea.   Pectoriloquism,
sought for in several points, was not  discovered.*  This man  died
on the 31st.
  Dissection twenty-four hours after death.  [For this see the work,
page 68.]
  Case  16, Page 73.   (No. xxxvi. in the original).   Hemopty-
sis.   Pulmonary Apoplexy in a subject affected with hypertrophia
and dilatation of the.heart.  A labourer aged 45, subject for seve-
ral years  to a  feeling  of suffocatiou on  using  violent exercise,
came into the hospital in the end of August, on account of his dysp-
noea having become greater  and more permanent during the pre-
ceding fortnight.  At this time  there was no emaciation, but the
face was pale;  the feet  and legs were oedematous, and  the  pulse
was scarcely percepliblcin both arms; there was no appetite, and
the sleep  was  frequently interrupted  by sudden  startings.   The
respiration, though  short and impeded, was very audjble by means
of the cylinder.  The chest sounded  well throughout, except in the
region of the  heart; and the  exploration  of this organ  by the
cylinder  gave the following results:—impulse of the left  ventricle
very strong and sonorous; sound and impulse of the right ventricle
middling;  sound of the auricles quite imperceptible.   In  conse-
quence of this the diagnostic was given—Hypertrophia of the heart.
(V. S. & Aperients.)   In a month's time the patient finding  him-
self better left the hospital; but  he returned  in  another month,
with precisely  the  same  symptoms, which being again relieved,
he left the hospital a second time after six weeks'  stay.
  On  the  16th of January he once more returned to the hospital.
At this time the difficulty of respiration was very great, especially
when lying on  the back; it was relieved by bending  forward and
by lying on the belly; in this  last position  he  felt a pulsation in his
throat  opposite the  top of the sternum.   The oedema was increas-
ed, and he had cough and diarrhoea, with a pain in the epigastrium.
The heart still gave a very strong impulse, and the pulse continued
imperceptible.   The symptoms continued much the same until the
4th of February, when he was seized  with haemoptysis.  At this
time the chest  yielded a good sound throughout; but the respiration
was nearly inaudible over the inferior portion of the right  side.

  * Neither was the metallic tinkling observed. The hippocratic succussion
 was not tried. 
CASES.
291
Nearly over the whole  chest, a mucous rattle  (apparently with
very large bubbles) was heard, and more strongly on the right side.
He died on the 8th.
   Dissection sixty hours after death.  The pericardium  contained
nearly an ounce of serum.   The  heart was, at  least, thrice  the
natural size.  * It had on its surface several irregular white  spots,
half as large as  the palm  of  the hand.  The right  ventricle was
partly, and the right  auricle  entirely, filled  by a  firm  polypus,
which,  in some places, showed some traces of vascularity.  This
ventricle was in  other respects  natural,  except that  its columnae
were flattened, and that it contained near its  apex  two  or  three
of those bodies which I have named globular excrescences.  The
auricle  was natural.
   The left ventricle was from  nine to eleven  lines thick and  of
a remarkable degree of  firmness; its parietes did not at all collapse
when laid upon, although the cavity was at least double the na-
tural  size; being capable of containing the  fist.  The columnar
carneae  were  very large and very strong.  The mitral valve con-
tained several cartilaginous  indurations, but  retained its shape:
the sigmoid of the aorta were  sound.   On  the inner  surface  of
this  ventricle there were one or two white spots of the  size of the
nail, apparently situated beneath the lining membrane.  The aorta
was slightly dilated at its  origin, and more so in  the arch, and was
otherwise diseased, containing many cartilaginous and  bony  in-
crustations.
   The morbid appearances found in the lungs are detailed in the
work, page 74.
   Case ^6,  Page 96.  (No.  xxxiv. of  the  original).   (Edema
of the lungs supervening'in the convalescence from peripneumony.
The only thing of any importance omitted in- the abridgment  of
this case, given in  the body of the  work, is  the account of the
signs of diseased heart afforded by percussion and auscultation,
and  the morbid appearances found in this  organ: I shall now
briefly notice these.   When she came  into  the hospital, in ad-
dition to the symptoms mentioned, it is stated  that " the resonance.
of the chest is not good on the  right side behind, and  the left
side before; this resonance is quite  wanting  in the  region of the
heart;  and the  respiration,  as  explored  by  the stethoscope,  is
inaudible in these points.   The action of the heart gives scarcely
any impulse,  but yields  a distinct  sound."   In consequence   of
these, and the other symptoms mentioned in  the work, the di-
agnostic was given—Partial  peripneumony of both lungs, and di-
latation of the heart without hypertrophia.   The morbid appear-
f 
192
APPENDIX.
ances in the lungs are detailed in the work.   The following ar<.
those observed in the heart:—The  pericardium  contained about
two ounces of serum.   The heart was larger than the hand of the
individual; it was soft and easily torn, and its cavjties  were very
large                                            #
   Case   (No.  xxiv  of the original, not translated in the body
of the  work).   Pleurisy.  Pleurisy with  hoigophonism, cured.
A man, aged 42, came into the hospital  the  23rd of April.   Six
years before he had had an attack  on the chest attended  by a
severe  stitch in the left side; and he had a similar attack in the
spring of last  year.  Ever  since  his  first seizure he  had  been
subject to  colds,  especially in   winter; and  during the  last year
his cough had been almost constant.  During the four days preced-
ing his entry into the hospital  he suffered from stitch  in the left
side, dry  cough, impeded  respiration,  and  fever.   On  coming
into the hospital he exhibited the  following symptoms: cheeks
very red, pulse frequent, skin  hot, decubitus  on the  left side im-
practicable, very  acute  pain  in the left side.   The respiration
very distinct, and even loud, below the left clavicle," and  as  low
as the fifth rib on the same side anteriorly,*  of  moderate  inten-
sity below the axilla,  but very indistinct behind,  especially on the
lower parts, where it is accompanied  by a  slight crepitous  (al-
most mucous)  rattle.  On  the right  side the respiration is  less
perceptible below the clavicle  than on the left side; behind  and
below the  axilla, it  is very  distinct  but not strong.  On per-
cussion  the  chest sounds,  perhaps,  somewhat worse  below   the
right than the left clavicle;  but behind,  and  below the  axilla it
 sounds much less on the left than  right  side, particularly on  the
lower; parts: this difference of sound is.perceptible even over  the
scapulas.   Haegophonism is extremely evident about  the point of
the  left scapula and all along  its inner edge.   The patient's voice
appears as if it traversed  a trumpet and  not' the  tube  of the  ste-
thoscope.   Hasgophonism is also perceptible below the axilla, and
 as high as  the fifth rib, but  less  distinctly.   In consequence  of
, these signs the following diagnosis was given:   Pleurisy of the
left  side, complicated with a  slight  degree of peripneumony.f (Ve-
 nesection.)

