"R742* 184-5 ■>>J> ► > > > }>« ► >r> > > '.■> * :> :> > > :>> > )> >> 3 > > ^>- 5^> >-- ~> )5> "3? ;>> •'- fer. ^CX0C!O'D£)fGOfC-;1 ^> >. >^ D 2 ^> > > Naoooaaoees- ?^ > ►. >.^> . >-> »>>>€*> »3> *-*S "> >N>»33 5> > >": » > >>'■» | S 3 0.^1 »> ■ 2> > > ^ 3»^l i»"> ^ ' \ z> :>»:>:>> D>> |B>J > > > > 3»~ 3 > ' > 3T3L>: 5p* >^> S 3 3D.. ~^VeeW> » > :> ooe> ^^ O > » 3 j> ZJP- £>">-'> > :>x> »» ^ > >. ► >jg> >* >^> - ► ~>2> >" > > _- > »t> r»- ">. . > 3. or> ^> »> >* ,,v' -< > ^ 3 > > ^3>^> > >>2j> > ) > > > 3 > -> > -> y 3> > > > 3 >> J>Jj - > ->> >)-> :3> > 35 >•» ^» .•» ^ > > >> aj^tj > > -> 3 > :» ><& :»> ~>> &^^ -»*> IS > > =* »» ^> )> - .:>;>.£>> > ■ > > >>> > \ »•> M* >T> >> > ? . > »» ;> » j» > "> > >. o jji> > ) >> > J ^ >■>•> >5> > > 3> > > > »'">>■> 2> > > >o ^» 5 >■>>> 33 -> i 3D > ^> S33> S>' > > >» > t> >>>> »3 3 >3t> "> ^> >>.» >:> ■> »3 » >.- ■S5S* 33> > > >o 3 . •> > >> 3> > y^s> ) »X> "5>5 >>2> 3 > > > > >> . > >>.> > j >u> D3 > 3X> 3 > >3 "&■> ' >^> > > 0X> > Jj>> C§> > •> > >3 "»-»>> -,» > >>)> >^>'>> ) ■» D> ~» 3> '> 3" 5 > >>> > » > >» > 3333 » 3> »■>»> 3 >>:>>> 'a ft,:» > -> > 3» >3> 3» 5 y ^J^ 3 > >) >J ^S» "> ->_ 3 "> JP> >J> >» ^ » -> o 2» ^'^> Jg■ > °>.i_ ^ 3>2) )> > > > 3 3>^ » 3 > Z 3 3 D . > >^> - 3^ >>^ 3> ^> > ^> 30 3 3 > -= >" ^ 2> IS 3 3 -3» > > 3> > ■ 3 > 3 '> > > 3 T» 3 > >> 3 > > 3> . >> ► 3? » 3)> - 5>^> ' 3 > •> -^ >.5> -— ^> >>^ '3, > >^)> > "> >^ ^> > > 3» 3 > 5 3> 3 >^>:> 3 1-5^ 5?« ^£ 3>i> » \W >^ 3>- »2> ">» V >"3». > ) o > ? >> > > >» 3 ) Vj 3 > ) 3 3"-V^> > o * > >3 3 3 >' 3 ^» ^^> " > J> > > O 3 3 ^ » > > ~» > > > > » > 3 * ">- ^ > > > > > ) 3 > >3 > > > > 3 > ^> ■> > ^ » ^ > > ^ ^ » >* 3 3 ;> ->: 3> >) >> 3 > 5 ~»:> >3 * j> > >S> *> >^> 3> 3 3 t3» V> > i » 2k» ^> "> > > ^ ,i » 3> > 3 n> 3> s> 3 £ ^ >> » .> » » ' 1 "> >^ "> > »^> 3 >^> > r> 3 >-^^ 3 ?l3 , 3 »3 • |3 "3 so >^^ 3 ».) > ^> > >> > 3 >5> , > '3 3 ) a 3 ■ "j> y> >■ ■> - J> > 3 ■j> > > J> "3 3 »3 > >v,> » r> > £> »-3 ^> >> 3> ^») ~_ , > » >» > > 3^ 3- > 3 :>> 3-. 3> "> ^> >- ^ ^> ^>) > _- -y >3 3- : 3 ^3. 3 >> > 3 v>3- 3 ^>> 3- "3 >> >5» 3 O J3 3 3 » ^> ^> :» ^ 3 33 j> j3> 3 3 y>-' » > > Z> > »3» 3> >» > ^ ^-» 33 3 3 3 > > ^> '3> ^_ > > :> >> > i3i ~3 O » C* ^> 73 >") ^3 _ 3 v> » ■»'""^ .~^>3U> / A TREATISE ON u PATHOLOGICAL ANATOMY: CARL ROKITANSKY, M. D., PROFESSOR EXTRAORDINARY OF PATHOLOGICAL ANATOMY AT THE UNIVERSITY OF VIENNA. PAR T I. CONTAINING . THE ABNORMAL CONDITIONS OF THE ORGANS OF RESPIRATION. TRANSLATED FROM THE GERMAN, WITH ADDITIONS ON DIAGNOSIS FROM SCHOENLEIN, SKODA, AND OTHERS. .( DR. JOHN C. PETER II ' _________________ NEW-YORK : WM. RADDE, 322 BROADWAY LONDON: H. BALLIERE, 219 REGENT-STREET 1845. 6(S Entered, according to Act of Congress, in the year 1844, By WILLIAM RADDE, In the Clerk's Office of the District Court for the Southern District of New-York. J. F. TROW & CO., PRINTERS, 33 Ann-Street, N. T. • TO ALEXANDER S. WOTHERSPOON, M. D. ASSISTANT SURGEON tT. 3. ARMY, AND LATE RESIDENT-PHY8ICIAN TO THE NEW-TORE • HOSPITAL. THIS TRANSLATION fis respectfully ©etofcateH, KB A TRIBUTE TO HIS ACQUIREMENTS IN PATHOLOGICAL SCIENCE, AND A TESTIMONY OF THF. TRANSLATOR'S NUMEROUS OBLIGATIONS, BY HIS FRIEND, J. C. PETERS. * TRANSLATOR'S PREFACE. It has long been admitted that the great impulse which has lately been given to the studies of anatomy, physiology, micro- scopy, and pathological chemistry, had its origin in Germany; faint rumors, too, have reached this country of equally great ad- vances made in pathology and pathological anatomy, and many expectations have been excited as to the nature of the rich har- vest said to have been reaped by the proverbially profound and studious Germans. It is already considered a disgrace for an American physician to be unacquainted with the labors of the French, English, and Irish pathologists, and, as the Germans have now outstripped their neighbors, the time is not far distant when the same stigma will rest on those who are ignorant of German pathological literature. Hence, we think that we need make but few excuses for undertaking the translation of any reputable German work on morbid anatomy, and are still less in- clined to make any for selecting that of Rokitansky; but we would fain beg the indulgence of our readers for the manner in which our task has been accomplished, as it was no easy one. " Rokitansky's book is what it professes to be : it is morbid anato- my in its densest and most compact form, scarcely ever alleviated by cases, histories, or hypotheses; it is just such a work as might be expected from its author, who is said to have written in it the results of his experience gained in the careful examina- tion of over 12,000 bodies, and who is possessed of a truly mar- vellous power of observing and amassing facts ;"* but his style of writing is often rough, and even ungrammatical, although his difficult and uncouth language is ever forcible and explicit, and * See British and Foreign Med. Rev. Jan. 1843, p. 84. vi TRANSLATOR'S PREFACE. expresses his meaning with all the accuracy and perspicuity which half of the European tongues compressed into one are capable. Hence, we are scarcely ashamed to own that