  *  It would seem probable from  this that there was adhesion between the
 ribs and summit of the left lung, the consequenc of some of the preceding
 attacks of pleurisy.
   f The latter part of the diagnostic was founded entirely on the existence
 of the crepitous rattle. 
<;ASE!5.
293
  24th.   Fever still  high,—continued  incapacity to lie on  the
left side,—almcrst* constant  cough, with  liquid semitransparent
sputa, which adhere but slightly to the vessel; respiration distinct
on the left side anteriorly, as low as the fifth rib,—quite impercep-
tible over the whole of this side  behind, (where it is  replaced by
a mucous and slightly crepitous  rattle,)  but very distinct on the
side  as low as the seventh rib.   Haegophonism not discoverable
on the upper and  anterior parts, where the respiration  is still
perceptible,—doubtful below the fifth rib,—but  most distinct over
the whole of the back.   Near the angle of the scapula  the patient,
when speaking, seems to blow into the tube of  the cylinder; and
in breathing, seems to inspire and expire by  the same.  Nothing
of all this is perceptible on the right side, where the respiration is
very distinct  throughout.  The haegophonism becomes  less distinct
when the patient lies on his face.  I concluded from these signs that
the left lung was compressed upwards and laterally, in which points
it was probably attached to the ribs.   (Eight leeches to the side.) •
   25th. Results the same, only the respiration more easy.   Sputa
adhering  to  the  vessel.*   (Eight leeches  to the  anns.)   26th.
Pain  of side nearly  gone, cough mueh less", expectoration more
easy and sputa more yellow and opaque, pulse less frequent.' The
patient «lept  well.  (Small bleeding.)
   27th.   Fever  nearly gone, respiration easy, no pain o'f side.
Respiration more distinct on the left side, and haegophonism much
less evident.   Respiration very distinct over the whoje right side.
(Blister to the side.) '
   28th and  29th.  Much the same,—still much  cough, but ex-
pectoration  easy, the sputa  partly  frothy  and semitransparent,
partly yellow and opaque; can lie on either side.
   May 1st.  Still better.   Haegophonism  still evident, but  less
strong, along  the whole  inner border of the scapula, and over
the  whole of the left side  behind; but the respiration, which had
hitherto been merely bronchial over the site of  the haegophonism,
is now possessed of the usual pulmonary character; it  is perfectly
and  forcibly  audible on the side, except in the lower parts, where
it is much feebler.
  ' The patient continuing to amend daily,  the haegophonism  be-
came progressively less distinct  and  ceased entirely on the 8th;
the  respiration became  very distinct  over the  whole of the  left
side, though, probably, scarcely so loud as  in the other.
   Case.   (No.  xxv. in the  original, not translated in the  body of
* Sign confirming1 the complication of peripneumonv. 
394
A1'PEN"D1X.
the  work).  Pleurisv.   Chronic Pleurisy  of the left side,  with
ascites  and organic disease of  the liver.   A ma*n -had an attack in
the chest when 24  years old; but afterwards enjoyed very good
health, until the summer of  1818, when he  became slightly ana-
sarcous, and this was followed in  December by cough.  He came
into the hospital on  the 13th of the following March, in his 47lh
year.   At this  time  he  presented the following symptoms:  mode-
rate oedema of the feet  and legs, slight expectoration, partly white
and frothy; partly yellow and  opaque;  the chest sounds equally
well  throughout,  and  the respiration (on a hasty  examination)
seems scarcely  perceptible  on both sides.
   17th.  The  chest, on a  more  careful  examination,  gave  the
following results:  The  left side behind seems to sound worse than
the right,—both sides  laterally  yield  a  very  dull  sound,—the
anterior superior  parts sound  better.   The  respiration is very
distinct  over tbe  whole  of the right side;   on the left, on the
contrary, it is but very  little  perceptible  below the clavicle and at
the roots of the lungs, and not  at all audible  over the remaining
parts of this side. Tbe following diagnosis was given: Imperfectly
cured pleurisy ofthe left sidb, coexisting perhaps with tubercles.
   In' the end  of March the cedema, wliicli had been  lessened,
now became greater, the  belly swelled, and  the appetite  dimi-
nished.  At this time, the respiration on the right side  was accom-
panied with a strong and sonorous rattle on the side and anteriorly,
and was scarcely perceptible on the  same  side behind, and over
the whole of the left side.   Percussion  elicited  a very imperfect
sound from the  whole  of the  left side, except  on  the anterior
superior part; but the whole right  side sounded well.   Haegopho-
nism  existed very distinctly over  the supra-spinous  fossa of  the
left scapula.  The  voice,  having the bleating character strongly
marked, seemed to come through  the tube of  the  stethoscope, and
was more acute than the natural voice of the patient.   In conse-
quence, I modified  the  diagnosis as follows:  Chronic pleurisy of
the left  side,  with pulmonary  catarrh.
   From the 30th March to the 15th April, the repeated examina-
tion of the chest showed that on the right side the sonorous  rattle
had in a great measure ceased,  and that the respiration was louder
than natural, and marked by the peculiar sound which I  have  de-
nominated puerile; whilst, on the left side, the respiration seemed
extinct, except  along the inner  border of the scapula and imme-
diately below .the clavicle,  in which places it was just barely per-
ceptible.   The point just mentioned (under the clavicle) was  the
only one on  this side  which  yielded any sound on  percussion. 
cases.                        295
During the first days of April,  liregophonism  was still  audible
along the inner margin of the scapula, but the voice had assumed
a grave key,  and was heard better with the stopper of the  tube
removed,—it disappeared entirely on the 5th.  The natural respi-
ration was  short and  somewhat  noisy.  The  patient  lay usually
on the left  siele, sometimes on the back,  but he could not lie on
the right side.   About  the  middle of the month the  respiration -
seemed more easy, and the patient  could lie two or three  hours
on the right  side; but  the anasarca increased, and hectic fever
came on.
   From the 7th to the  14th  of May, the resonance of the chest
became clearer on the anterior  and upper  part  of the left  side,
and the respiration  became  more  audible  in the same point; it
was also somewhat perceptible below the  axilla, and was  here
accompanied by a pretty strong mucous rattle:  in every other part
of  this side both the resonance and the respiration were wanting.
He died on the 17th.
   Dissection thirty hours after death.   The  thorax appeared larger
on the upper part, and smaller on the lower part, of the left side,
than the right.  The left cavity of the pleura  contained at least
two pints  of a very bloody serum, and the lung, on this side, was
thereby compressed towards  the mediastinum  and  upper part of
 the chest.   A large vacant space was thus left between the lung
 and ribs,  which space gradually  lessened  from below upwards,
 but was  still  an inch  in  diameter as high as the middle of the
 scapula.   This space was lined  by a false membrane, the internal
 surface of which was tinged uniformly of  a bright scarlet colour,
 and  was  crossed in every direction by fine fibrous bands  of the
 same kind.   In many parts of these false membranes there were
 clots and thin  layers of a  dark-coloured blood.   The under layer
 of membrane which adhered to the pleura was of a greyish yellow
 colour, homogenous,  and  of a structure and  consistence resem-
 bling the  fibro-cartilages.   It  contained  within it an immense
 multitude  of greyish tubercles, of a size from that of a millet-
 seed to a grain of corn, or even a pea.  These were of a firmer
 consistence than the including membrane;  and  they formed  more
 than one half the whole of its substance.
    The left lung, compressed as already mentioned,  was  reduced
 to nearly  one-fourth of its  natural size; it was adhering to the
 pleura by its inner  side, its summit, and by  two-thirds of its ex-
 terior aspect superiorly.   Detached from  the false membrane it
 was sound,  only compressed, flaccid, and void of air except in its
 lower lobe.   The blood-vessels and smaller bronchial tubes were
 flattened and much contracted. 
296
APPENDIX
   The right lung adhered to the ribs only in B few points, and by
 old  and perfectly organized attachments.   It was gorged  with  a
 great quantity of frothy serum which flowed out on its being cut.
   The cavity of the peritoneum contained five or six pints of se-
 rum.   The liver was reduced to one  third  of its usual size, and
 when cut into was found to be entirely composed of a  multitude
 of small grains, of a round or  ovoid  shape, and  varying in size
 from that of a millet-seed to a hemp-seed.
   Case. (No. xlv. of the original,  not translated in the body of
 the  work).   (Supposed)  Ossification of the mitral valve.  A strong
 muscular young man, aged 16, came into the hospital complaining
 of oppression on the  chest and palpitation; symptoms  which  had
 seized him suddenly, together with haemoptysis and epjstaxis  two
 years before.   These symptoms were  relieved  at the  time,  by
 rest; but returned as  often as he made  any considerable degree of
 exertion.  He presented  the following symptoms on coming  into
 the hospital: respiration and resonance good over the whole chest;
 the hand, applied to the region  of the  heart, feels the  pulsation
 strongly, and  accompanied with the* purring sensation mentioned
 in the treatise (page  257).  This vibratory sensation is not con-
 tinuous, but returns at regular intervals. The stethoscope, applied
 between the cartilages of the fifth  and  seventh ribs, gives  the
 following results:—contraction of the auricle extremely prolonged,
 accompanied with a dull but strong sound exactly like that produced
 by a file on wood.  This sound is attended by a vibration  sensible
 to the ear,  and which is evidently  the same as  that  felt by the
 hand.  Succeeding this, a louder sound and a shock synchronous
 with the pulse  point out the contraction of the  ventricle, which
 occupies only one fourth the time, and has something harsh in its
 sound.   Under the lower end of the sternum the contractions of
 the heart are quite different.   Here  the impulse  of the right ven-
 tricle is very great, its contraction accompanied, by. a very distinct
 sound, and being of the  ordinary duration—viz.  twice as long as
 that  of  the auricle.  The sound of the auricle is somewhat obtuse,
 but without any thing analogous to the  vibratory character of the
 left.
 * The action of the heart is audible  below both clavicles, on both
 sides,—(but feebly, especially on the right)—and over the whole
 sternum.  On the right side and below the left clavicle, the con-
 tractions of the heart have the same rythm as at the end of the
 sternum.  On the  left side, on the contrary, the  whizzing sound
of the left  auricle already described is  much feebler  than in the
left precordial region.   From these sign? the following diagnostic 
CASES.
297
 Was  given:   Ossification of the mitral  valve, slight hypertrophia
 of the left  ventricle; perhaps slight ossification of the sigmoid valves
 of the aorta? great hypertrophia  of the right ventricle.
   The pulse, in this case,  was pretty  strong and  very regular,
 and all the functions  natural,  only the sfeep was habitually dis^
 Curbed by frightful  dreams,  and the  lad  could not use any severe
 exercise, nor even  walk  rather  fast, without being attacked by
 strong palpitations and a feeling of suffocation.
   Four venesections, after intervals of a few days, gave  much re-
 lief.  After the first,  the pulse  became  weak; and  immediately
 after each bleeding the purring vibration became imperceptible to
 the hand, and the whizzing of the auricle changed from the sound
 of  a file to  that of a bellows, the valve of which we keep open by
 the hand; but the shock of the right ventricle continued to be very
 strong.   This patient left the hospital after a month.
   Case 43, Page  186.  (No. xlvi. of the original).   Excrescences
 on the mitral  valve and  left auricle; rupture of one of the tendons
of this valve, and hypertrophia, with dilatation, of both ventricles of
the heart    [The general symptoms and appearances on dissection
are given in the  body of the work; I shall therefore  only add the
account of  the symptoms more immediately  indicative of the  dis-
ease in the  heart.]
   The pulsations of the heart,  examined by  the cylinder, give a
very dull sound, but a strong  impulse on  both sides:—they are
heard a little in the back.   During the contraction of the left au-
ricle  (which is almost as much  prolonged as that of the ventricle)
a sound  resembling that of bellows is perceptible.   The purring
sensation is very  distinct on applying the hand over the  cartilages
of the sixth and seventh  ribs.   The action of the heart is, in
some other  respects, irregular; the jugulars are swollen;  the respi-
ration is distinct over the  whole chest;  the  pulse is hard, small,
and very regular; the breath  is rather short.   After this examina-
tion the following  diagnostic  was given: Hypertrophia of both.
ventricles;  excrescences  or  cartilaginous contraction of the mitral
valve.
  Case. (No. xlviii. of the original,  not translated in the body of
the work).   Double Peripneumony with Pericarditis.  A man,
aged 30,  who had been  subject to a  slight cough for some years,
and latterly, to dyspnoea, came  into the hospital on the 30th Jan-
uary, apparently  affected with pulmonary catarrh.  (V. S.)   On
the following day the difficulty of respiration  suddenly increased,
the pulse became irregular, and the  sputa were viscid.   To re-
lieve his  breathing the patient sat upright.   (V. S. fy Leeches.) 
298                       APPENDIX.
  February 1st   Orthopnoea much relieved.   Pulsations of the
heart very irregular,  both in frequency  and force; contractions of
the ventricles sonorous,  and  the impulse considerable,  but the
pulse extremely small and feeble; resonance of the chest middling,
perhaps  less in Hie back  and region of the heart;  respiration in
the back very little perceptible and  accompanied by a slight cre-
pitous rattle.  Diagnostic: Pericttrditis, with peripneumony of the
posterior part  of both fangs.*  2nd  and  3rd.—Much  the same.
(Eight leeches each day).
   4th.  Orthopnoea  returned.  Contractions  of the  heart  very
feeble and  unequal;  sound of the auricles  inaudible;  impulse of
the ventricles pretty  strong and without  noise; 'the action of the
heart seems con-fined to a small point on the parietes of the chest;
pulse nearly imperceptible. (Eight leeches).
   5th The same.  (Blister to the region of the heart).
   6 h. Heart and pulse  as before;-respiration  very audible over
all the anterior  and lateral parts of the chest,  on the back it is
scarcely  perceptible and  accompanied by a more distinct crepitous
rattle than before.
   For several succeeding days the  patient was obliged to sit up
constantly in his bed, with his  head  bent forwards,  and immova-
ble, for fear of increasing the orthopnoea.   Respiration very per-
ceptible  anteriorly and on the sides,  and  accompanied from time
to  time  with a  rattle which  was  rather  mucous than crepitous,
and much more marked during respiration than inspiration;! pos-
teriorly the respiration was quite imperceptible.   Cough frequent,
with scanty expectoration;  sputa  transparent,  somewhat frothy,
and so tenacious as to adhere to tbe vessel when this was revers-
ed.   Pulsations of the heart difficultly  analyzed, owing  to their
frequency;  one strong pulsation followed by three or four gradu-
ally decreasing in force;  pulse  feeble and intermitting.  A sound
like the  fluctuation of a liquid heard  momentarily in the region of
.the heart; which sound seems occasioned  rather by strong inspira-
tions than the  actions of the heart.   Lower extremities  oedema-
tous, no  sleep. (Soap-pills, cautery on the left side.)
    13th.  Orthopnoea still  greater; sputa almost entirely sanguino-
lent; respiration less  distinct on the sides; impulse of the  heart
still strong.  He  was again bled, and thereby much relieved.