the present is the fourth version which we have made ; twice we essayed the task unaided, and although we had read the work repeatedly and carefully, and were familiar with Rokitansky's style, from hearing his lectures and enjoying familiar private in- tercourse with him, we could not succeed in making even a passable translation. We had thrown up the task in despair, although our admiration and friendship for Rokitansky had drawn us to it as to a " labor of love," and we had received not only his permission but his request to undertake it, when Dr. Wotherspoon volunteered his assistance and almost forced us to the third trial. Even the result of our joint labors did not meet a very low ideal of what the work ought to be, and hence we not only revised and compared it with the original text, but re-wrote the whole. We pledge ourselves for the faithfulness of the trans- lation, and although Dr. Wotherspoon took considerable pains to render the style more English, it will still be found foreign and rude in many respects ; as it is, we flatter ourselves that it will bear a comparison with the translation of parts of it, given in the January, 1843, No. of the British and Foreign Medical Review, the editor of which, it is well known, is a great stickler for purity and accuracy of style. We beg also distinctly to state that all the notes on diagnosis are mere compilations, in which we have not only used the ma- terials of the authors whose nanies will be found appended to each, but also their language ; we are even constrained to apolo- gize for the mutilation of the latter, which want of space often forced us to make at the expense of elegance. The names of Skoda and Schoenlein are here introduced for the first time to the American medical public, as able diagnosticians ; the latter en- joys the reputation of being the greatest master of general diag- nosis in Germany, and the former as the most original and accurate auscultator and percussor. It is a sufficient pledge of their abil- ity, to state that the majority of the novel and important addi- TRANSLATOR'S PREFACE. vii tions to diagnosis made by Graves, Stokes, and many others, may - be traced to these two sources. Occasional notices have been made of Rokitansky's work in English, Irish, and American journals; and as most reviewers think themselves called upon to make an exhibit of the superior knowledge which they possess upon subjects to which others have devoted the undivided attention of a whole lifetime, it is not to be expected that Rokitansky should escape unscathed, especially from those who have never seen his work, and who are farthest removed from the field of his labors. The editor of the Dublin Medical Journal (see July No. for 1843) ventures a wholesale condemnation of Rokitansky's method of studying and teaching pathological anatomy, and that after merely reading a short but favorable account of the Vienna School of Medicine in Wilde's Austria; he says, " The readers of this [the Dublin] journal, who have attended the instructive meetings of the Dublin Pathological Society, will have no hesitation in coin- ciding with us in opinion that the plan of teaching pursued by Rokitansky is little better than useless. He must have observed, that the cases brought forward at that Society, unaccompanied by an accurate detail of symptoms, and faithful records of the effects of treatment, were little better than worthless ; as specimens of diseased structure they were interesting, no doubt, to the mere morbid anatomist, but any of our museums conld have furnished, perhaps, infinitely better examples of the same alteration of struc- ture. It is not in this way that the science of medicine can be advanced; that object can only be obtained by placing on record an accurate account of the symptoms present during the life of the patient, the result of treatment, and the morbid altera- tions disclosed on dissection—this is the true method of study- ing pathology, and it is for this reason that the works of Andral, Cruvelhier, and others, who have pursued the same path of inves- tigation, have succeeded in leading to improvements in the prac- tice of medicine." We cheerfully admit that the above would be serious and fair objections, if they were true; but all these things and more are done in Vienna, but not by the same laborer. It is well known* Vlll translator's preface. to every one who has studied in the huge " General Vienna Hospital," that there are clinical professors there, who have successively risen from the post of resident physician to that of secundarius, thence to that of primarius, and professor extraordi- nary, and finally to professor in ordinary ; that there are aged resi- dent physicians who have been elected by " Concours," and if found worthy are sure of professorships ; that medical students are not allowed to walk the hospitals before they have studied three years, and that then each is put in charge of a patient, under the supervision of the resident physician and clinical professor ; that an accurate record, containing the history of each patient, with the variations of his symptoms from day to day, and