  * I founded my opinion of pericarditis  on the circumstance of the forci-
ble action of the heart coinciding with the extremely  feeble pulse, and on
the irregularity of the heart's action in a man who appeared to have had
no previous  symptom of this kind.
  f This sign announces the  rattle to be in the small bronchial ramifications, 
GASES.
299
   14th.  Sputa less sanguinolent, but orthopnoea greater. (V. S.
 repeated).
   15ih.  The respiration has become puerile on the anterior and
 lateral parts of the chest, but it is not so distinct as before on the
 right side anteriorly; a distinct crepitous  rattle  on  the  right side.
 The chest sounds equally well before, and on both sides.   Diag-
 nostic:  Peripneumony gains  the  anterior and lateral parts of the
right lung; but remains, on the left, confined to the posterior  parts.
 He died on the 18th.
   Dissection twenty-four hours after death.   The pericardium con-
tained about four ounces of a limpid serum.  The  walls of both
ventricles were thick,  but not so as to constitute disease.  An ir-
regular white spot  was found intimately  adhering to the pericar-
 dium on  each ventricle.   The portion of the aorta contained in the
pericardium  was  coated  exteriorly with  small firm greyish tuber-
cles, resembling the tubercles of the lungs in their first stage. The
 mitral valve  was  irregular and contained three or four small semi-
 cartilaginous tumours.
   The cavity of the pleura was entirely  obliterated on both sides,
by the universal adhesion of the membranes, by  means  of a short
and in most places  well-organized cellular  tissue, except at their
base, where the medium of attachment  was a membrane  of  a
greyish-white colour, semitransparent, of a fibrous texture, and
 nearly two lines thick.
   The lungs, when detached, floated in  water, though heavy and
large.  Their surface was livid,  and more  so behind.  The sub-
stance of the lungs was  soft and  crepitous on their anterior part,
to the depth of two  fingers' breadth on  the right lung,  and four
fingers on the left; but became  progressively firmer  and less cre-
pitous on tracing  it  backwards, until, on the whole of  the poste-
rior  part,  their  texture  was as  dense  as  liver, of a violet  red
colour and entirely without crepitation.   These portions, when de-
tached, did not float on the water.  The hepatization was nearly
one third more extended  in the right than in the left.  The lining
membrane of the bronchia was of a reddish brown colour.
   The cavity of  the peritoneum contained nearly a pint of yel-
lowish serum.
END OF THE TREATISE 
 