the effects of treatment, is kept hanging over the bed of each patient; that in case of the death of the patient, the resident physician and the pupil who had him in charge, and, on all important occasions, also the clinical professor, and his whole class, are in attendance at the dead-house on the following morning; that when the name and number of the patient is called, these take their station at the post-mortem table, and the autopsy is performed by Roki- tansky or one of his assistants ; that a detail of the post-mortem appearances is dictated in a loud voice to a secretary, who writes them down on sheets similar in size and shape to the papers on which the Hospital records are kept; that when the examination is finished, the clinical professor or the resident physician is called upon for a short resume of the case ; that, finally, the record of the post-mortem and of the history of the case is placed among the archives of the pathological museum. It is well to add, that Rokitansky was first educated as a hospital physician ; next, he was trained up in the dead-house in the celebrated Sifft, and finally was elected to the professorship of pathological anatomy ; that all medico-legal, or so-called coroner's cases, are submitted to him for examination, so that life and death hang upon his verdict almost every day, and he is forced to acquire a most ex- tended knowledge of practical medicine, which is the more necessary to him as he is daily called upon to verify or condemn the diagnoses of numerous clinical professors. Such is the translator's preface. IX training to which his naturally researchful and truthful impulses have been subjected through a long series of years. Right honestly and modestly does he perform his delicate duties; ever inclining to the side of mercy, he is firm enough to add the weight of his testimony to that which has been accumulated against a trembling or hardened criminal, and never is found weak enough or mean enough to gloss over the mistakes or flatter the vanity of hospital physicians. In order to fully appreciate Rokitansky, he should be seen and heard when a discussion ensues between him and the clinical professors; at such moments the fruits of his extensive knowledge, gained by long service in a hospital where nearly thirty thousand patients are treated yearly, by nearly twenty years' service in the dead-house, and by a most extended and accurate course of reading, are brought to bear upon the case in question, in a rapid and condensed, but graphic and truthful manner. These ever-occurring discussions would alone prevent his sinking into a mere morbid anatomist, for daily he is thrown in collision with learned clinical professors, and their opinions of the origin, nature, progress, and proper treatment of disease are constantly dinned into his ears, and are as frequently con- trasted with Andral's, Louis's, Cruvelhier's, and other morbid anatomists, and his own deductions drawn from the cadaveric appearances, and quickly he is transformed into a learned gen- eral pathologist. Impartial reviewers should be cautious how they hazard a lance against the victor in a thousand conflicts. It is interesting to inquire what effects are produced upon the clinical professors and resident physicians: daily they appear in the presence of their classes, before a reserved but kindly man— before an experienced and truthful pathological anatomist, as it were, to render an account of their convictions as to the nature and treatment of disease. Frequently we have seen the cheeks of proud clinical professors and vain resident physicians mantled with shame, when an impartial and careful post-mortem has revealed their errors in diagnosis and treatment ; but still more frequently we have seen the accurate predictions of Skoda, Helm, Schuh, &c, &c, confirmed and received with plaudits by the assembled host of students and foreign physicians, who have X translator's preface. watched the case during life, and now witness the examination after death. The consequence is, that those professors who are too proud to learn never show themselves in the dead-house, their cliniques are deserted, and government waits but for a plausible pretext to depose them from their rank ; but the zealous and honest become doubly anxious to excel in diagnosis and treat- ment, for the various shades of structural alteration revealed by the scalpel of Rokitansky, form so many problems for them to solve. Many of these new diseases are quickly diagnosed, and suddenly a "New or Young Vienna School of Medicine" springs into existence, at the head of which the modest Rokitan- sky is thrust by universal acclaim long before he had commenced to be ambitious of worldly distinction. Hence we cannot see why the Dublin Journal should so quickly take the alarm because Rokitansky, different from all other pathologists, does not engage in the study or treatment of disease during life—because he is not now a practical physician, and seldom sees one of the many hundreds of sick, the bodies of which he dissects. This anomaly, although peculiar to this school, undoubtedly possesses many advantages : as Wilde truly observes, "We all know how difficult it is to dispossess the mind of any previously conceived and long cherished idea, by which we either treat or explain the phenomena of disease. We have all witnessed how frequently men generalize from a few particular cases, and how easily they find the morbid appearances to agree with the previous diagnosis."