        NOTES

            BY

THE TRANSLATOR.
      Connexion of Tubercles with Inflammation, Page 38.

   Hitherto great confusion has existed in our notions respecting
the true character of the appearances  found  in  the lungs after
death.  Among others, the common notion of consumption being
merely the consequence of the suppuration of an  inflamed lung,
has had a very injurious effect in practical medicine.   It is to be
hoped that the more correct knowledge now obtained of the  true
nature of  the mobid appearances, will establish  a  more rational
practice.   From the anatomical character of tubercular phthisis,
it is evident that we have little or nothing to expect from the  em-
ployment of venesection and other antiphlogistic  measures,—or,
indeed, from any other;—while the great infrequency of the  ter-
mination of simple inflammation of the lungs (peripneumony) in
abcess, that is—in an irremediable condition of parts,—affords us
every chance  of  this  affection  yielding  to such  measures,  and
therefore justifies their powerful and  long-continued application.
In a practical point of  view, therefore,  the present work must be
of immense benefit, in  settling both the pathology and diagnosis
of the diseases of the chest.  Any person accustomed to see many
cases  of pulmonary  disease must  be struck  with  the confusion
that prevails among medical men respecting them.   With   many,
every chronic  affection of the chest  is  either Consumption or
Asthma, and the same class of remedies, and  regimen, is applied
to all.  How often are  patients sent abroad in a  state of  health
which is utterly hopeless! and how often do we hear of Consump- 
302
NOTES BY THE TRANSLATOR.
 tions cured, when the sole merit of the curer was ignorance of the
 nature of the disease!
   By for the most  valuable remarks yet published in England on
 this very  important matter, of the discrimination of the various
 diseases commonly classed under  the  name of Consumption, are
 those in the work of Dr.  Armstrong on Scarlet Fever,  &c.  and
 in Dr. Abercrombie's paper in the 66th number of the Edinburgh
 Medical  and Surgical Journal.   To these two  essays  I  would
 earnestly   call  the attention of  every practitioner  who  values
 either the welfare of his patients, or his success in  his professional
 career.   To  Dr.  Armstrong the  profession  is   already  under
 very great obligations;  and the several late papers by  Dr.  Aber-
 crombie in the  Edin. Jour., written in a true philosophical spirit,
 lead us to anticipate the most important  advantages to medicine
 from his  future labours.

          Tubercular infiltration of the Lungs, Page 38.

              This is noticed by  Baillie, Page 76.

           Extensive distribution of Tubercles, Page 39.

   The extensive distribution of tubercles mentioned by  our  au-
 thor, and very generally admitted by other writers,  I  consider  as
 throwing light on many obscure affections.   Is it  really  true,  as
 MM. Laennec and Bayle  assert,  that  the  diarrhoea of consump-
tion is the direct consequence of their presence in  the  intestinal
 tunics?

         Cicatrization  of Pulmonary Fistulae, Page 42.

   Dr. Young, in  giving an account of the Historia Anatomica  of
 Lieutaud, notices a case  " of a  cicatrix  found  in  the  lungs,
 where a consumption had  been cured,  from  Valsalva."   Youngj
p. 225.  The facts detailed in this section are extremely interest-
ing; if they destroy the hope  entertained by many, of the curabi-
lity of  consumption in the early stage, they give us hopes, where
 in general no hope has  hitherto existed, in the latter stage of the
 disease.   These facts seem to afford a better  reason  for sending
our confirmed consumptives to warm  climates, than  could  have
previously been offered by most of those who  were in" the habit
of doing so.—I have no doubt that many  of the  readers of this
 work, of more  extensive  information  than the Translator,  can 
                NOTES BY THE TRANSLATOR.             303

corroborate  many  of the  author's  statements  by facts  adduced
from other writers.

              Expectoration in Phthisis, Page 55.

  For an extensive and minute chemical account of the different
kinds of expectorated  matter, see  Dr. Pearson's papers in  the
Philosophical Transactions for 1809 and 1810.  The question of
the mere purulency or  non-purulency of the sputa is of very in-
ferior value in a diagnostic  point of view,  to what it  was  once
considered;  since  it  is now well  known  that the expectorated
matter may be purulent in'other diseases besides Phthisis.

  Tubercles on the surface of the Peritoneum and Pleura, Page 39.

   " In these situations they are found small and very  numerous,
usually in their first stage, and  occasion death by  dropsy before
they can reach  the period of maturation."  This  is the disease
described by Dr. Baron,  and is mentioned  in  many parts of the
present treatise.  As a cause of dropsy, it must often at once in-
dicate the employment of antiphlogistic measures, and prove their
 perfect inutility.

 Tubercles in the substance  of the  Vertebrae, or the point of union be-
              tween these and the Ligaments, Page 39.

    In many chronic affections of the spine,  in strumous subjects,
 unattended by  curvature, I am  disposed to attribute the symptoms
 to this cause.

                        Vomicae, Page 56.

    Among others  see  the work of Dr. Baron on Membranes. 1
 apprehend this author confounds   three different  diseases  under
 one  head.

                     Peripneumony, Page  59.

    All the  appearances mentioned   by our author  in this disease
  have been noticed  by other writers;  but he is entitled to  the ho-
  nour of having first  ascertained their relations to each other, of
  having united  them all in  one connected  and distinct  view, and
  fixed their true characters as different stages of the same disease 
304
NOTES BY THE TRANSLATOR.
 Hepatization of the Lungs is noticed by almost  every writer on
 the Lungs, but its true character has been misunderstood even by
 some of our best  and  very recent authors   It  is considered as
 an  inflammatory  affection in the  very short notice of it given  by
 Baillie.  But it is singular that  it  is said  to  be of such  rare  oc-
 currence, see Morb.  Anat. page 80.  See also Hastings on  Bron-
 chitis, and many cases in the various medical Journals.
   One great  advantage of the  anatomical knowledge of  diseases
 is, that, whatever system of nosology we  follow,  in the treatment,
 our ideas will  always  be attached  to some fixed  and intelligible
 condition of parts, the removal of  which  will form the object  of
 all  our  remedial  measures; while, without  this  knowledge,  we
 shall be the sport  of theory, and combat often words  in  place  of
 things.  How often I  have heard of effusion into the lungs as a
 frequent cause of  death, without being able to attach any precise
 idea to the expression!