—Vide Broussais's gastro- enterite. " This is because the physician and pathological anat- omist are one and the same person. The Vienna school, previous to the present mode of examining diseased structures, offered a well marked example of this defect. The protocols of the different medical and surgical sections of the hospital teemed with numbers of cases whose post-mortem appearances fully cor- roborated their previous diagnosis, yet but little advance was made in. pathological science in those times. Furthermore, al- though I [Wilde] do not believe that diseases have altered, yet we now find pathological appearances quite different from what they seemed to be prior to the introduction of Rokitansky's me- translator's preface. xi thod. The first emancipated himself from the incubus of ideal pathology and false diagnosis, and now teaches general patholo- gy and morbid anatomy unobstructed by them." It is sufficient for Rokitansky's class to witness at least four or six, and fre- quently ten or twelve, post-mortems every morning; to hear the record of each case read, and the post-mortem appearances dic- tated aloud ; to be required every afternoon to perform an autopsy in turn, describe the healthy and morbid appearances they meet with in each cavity and tissue, and answer the ques- tions of the professor upon the subject; to listen to Rokitansky's remarks upon all the morbid specimens which have been collect- ed during the day, and finally, when thus grounded in the princi- ples of pathological science, and their eyes made familiar with diseased appearances, to follow him to the museum and hear an elaborate course of lectures, illustrated by the largest and most valuable collection of morbid specimens now extant. The rest of practical medicine can be learned at the bedside in the hospi- tal, from teachers as competent in their peculiar departments as Rokitansky is in his, and mainly rendered so by the impulse which has been given to their studies by the peculiar labors of Rokitansky. The Philadelphia Medical Examiner (see No. for August 5, 1843) has taken its cue and its materials from the Dublin Jour- nal : from it Ave learn that " The present Vienna school of Pathological' Anatomy, under the celebrated Rokitansky, has of late acquired much notoriety. Though an unrivalled pathologi- cal anatomist, he is in reality no pathologist, and as all his de- ductions are drawn from cadaveric appearances, his opinions on disease should be received with great reserve. We hazard this little caution here, because Rokitansky's reputation is a rapidly growing one, and as authority is every thing now-a-days in med- icine, in a few years we shall not be surprised if the most as- tounding theories become the vogue, solely because they emanate from the fashionable Vienna professor. His late theory on Ty- phus is a specimen of what we may anticipate from a man whose studies are thus exclusive. As Rokitansky is the acknowledged head of the Young Vienna school, and as he is a man of great XII translator's preface. abilities, as well as a clear and attractive writer, his influence is by no means limited." Rokitansky's theory of typhus consists in the statement of fact, that a peculiar typhous-matter is found in the intestinal ul- cers, mesenteric and bronchial glands ; that the quality of the blood is much altered, as evinced by chemical analysis and its outward appearance ; and he suggests that typhous fever is an acute dyscrasia, which may be classed and compared with the cancerous and tuberculous, which are also marked by a peculiar alteration of the blood, and the deposition of heterologous deposits. Those who have never read his work may pronounce Roki- tansky a clear and attractive writer ; those who have, will be more apt to agree with the British and Foreign Review, that " it is written in such vile, crabbed Bohemian-German, that few, even of those to whom good German is familiar, will ever wade through it;" we may add that those who do, will also agree with the latter, that " no modern volume on morbid anatomy contains half so many genuine facts as Rokitansky's; and that it is alone sufficient to place its author in the highest rank of European medical observers." As to astounding theories becoming the vogue, merely because they emanate from the fashionable Vien- na professor, the British Review declares that Rokitansky's work is no more than it pretends to be, viz., Pathological Anatomy, in its densest and most compact form, scarcely ever alleviated by a the- ory or hypothesis ; and concludes by stating that he has said but little of its merits, as the best evidence of this is found in the extent to which he has abstracted from it, without passing the bounds of what is novel or important; and adds, nor would that fault have been committed