                Abscess of the Lungs, Page 61.

   The assertions of our author respecting the relative infrequen-
 cy of this  termination of peripneumony  is very  opposite to the
 best English  authorities.  I have no doubt that a  great many
 supposed abscesses have been  merely softened  tubercles,  as de-
 scribed by our author in the chapter on Phthisis.
   In page  56 he states an abscess of the lungs from simple inflam-
 mation to be a thousand times less  frequent  than  a case  of Em-
 pyema.
   For some excellent observations  on Chronic Peripneumony see
 Dr. Armstrong's work  on  Scarlet Fever; also Dtr. Duncan's on the
 three varieties of Consumption.
   A most striking  instance of the evils of a symptomatica! classi-
 fication of diseases is exhibited in the  conjunction, by Dr. Cullen,
 of Pleurisy and Peripneumony under one name and species (Pneu-
 monia).  Many of their symptoms  are undoubtedly the same, and
 it may often not be easy to distinguish the two diseases when exist-
 ing separately; yet it is evident, no  two affections can be really
 more distinct in their nature than an inflamed pleura with effusion
 in the chest, and an inflamed lung  with thickening  of its  paren-
chyma. 
NOTES BY THE TRANSLATOR.            305
        -   Tenacious Sputa in Peripneumony,. Page 63.

   This character of the sputa is very characteristic: it shows the
 importance of examining the expectorated matter in all cases of
 diseased lungs. Indeed a crachoir ought to form an invariable part
 of the furniture of a pulmonary invalid.
   The third variety of Peripneumony is confounded by many ob-
 servers with Phthisis.   See Portal, Morgagni, Southey, &c.

          Haemoptysis, or Pulmonary Apoplexy, Page 69.

   Mr. Burns I think cursorily notices, and perhaps  accounts  for,
 the  condition  of the  lungs  named Pulmonary Apoplexy  by our
 author.   He considers it as always the consequence of disease of
 the heart,  viz. dilatation of the right side.   " The pulmonic  ves-
 sels by the congestion and continued vis a tergo are ruptured; blood
 is forced into  the air-cells; haemoptysis is produced;  or if urged
 still further, all the  cellular  structure  of the  lungs  is crammed
 with blood; these organs cut like  liver, and sink  when put into
 water.  This I am convinced from repeated observations is a fre-
 quent  cause of hemorrhage from the lungs, and I have seen several
 who have  lost their  lives from not preserving the muscular action
 within proper limits."  Burns on the Heart, p.  53.   Mr. Burns's
 view of the matter is highly  important, and, like all  pathological
 facts, tends directly to the improvement of practical  medicine.
 Certainly his  idea receives countenance from the  general  fact
 (noticed by him)  of haemoptysis being mentioned  by almost all
 writers as a symptom of enlarged heart.  It is  worthy of  notice
 that the two cases (15 and 16) of Haemoptysis given by our  author
 are complicated with disease  of the heart, but only in one of these
 was this in the right side.  What further enhances the probability
of this explanation of the phenomenon, is the fact of occasional
rupture of  the pulmonary substance in  these cases, as  mentioned
by M.  Laennec, page 71.

                 Pulmonary  Catarrh, Page 74.

  For  a much fuller account of  all the  varieties  of this disease
see the excellent Treatise on  Bronchitis by Dr.  Hastings.   See
also, the valuable little work of Dr. Badham on the same subject,
39 
JOG
NOTES BY THE TRANSLATOR
and the treatise of Dr. Cheyne on the Pathology of the  Larynx
and Bronchia.
  M. Laennec perhaps exhibits this affection in a  simpler  state
than it is often met with  in  practice, especially in  severe  cases
Unquestionably the inflammation often extends to  the  substance
of the lungs.  Dr. Hastings  particularly notices  this, page  282,
where he states the inflammation of the lungs as frequently reach-
ing the degree of hepatization.  This  is  also noticed  in many
cases of chronic Bronchitis given by Dr. Hastings.  For instance,
see Case 1, 2, 5 (particularly), 8, 18, and 22.   It  is worthy  of
remark that out of the 19 cases  of the acute disease given by the
same author, only one or two exhibit the  complication  of perip-
neumony—viz. No. 3, and 19, and these only in a  slight degree.
   However different Bronchitis  and  the true tubercular Phthisis
are in their nature, it  will  readily  be admitted by every prac-
titioner of  experience, that, in  certain  cases, it  is impossible  to
distinguish  them by any or  all the  usual  symptoms.   This  is
acknowledged by almost all writers on the subject of these diseases,
Among others, see Armstrong, page 184; Young , page  31;  Has-
tings, page  290.   Of the great importance, however, of a  distinc-
tion between these diseases there can be no doubt,  when we con
sider their  very  different  pathological   character; and  on  this
account, the new method of diagnosis of our author is unquestiona-
bly of the greatest value to these two diseases.
   More than one half the miners of Cornwall die  of varieties  of
this disease.  In them it is  very often complicated with disease
of the heart; and is to  be  attributed to a great  complication  of
causes. I hope to lay before the public an account of this affection
so dreadfully destructive of  human life.

              Dilatation of the Bronchia, Page 79.

   Perhaps this ought not to be considered as a distinct disease, but
rather as an accident or symptom of Bronchitis or some other dis-
eases of the lungs accompanied  by cough.   I know of  no  author
who has previously noticed this  affection, except Storck.  See his
Biennium Medicum. Leyd.  1761.

               Emphysema of the  Lungs, Page 82.

   This is a new disease, at least in practical medicine. It is only
by the progress of pathological knowledge that we  can  hope for a
true nosology.   Uncler  the term Asthma,  as many  very different 
NOTES BY THE TRANSLATOR,
307
 diseases are confounded as under  the  term Consumption.   It is
 hoped that the present work will be of no small use in leading to
 the discrimination of diseases, which cannot be confounded with-
 out the greatest injury to the subjects of them.  Our author, unlike
 some of his countrymen, does not range all asthmatic affections as
 consequences of disease of the heart, although he  evidently con-
 siders the disease as much more frequently symptomatic than idio-
 pathic.  If the term is  to be retained in medicine, it ought  to  be
 restricted to the idiopathic or spasmodic variety; or used  as the
 generic name comprehending the various species symptomatic of
 Bronchitis,  Diseased Heart, Emphysema and  (Edema  of the
 Lungs, &c. as well  as the nervous or the  idiopathic, so well  de-
 scribed by Dr. Bree.  See his Treatise on  Disordered  Respira-
 tion.

                (Edema of the  Lungs, Page 92.