though much more had been borrowed. In conclusion, we would state that the second part of the work is almost ready for publication, but will not be forthcom- ing unless the sale of the first part warrants it. In the mean time we intend revising and re-writing it; we also hope to com- pile better notes on diagnosis than those which are appended to the first part, which was already in the printer's hands before our publisher insisted upon their being added. ABNORMAL CONDITIONS OF THE ORGANS OF RESPIRATION. They may be divided into those of the tracheal trunk and its branches, viz. (the larynx, the trachea, and the bronchi ;) into those of the lungs and of the pleural sacs. Departures from the normal state, in the thyroid, and thymus glands, will be treated of in an appendix. I. ABNORMAL CONDITIONS OF THE AIR PAS- SAGES. 1. EXCESS AND DEFICIENCY OF DEVELOPMENT. An entire absence of the air passages always occurs, when there is a simultaneous deficiency of the lungs* A partial defi- ciency, as of the trachea, may exist without the absence of the lungs, the bronchi then being given off immediately from the larynx. Occasionally we find deficient development of these organs, owing either to the absence of individual component parts, as of single laryngeal cartilages, tracheal rings, &c.; or to imperfect development of the same in length and breadth, pro- ducing proportionate deformities. An excess of development is seen in the duplication of the lungs in double monsters, the upper, or lower section only of the apparatus being double. We may also mention the occasional presence of a supernumerary third bronchial tube, sometimes seen 2 2 dilatations of larynx, etc on the right side, in persons otherwise normally developed. Finally, supernumerary laryngeal cartilages and tracheal rings occur, and increase in a greater or less degree, the length of the tracheal trunk. 2. ALTERATIONS IN SIZE. As regards the calibre of the air passages, we shall here take up the consideration of acquired dilatations and contractions, set- ting aside individual peculiarities, in which the whole apparatus is either very much increased in size, or where, on the other hand, it remains undeveloped with its walls slightly and delicately con- structed. With regard to the thickness of the walls of the air passages, we shall have to consider the hypertrophy and atrophy of their component tissues. o. abnormal dilatations of the air passages. These occur in various forms in the larynx, trachea, and bronchi, existing either as dilatations of the whole apparatus, or more frequently, as dilatations of single parts only, as of the bronchi. 1. Dilatations of the larynx and trachea. Uniform dilatation of these canals is not unfrequently seen in Marasmus, or Atrophia senilis. Its existence in extreme old age is interesting, because it always occurs in connection with, and in proportion to, an Emphysema senile, which is a Marasmus senilis of the lungs. They are all dependent upon an emaciation of the component tissues of the parts affected. Another form of dilatation is one proceeding from an hyper- trophy and relaxation of the posterior tracheal wall, with or with- out saccular or hernial protrusion of the mucous membrane. This, as might be expected from the protected state of the inter- stices between its cartilages, is extremely rare in the larynx, even in a slight degree; while on the other hand, it is not only of fre- quent occurrence in the trachea, but is at times developed to an astonishing extent. Notwithstanding that dilatations of the bronchial tubes have been well known since the time of Laennec, this cannot be said either of dilatations of the trachea in general, or of this form in particular. The posterior tracheal wall is relaxed, and exhibits a remark- DILATATIONS OF BRONCHI. 3 able increase in capacity, particularly in the direction of its breadth. At the same time its mucous membrane, the transverse muscular fibres, and the muciparous glands, are all in a state of hypertrophy, and the excretory ducts of the latter dilated; on the other hand the elastic yellow longitudinal fibres are atrophied and scarcely visible. If the protrusion of the mucous membrane, mentioned above, should now take place, it gradually passes through between the thickened muscular fibres, presenting at first a fissure, or a funnel-shaped cavity, finally becoming a transverse sac, deepest at both extremities of the tracheal rings, where we generally find the distorted fissure-like mouth of the excretory duct of a muciparous gland. The larger this hernia or false diverticulum becomes, the more prominently do the muscular fibres, between which it protrudes, project on the inner surface of the trachea; and if the herniae be numerous, and close together, the projecting muscular fibres form a species of lattice-work; their ends are sometimes single, sometimes foisked. This condition arises in consequence of repeated and chronic tracheal catarrhs, and may be compared with many similar dis- eases, arising in other parts from analogous causes. In the sac- cular dilatation with protrusion, the tracheal mucous membrane may, in the very commencement of the disease, be drawn through the transverse muscular fibres, by the traction exerted on it by the hypertrophied mucous glands through the intervention of their excretory ducts. At times these protrusions are found along the whole course of the trachea, sometimes extending even beyond it in "the bronchi. These dilatations of the trachea have a striking similarity to the equiform dilatations of the bronchi, proceeding from hyper- trophy and paralysis of their walls. 2. Dilatations of the bronchL Bronchectasis. Besides dilatations of the bronchi from emaciation, as seen in Marasmus senilis, other forms of this affection occur. Indeed, this section of the lungs is distinguished by their frequent occur- rence, and the extent and degree of development which they attain. They are among the most important diseases of the air passages. We distinguish in particular, two forms of dilatation. a. In the first, we find a bronchial tube uniformly dilated for a certain distance i. e., the dilatation, has taken place equally to- 4 DILATATIONS OF BRONCHI. ward all points of its periphery, so that a bronchus, which in its normal state will hardly admit of a fine probe, attains to or even surpasses the volume of a crow or goose quill. This enlargement is remarkably distinct, when we find a dilated bronchial tube far exceeding in size the branch from which it springs. It is rarely confined to a single tube, but, as a rule, affects a whole division of the bronchial tree. The branches and twigs may be increased in size in a degree proportionate to their normal volume, or, as is more frequently the case, they are found the more dilated the nearer we approach the extremities of their ramifications. In this they observe a law to be treated of hereafter. b. The second form is the saccular dilatation. In this, we find a bronchial tube enlarged, so as to form a spindle-shaped or roundish sac. In the latter case, the dilatation is often greatest in some particular direction, and then the greatest diameter of the sac may fall without the axis of the entering or departing tube. Such sacs may in rare instances attain the size of a hen's egg, more commonly that of a bean, a hazel or walnut. We find also, that one or more portions of a bronchial tube may be dilated, so as to form a sac, while the remainder retains its normal calibre; or the whole of the bronchial ramification may be affected. In the latter instance*, numerous similar sacs of various sizes are so arranged with regard to each other that they form a large, many branched, sinuous cavity, the individual excavations of which are bounded off, and separated from each other by ridges, or valve- like duplicatures of the bronchial walls. The saccular dilatation of the terminal branches of the bronchi forms a peculiar. subdi- vision. We frequently see these distended in the form of thin, membranous vesicles, which are tightly filled with air; they are found either singly, or in groups, in the apices of the superior lobes of the lungs, or in the neighborhood of cicatrized tubercular cavities. This condition arises when a bronchial tube becomes compressed and almost obliterated in passing through the con- tracted parenchyma of the apex of a lung which has been ren- dered almost impermeable by obsolete and chalky tubercles, and by a deposit of pulmonary pigment; its termination then ex- pands itself into one of the above described vesicles. If the bronchial tubes going to these are pervious, we can empty the sacs of their air by pressing on them; if they are not, they resist this and remain unchanged. Of the two forms of bronchial dilatation, the second occurs the more frequently, especially in young subjects. The degree DILATATIONS OF BRONCHI. 5 of dilatation may be determined by measurement, with due atten- tion to the original size of the tube, and the calibre of the parent branch from which it proceeds. Its extent, as may be gathered from the above, may be either very limited, or on the other hand so considerable, that all the bronchi of a single lobe, or a whole lung, may be affected. Bronchial dilatation affects especially the smaller tubes, and as a general rule is most frequent in those of the third and fourth order, never occurring in the largest bronchial trunks, or at least very rarely, and then only in the manner described when speak- ing of tracheal dilatations. The bronchi situated near the periphery and edges of the lungs, and especially those of the upper lobes, are most subject to this affection, and this among other circumstances shows its analogy to true vesicular emphysema. The walls of the dilated bronchi are found in various condi- tions. At times the mucous membrane and fibrous sheaths are hypertrophied and thickened; the former showing the effects of a chronic catarrh, being swollen, spongy, villous, softened, easily torn, and of various shades of a dark red color. The walls of the bronchi are rigid; they gap open upon the cut surface of the lung ; the thickened white fibrous sheaths contrast strongly with the internal red and swollen mucous membrane, from which a thick yellow purulent mucus is seen to exude. Such is