   This condition of the lungs is noticed by many English authors.
 Dr. Baillie says he has not seen any well  marked example  of it.
 Morb. Anat.  page 77.  Dr.  Parry considers it  (Elements, page
 106)  as a frequent, and indeed  necessary  consequence of perip-
 neumony, and in this he seems corroborated by the  experience  of
 our author, page 93.  Dr. Darwin notices it among other dropsies
 under the  title Anasarca Pulmonum.  SeeZoonom. vol. iii.  page
 172, London, 1801.  See also  Dr. Perceval's  Essays, Med. and
 Exper.  vol. ii. page  177.  He says, " The difficulty of respiration
 is constant, and increased by the least  motion, though not  much
 varied by  different attitudes of the body, the patient complains of
 great anxiety  about the precordia, and when he attempts to take a
 deep inspiration, he finds it impossible to dilate his chest, and his
 breath seems to be suddenly stopped." It is obvious that these re-
 marks  afford only a very imperfect diagnosis of this disease-
   It is somewhat singular that this affection does not seem  to oc-
 cur in those cases  of general  dropsy  which are consequent on
 Bronchitis.   See Dr. Hastings's Treatise,  page 352.

           Bony Concretions in the Lungs, Page 104.

   These generally consist of a  large proportion of phosphate of
 lime, a  small proportion  of carbonate, and animal  matter.   See
Thomsons's Chemistry,  5th edit! vol. iv. page 572. See  also Dr
Prout's Analysis, Lon. Med. Repos. vol. xii. page 352. 
303
NOTES BY THE TRANSLATOH
              Black Pulmonary Matter, Page 112

  In  the  Philosophical Transactions for 1813, Dr. Pearson has
given an  account of  this matter, and a  chemical  analysis of it,
which, as  usual, are overlooked by our author.   I give (he  result
of Dr. P.'s examination in the words of Dr. Young:—u He [Dr.
Pearson] considers the bronchial bodies as true  lymphatic glands,
and thinks the black substance which often  tinges  them, consists
of charcoal, derived from  small particles of dust, floating in the
atmosphere, which have been taken in by the absorbents, and de-
posited in  their glands : and he has found some  of the lymphatics
occasionally filled  with a similar substance.   He  supports his
opinion  by chemical  experiments,  which  show  the insolubility of
the black  substance  in  nitric acid, while he has been unable to
find any other animal substance,  the ink  of the , cuttle-fish not
excepted, that resists the action of  the  acid.  The glands  of the
mesentery, he says, are also  sometimes black, but their blackness
disappears  upon immersion  in  the nitric or muriatic acid."*

                Medullary  Tumour, Page 117.

  It is extremely  discreditable to  M. Laennec  not  only to  have
taken no notice of the English works that mention this species of
tumour, but to have claimed the discovery of it to his own country.
He may certainly plead the custom  of his country in excuse; but he
might have had sufficient candour to consider this as a custom more
honoured in the breach than the observance. It is scarcely necessary
to refer  the English reader for an  account of this affection  to the
works of Burns, Hey,  and Abernethy, and more especially  to the
treatise of Mr.  Wardrop on  Fungus  Hosmatodes, or Soft Cancer;
Edin* 1809   A remarkable case of  this  disease existing in many
organs at the same time, and among others the lungs, is given by Mr,
H. Earle in the third vol.  of the Med. Chir.  Trans, page 59.

                     Pleurisy, Page 122.

  The chapter on Pleurisy offers an  admirable specimen of Pa
thology.   It contains  much that  is novel;  and  much  that  mud
tend to the improvement of practical medicine.
* Young on Consumption, page 468, 
                NOTES BY THE TRANSLATOR.            309

   The fact of the inflammation of serous membranes being always
accompanied with a serous effusion, although noticed by patholo-
gists for a good many years, since the publications of Carmichaei
Smyth and Bichat, appears  to be still very imperfectly  known to
the profession in  general.   The phenomenon has been  stated by
no writer more distinctly than by Dr  Parry in  his late  most ela-
borate work on Pathology.   See page 107 et sequent.   With the
knowledge of  this fact before our eyes, it  is surprising that the
recent doctrines  respecting the inflammatory character of many
dropsies, did not arise among us  sooner.   In  the cure  of acute
pleurisy, ought  the knowledge of the fact of serous effusion to in-
fluence  our practice in ordinary circumstances?  Of course, the
best remedies for checking  or preventing it are those which tend
directly to reduce the inflammation; but when the inflammation is
checked, or while we are endeavouring to check it, will  it be well
to keep in view the dropsical affection (for it is truly such) which.
though a mere consequence of the original disease, is now itself a
disease?   On this principle ought we to follow up theantipblogistic
treatment with  means calculated to promote the action of the ab-
sorbents and  the kidneys.

             Thickening of the Pleura, Page 123.

   This is asserted  by Dr. Baillie, page  54, although denied by
our author, page 123.  I think the very  definition of inflamma-
tion (redness, swelling, &c.) necessarily  involves  some degree  of
thickening.
   Where so  many cases of Acute Pleurisy are on record, and so
many must have  been met with by every  practitioner of experi-
ence, it may  seem useless to refer to any individual case.  Owing
to its conciseness, however,  and its. perfect accordance with  what
I have myself seen, I must refer to the appearances on dissection
in a case detailed in the Lond.  Med. Repos. vol. v. page 479.
   Cartilaginous thickening of the  Pleura is mentioned by Parry.
Elements, page  114.

                 Chronic Pleurisy, Page 129.

   No disease has been more misunderstood than  this,  both in a
pathological  and practical point of view.  For an excellent ac-
count of the external symptoms of this affection see Dr. Armstrong's
treatise on Scarlet Fever, &c. page 193: see also Dr. Abercrombie's
paper already referred to in  the Edinburgh Journal.        i 
310
NOTES BY THE TRANSLATOR.
              Contraction of the Chesf, Page 131.

   M.  Larrey in  a  late number of the Journal Compliment,  des
 Sc.  Med. for May 1820, details several very  interesting cases of
 Chronic Pleurisy and Empyema, resulting  from wound, in some
 of which this contraction of the  chest was \ery strongly marked.
 See  Medico-Chir. Review for Dec.  1820.   It would appear that
 this  condition of parts existed in some of the cases called Tubercu-
 lous Accretions by Dr. Baron.  See page 173-4, &c. of his work.

                Empyema, Pages  130 and 149.

   This operation has often been performed, and with much ad-
 vantage,  in  this country.  A very interesting case of chronic
 pleurisy, in which this operation was performed, has been lately
 published by Dr. Hennen in  the 65th No. of the Edin.  Journal.
 It is to be remarked  as a most striking instance of the  want of
 precision  in  our ideas respecting diseases of (he chest, that  this
 learned and experienced gentleman should have denominated this
 most decided case of Pleurisy—Hydrothorax.
   In the cases of M. Larrey above referred to, he mentions  an
 oedematous  state of the teguments  behind the  hypochondrium of
 the affected side as an invariable pathognomonic sign of effusion
 of blood into  the chest.   The  same  condition of the  chest is
 noticed by our countryman  Mr. Sharp in the  case of Empyema
 (Crit. Inquiry, § Empyema); and also by Mr. Hey, (Surgery, page
 476.)

         Fluctuation in Empyema,  Pages 142 and 249.

  Many English authors mention this symptom.  In many of the
cases recorded we have  not sufficient data to enable us to ascer-
tain  the correctness of M.  Laennec's idea of the uniform coexist-
ence of pneumo-thorax with empyema in all cases wherein succus-
sion  produces  the sound of fluctuation.  In Mr. Hennen's case
this  effect  was  very perceptible,  and from some parts of the
narrative it would seem probable that there was here  an  effusion
of air  also. 
NOTES BY THE TRANSLATOR.             3H
                  Place of Election, Page 149.

   In one case,' contrary to the usual practice, Mr. Hey operated
between the fifth and sixth ribs.