gene- rally the condition in the first or equiform variety of bronchial dilatation. At other times, especially in the saccular form of this disease, the walls are found in a state of relaxation and emaciation. The mucous membrane of the sacs is but little if at all reddened; on the contrary, it is generally paler than usual; its tissue is but slightly if at all loosened or softened, but is smooth, and ap- proaches the character of a serous membrane. The cavities contain a thin, puriform, pale yellow, or almost colorless glassy mucus. This great difference in the condition of the walls in these two forms of dilatation would lead us to conjecture an equal differ- ence in regard to their proximate and exciting causes, and these we shall proceed presently to point out. The pulmonary tissue in the neighborhood of the dilated tubes is increased in density and unfit for the purposes of respiration. We will enter into a more thorough examination of the state of 6 DILATATIONS OF BRONCHI. this parenchyma, in connection with the formation of a theoiy of its origin, and its importance as a cause of bronchial dilatation. Laennec and most of the succeeding pathologists believe that bronchial dilatation is always produced in a mechanical way, by the accumulation of catarrhal secretions in certain portions of the tubes, aided by powerful inspirations during paroxysms of cough- ing, the walls from some unknown causes being at one time ren- dered thicker, at another thinner than natural. The condensation of the surrounding parenchyma; according to them, is a conse- quence of the compression exerted by the dilating bronchus. Hence Laennec describes the dilatation of the tube as the primi- tive affection, and the condensation of the parenchyma as a secondary change. Within a short time, Corrigan has put forth a theory directly opposed to this ; and believing the disease to be exactly analogous in its anatomical elements to cirrhosis of the liver, he has given it the name of cirrhosis of the lungs. According to him, the atrophy and obliteration of the pulmonary tissue is the primitive effect in the development of the disease; the dilatation of the tubes a consecutive affection, arising not only in conseqiience of an endeavor to fill up the space left vacant in the contracting lung, by the forcible expansion of the bronchi during the act of inspiration, but also by a dragging apart of the walls of the tubes from the shrinking of the pulmonary tissue itself. The alteration of the parenchyma of the lung in extreme cases consists in an atrophy, obsolescence, and contraction of the air cells, or even conversion of them into a cellulo-fibrous or callous fibro- cartilaginous tissue, which may either be white, or else punctated, streaked, or colored throughout with black pigment, and to which the fibrous sheaths of the bronchi become so intimately attached as to form a connected whole. When we consider the vast extent to which the" pulmonary tissue around the affected bronchus is atrophied, the nature and degree of this change, and recollect the fact that it does not always appear equally developed around the dilated tube, nor most marked the nearer we approach to it, then it becomes a matter of doubt if all this can be produced by the mere pressure of a thin, dilating bronchial tube, more especially as We see that simple condensation of tissue only, is induced by long continued and severe pressure from pleuritic effusions, &c. A closer examination enables us to obtain other facts which DILATATIONS OF BRONCHI. 7 are sufficient to explain this metamorphosis, and which are of great importance in the production of dilated bronchi. Under whatever form bronchial dilatation appears, a bronchitis may be regarded as the most frequent ^primary exciting cause. It acts in very different ways, but not mechanically, from the ac- cumulation of secretion, as supposed by Laennec. In the first variety, atony and paralysis of the contractile and irritable tissues of the tubes are present, occasioned by chronic inflammation and blenorrhoea. Their walls are then the more easily dilated by the inspirations and concussions in paroxysms of coughing, the more forcible these are obliged to be in order to throw out the accumulated secretions. This process is still farther aided by many of the smaller bronchi being completely filled with catarrhal mucus. This variety only arises in that portion of the bronchial system which forms the seat of the catarrh. The second form, or the saccular dilatation of the bronchi, arises, not in the catarrhal section of the bronchial system, but beyond it. It is the consequence of a bronchitis in the terminal branches of the air tubes, causing, first obstruction of them by accumulation of secretion and swelling of their mucous membrane; and finally entire obliteration of them. The more labored and the more protracted the single inspirations, so much the more readily does the inspired air which is obstructed in its passage through the tubes tend to produce dilatation. (Retnaud.) The expan- sion takes place toward the perfectly impermeable portion of the bronchus, for the parenchyma and air cells