               Idiopathic Hydrotlwrax, Page 151.

   The  great rarity of the  true hydrothorax  ought to make us
cautious how  we give this name to so  many affections as  we are
accustomed to do; and the undoubted fact of a  serous effusion
being an almost uniform  attendant on  the inflammation of serous
membranes, ought to make us slow  to trust  to mere diuretics and
other similar  remedies in cases wherein we  have strong reason
for suspecting dropsical  effusion, especially in  the  chest.  The
now very generally allowed connexion between dropsy and inflam-
mation, mentioned by our author in  many parts of  this treatise, is
still much better understood in England than  France.  It is there-
fore hardly necessary  to refer the English reader to the works of
Blackall and  Parry, and  especially Crampton,  for the practical
and pathological illustration of this  important  doctrine.

Symptomatic Hydrothorax from tubercles on the Pleura, Page 153.

   In this and  many other parts of the  treatise, our author notices
the tuberculous  affections of   serous membranes  lately so  ably
illustrated  by  Dr.  Baron.  It must be  very satisfactory to that
gentleman  to have his  statements corroborated by so great an au-
thority;  more especially  as they were evidently unacquainted
with each other's inquiries.   Dr. Baron's work is a most valuable
addition to our pathological knowledge; although the author appears
occasionally to have extended  his peculiar views to some morbid
appearances which  might perhaps  be explained  on the principle
of ordinary inflammation.

                   Hoema-thorax, Page 155.

   This is noticed by Dr. Parry, page 119, and sanguineous effusion
mentioned  as  an occasional  consequence of inflammation in all
textures. 
312
NOTES BY THE TRANSLATOR.
                  Pneumo-thorax, Page 159.

   Dr. Duncan, Jun. informs  me that he  has often met with this
uffection in cases of empyema.   Where  he suspects  it  before
opening  the thorax, he examines the diaphragm from the abdo-
men.—" In one case lately," he says, " as I  predicted,  we found
the  diaphragm on  one  side convex  upwards,  and on  the  other
convex downwards: on  puncturing  an  intercostal  space on this
side, the air rushed out and the diaphragm rose into the chest."

                Diseases of the Heart, Page 165.

   It is not very creditable  to  M. Laennec  not to have noticed
some of  the English  authors on disease of the  heart, especially
Mr  Burns and Dr.  Farre, and  also Dr.  Warren's  little  work.
In the  excellent treatise of the  former, much very valuable matter
is contained.   For many valuable  observations respecting the
affections of both the lungs and heart, the reader is referred to Mr
Howship's Pract. Obs. on Surg. &c.

                   Hypertrophia, Page  165.

   This is excellently  described by Mr. Burns, page 40.

              Dilatation  of the heart, Page  167.

   Mr.  Burns states this condition of the heart to terminate very
commonly in  chronic inflammation.   I fear M.  Laennec is occa-
sionally too exclusive in his distinctions.
   Dilatation of the heart is considered by Mr. James (Med. Chir.
Trans, vol. viii.)  as  frequently  caused  by obstruction in the mi-
nute secerning and nutrient vessels.

             Ossification  of the Heart,  Page 176.

   In addition  to the few  cases of  this mentioned by  our author,
a remarkable case is  noticed by Mr.  Burns, page 131,  in which
there was abroad belt of bone  round both ventricles.  In another
case he found both ventricles " nlere  calcareous moulds "—It is
singular that M. Laennec no where notices  the ossification of the 
NOTES BY THE TRANSLATOR.            313
 coronary arteries,  considered by  Dr. Parry as  the usual cause of
 Angina Pectoris.   See Dr. Parry's treatise.

        Carditis, Page 177, and Pericarditis, Page  197.

   These two diseases have been  commonly confounded in dissec-
 tion, and they cannot be separated in practice.  For an excellent
 account of this see Dr. Baillie's Morbid Anat.  See, also, the much
 less satisfactory work of Dr. Davis on Carditis.  I  have already
 mentioned Mr. Burns's opinion of this disease frequently super-
 vening to dilatation of the heart.

               Globular  Excrescence, Page 187.

   This is  noticed by Mr. Burns, page  194.   In a  case of  Po-
 lypus  mentioned  by  Mr.  Burns, page  200, he  states perfectly
 formed pus to have been contained in  it:—was this an instance of
 M. Laennec's Globular Excrescence?

         Red colour  of internal Membrane, Page 188.

   Some  recent attempts  have been  again made to connect this
 appearance with inflammation, and to make a general affection of
 the arteries of this kind to act an important part in the pathology
 of febrile diseases,—how truly, I am  very sceptical.

             Malformation of the heart,  Page  192.

   For a much more complete view of affections of this nature see
 the works of Mr. Burns and Dr.  Farre.

               Hydro-Pericardium,  Page 201.

   For some curious cases of this affection, in some of which  tap-
ping was successfully performed by Dr.  Romero, a Spanish phy-
sician, see Dr. Johnson's Review  for Dec. 1820, page 477.

                    The  Pulse,  Page 263.

   The remarks on the Pulse are  extremely important.  The in-
sufficiency of this as a test of disease must  be  acknowledged by
every practitioner of experience.   Yet it is surprising to perceive
                             40 
3H             NOTES BY THE TRANSLATOR.
the effect of habit  and early associations in this matter.  How
often  do we hear of a pulse being half a dozen or half a score of
pulsations above or  below par, and indications of cure founded on
this  important alteration!   For  some excellent observations  on
this subject see Dr.  lVry's  Elements,  page 48 and  seq.   " If
these things are so, surely  we  ought to wonder at the  confidence
with  which physicians look to the condition of the  pulse in the
radial arteries as the general evidence of the state of disease,  and
the chief rule  of the administration of remedies." Parry, page 50.
   The purring sensation mentioned by M. Corvisart and our au-
thor,  page 272, is  attributed by  Dr. Ferriar to simple dilatation
of the heart;  and by Mr. Burns to Hypertrophia, or to dilatation
with chronic inflammation,  or with lessened  size, of the arteries.
   In  employing the cylinder in diseases of the'heart, there is one
source of error  which I think it the more  necessary to point  out,
as I was myself more than  once misled by it in my earlier explo-
ration.   When  the instrument has been closely  applied for some
time the skin  occasionally adheres in some degree to it; and when
the motion of  the patient's body, or a deep expiration, detaches it,
in the moment  of  separation a sound somewhat resembling  that
produced by the tearing of  doth, or  by a rasp upon  wood, is ex-
cited; and may, without attention, pass for the sound said to cha-
racterise contraction of the  valvular orifices. 
EXPLANATION  OF  THE PLATES.
                          FLATE  I.
                                          •

   Fig. 1.  This represents a section of the superior  lobe of the
 lung, containing tubercles in different stages, and a vast tubercu-
 lous excavation.  There are also, here and there, some pulmohary
 spots, more numerous between the excavation and top of the lung.
   «.   Very large anfractuous excavation, produced by the soften-
 ing of the tuberculous matter, which still lines it partially^
   bb.   Columnar bands crossing from one side of the excavation
 to the other,  composed  of the pulmonary tissue condensed, and
 covered with a thin layer of tuberculous matter.
   cc.  Masses formed by the reunion of several immature tuber-
 cles, exhibiting, in the section of their substance, an indented ap-
 pearance.  The shaded parts represent the  grey  and  semitrans-
 parent matter of the incipient  tubercle, and the inner  white por-
 tions point out the same where it has become yellow and opaque.
   d.   The miliary granulations of M. Bayle.
   ee.   Bronchial tubes opening into the excavation.
  /.   Part of the exterior surface of  the lungs.
   Fig. 2.  A section of the upper lobe of the left lung, exhibiting
a vast and very ancient  pulmonary fistula, traversed by  obliterated
blood-vessels,  and lined by a thin semi-cartilaginous  membrane.
Between this cavity  and the top of the lung are seen spots of black
pulmonary matter, tinging the substance of the lung quite black.
   a.  Bottom of the fistula lined by the semi-cartilaginous  mem-
brane.
   bbb.   Bronchial tubes opening into it.
   ccc.   Obliterated   blood-vessels,  crossing the cavity and  then
ramifying on its walls. 
316            EXPLANATION OF THE PLATES.
  d.  Small«excavations, or ulcerations, occupying only a portion
of the thickness of the semi-cartilaginous membrane.
  ee.   External surface of the lung.

                         PLATE II.

  Fig. 1.   Section  of the upper lobe,  the  exterior of which  is
seen in Plate V. fig. 2.                 „
  a.  Fibxo-cartilaginous cicatrix surrounded by pulmonary sub-
stance strongly marked by the black matter, yet in other respects
sound and crepitous.
  b.  A bronchial tube greatly dilated and terminating in a cul-
de-sac at the cicatrix.
  c.  The  same  obliterated  and  continued into the  cicatrice.
(Some other bronchial  tubes seen open on the surface of the sec-
tion, point out the original diameter of the dilated branch.)
  d.  Bands of accidental serous tissue  uniting the lungs to the
pleura of the ribs.
  Fig. 2.   Incomplete cicatrization of a tuberculous excavation.
  a.  Group  of incipient  tubercles, grey  and semitransparent
externally,  yellow  and opaque in the centre.   These and  the
whole lung  are interspersed with spots of the  black pulmonary
matter.
  6.  Cartilaginous cicatrice, almost linear.
  c.  Extremity of this,  divided into two layers and enclosing a
small portion of dry tuberculous matter.
  d.  v Blood-vessels cut across.
  e.  Immature tubercles.
  /.  Exterior surface of the lung.

                         PLATE III.

  Fig. 1.   Deep  depression on  the  surface of the  lungs corre-
sponding to  a cicatrice within.
  a.  Portion of the upper lobe.
  b.  Depression corresponding with  the cicatrice.
  c.  Part  of the anterior border of the lung overlapping the de-
pressed  portion.
  d.  Part  of the posterior border of  the lung.
  Fig. 2.   Cartilaginous fistula, with very unequal  walls, in the
upper lobe of the lung. 
EXPLANATION OP THE PLATES.           317
  a.  Surface of the lung.
  6.
  c. d.   The cartilaginous mass.
  ee.  Part of the pulmonary substance comprised between the
cicatrice and summit of the lung, quite black with the black pul-
monary matter.
  /.  Fistulous  excavation in the centre of the mass, with two
bronchial-tubes opening into it.


                         PLATE IV.

  Fig.  1.   Part of the upper lobe exhibiting several of the air-
cells immensely dilated.
  aa.   Surface of the lung.
  bbb.   Large transparent vesicles full of  air, formed by the re-
union of several air-cells.
  cc.   Air-cells in a lesser degree ofdilatation.
  Fig.  2.   Part of the upper lobe also emphysematous.
  aaa.   Air-cells dilated and prominent.
  b.  A point covered with  dilated vesicles corresponding to a
rupture of  the substance of the lungs within.
  c.  Air-cell  much  dilated and apparently pediculated.
   d.  Extravasated air between the pleura and lungs.
   Fig. 3.   Summit of an upper lobe in the state of emphysema,
tied to  prevent the escape of the air, and dried in the sun, with  a
slice removed to show the dilatation of the cells.
   a.  Surface of  the Lung.
   b. c.  Slice  removed to show the cells.
   Fig. 4.   Portion of a sound lung tied and dried as fig. 3. with
the view of comparing it with the emphysematous lung.


                          PLATE  V.

   Fig. 1.  This  figure  represents  different forms of the tuber-
 culous  matter,  and some of its effects.
    aaa.  Immature or crude tubercles quite yellow.
    6.   Groups  of  incipient tubercles, still grey and semitranspa-
 rent externally.
    c.   Small  cartilaginous cyst, emptied of its  tuberculous con-
 tents.
    d.   Tuberculous  excavation entirely empty and lined by two 
318           EXPLANATION OF THE PLATES.
 membranes,  the exterior semi-cartilaginous,  the  interior  soft:  a
 bronchial tube opens into this excavation.
   e.   Small  empty tuberculous excavation, not lined by  any '
 membrane;
   /.   Surface of the lung.
   g.   Tubercle partly softened and evacuated.
   h.   Incipient tuberculous infiltration of the pulmonary tissue.
   Fig. 2.  Depression on the surface of the lung, indicative of an
 interior cicatrice.
   a.   The depression.
   b.   Accidental  serous tissue  uniting the  lungs to  the costal
 pleura.  N. B.  A section of this  figure is  given in Plate II.
 fig. 1.

                        PLATE VI.

   This figure  exhibits  the effects of contraction of the chest con-
 sequent on pleurisy.
   a.   The sound side.
   b.   The contracted  side.

                        PLATE  VII.

               A back view of the same subject.

                      PLATE. VIII.

   Fig 1.  The Stethoscope  or  Cylinder,  reduced to  one third
its actual dimensions.
   a.   The Stopper.
   6.   The lower end.
   c.  The upper half.
   d.   The auricular or upper extremity.
   Fig. 2.   Longitudinal section of the same.
   a.   The stopper.
   b.  Point of union of the two parts.
   c.  The upper half.
   Fig. 3.  The same section,  with the stopper removed.
   Fig. 4.   The stopper.
   a.   The body of it,  formed of the same wood  as the rest of
the instrument. 
              EXPLANATION OP THE PLATES.           319




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   F'g-5.   Upper half of the stethoscope.
   a.  Body of it.                   v


   Fie S6CreWA!!n 'h W°0d) f°r,fiXuin§ the two P°rtions toge*er.
   * ig. b.   Actual diameter of the stethoscope.

   a.  Diameter of the canal of the stethoscope.



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Laennec, Treatise on the diseases of the chest..., WF L158de 1823 c.2
Condition when received: The full leather binding was in poor condition.
The sewing was intact; however, the leather was broken at the hinges.  In
addition, the pastedowns were broken at the inside hinges. The spine leather
was weak and powdery.  Small sections of the spine leather were delaminating
and there were many small losses overall. There was a one inch square
missing fragment at the head of the spine. Comers on the front and back
covers were extremely worn to the extent that the inner paper boards were
exposed and delaminating into layers.
Conservation  treatment: Detaching and lifting leather on the spine was
secured  using a 1:1:1 combination of wheat starch paste (zin shofu.
Conservation Materials, Ltd.): methylcellulose (A4M, Talus): Jade 403M
(University Products).  The spine leather was consolidated using 2% Klucel G
(hydroxypropylcellulose, BookMakers) in ethanol (Nasco). The outside
hinges were reinforced using strips of acrylic-toned sekishu paper (all papers
from Japanese  Paper Place) adhered with  the above three-part adhesive
mixture. The inner hinges were reinforced using untoned sekishu and the
above adhesive three part mixture. The comers were strengthened using wheat
starch paste (above) between paperboard layers. In addition, methylcellulose
(above) was brush-applied to the surface of the exposed paper board comers.
Conservation carried out by Rachel-Ray Cleveland
NLM Paper Conservator, 2/2005 
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