which were supplied with air by it have now collapsed and become atrophied, thus giving rise to a space to be occupied by the dilating bronchus, which lies either entirely, or in some measure, in the midst of a collapsed and apparently compressed pulmonary paren- chyma; hence this last appears the exciting cause, the dila- tation the result. This, together with the fact that the collapsed tissues pass into the above described perfect atrophy, and contract still further, leaving additional space in the lung, approximates this theory to that of Corrigan. But we make the obliteration of the terminal tubes the first step; the obliteration of the parenchyma which they supplied, the second; the dilatation of the air tubes in order to supply the vacuum, the third. According to Corrigan, the primitive affection is not Bronchitis, but a disease of the parenchyma of the lung, not so much an inflammation of the interstitial cellular tissue, as a peculiar pneu- monic process, (to be treated of subsequently,) which slowly 8 DILATATIONS OF BRONCHI. extends from one lobule to another, depositing a product which becomes indurated, and unites closely with the pulmonary tissue itself, while the air cells become atrophied, obliterated, and trans- formed into the same substance. The resulting fibro-cellular tissue may in this, as well as in the first instance, tend to draw apart the walls of the bronchi during its contraction, and may thus lead to a farther enlargement of the bronchial sac and in- creased thinness of its walls. Be this as it may, a smaller or larger portion of the lungs becomes contracted and obsolete in proportion to the extent of the bronchial affection; yea, when all the bronchi of a lung are dilated, we find its entire parenchyma atrophied, and contracted to a small portion of its normal volume, and drawn up towards the roots of the bronchi, as if in consequence of external pressure from an effusion into the pleura. The cavity of the chest be- comes smaller than usual, for its walls sink in over the contracting lung. In rare instances a bronchial sac is entirely separated by obliteration, not only from its own branches, but also from the tube to which it is attached. It then presents a closed cavity, which in consequence of the persisting activity of its mucous membrane, becomes still farther enlarged from the accumulation of its secretions. At a later period, should this action cease, the contents of the sac gradually become inspissated and of smaller volume ; we then find a fibrous capsule inclosing a fatty chalky paste, or a solid earthy concretion. When single saccular bronchial dilatations contain purulent matter, they may be easily mistaken for tubercular cavities, espe- cially when they exist simultaneously with pulmonary tubercles, and are situated in the upper third of the superior lobes of the lung, viz., in the usual primary seat of tubercular disease. A closer examination will enable us to discriminate between them, for bronchial sacs and their cavities have a roundish shape ; their lining membranes are smooth, and uncorroded; there is no ulcera- tion of the bronchial tubes which open into them; their contents differ widely from tubercular pus; and the surrounding paren- chyma is either not filled with tubercles, or with such only as are obsolete. They may also occur in portions of the lungs not usually the seat of tubercles. In other instances general principles will enable us to decide on the diagnosis, such as the fact that the usual seat of bronchial dilatation is in the peripheric portions of the pulmonary parenchyma, and toward the edges of the lungs, while DILATATIONS OF BRONCHI. 9 they are rarely seated in the very summit; finally, when the bronchial disease is very extensive, it is found to be incompatible with tubercles. Bronchial dilatation, when extensive, owing to the atrophy of a large portion of the lungs, which attends it, occasions obstruction of the circulation, active dilatation of the right ventricle, conges- tion and dilatation of the whole venous system, cyanosis, exces- sive development and vicarious action of the permeable portions of the lungs, and is not unfrequently followed by bronchial and pulmonary haemorrhage and hemoptoic infarction. If it attain a very high degree of development, it causes debility, emaciation, general cachectic appearance, dropsy, and finally, total ex- haustion. In consequence of the venous congestion and cyanosis which attends this disease, it affords a remarkable immunity not only from pulmonary tubercles, but from tuberculosis in general.' This fact has been known since the time of Laennec, with regard to bronchial dilatation; but the cause, and general applicability of the above rule have not been discovered until lately, and only led within a short time to various projects for the cure of con- sumption.* * Diagnosis.—Dilatation of the bronchi may be easily mistaken for chronic phthisis ; so close is the resemblance of these two diseases, that Laennec, Louis, Andral, and other great masters have repeatedly confounded them. It is attended with habitual dyspnoea, more or less cough, muco-purulent expectoration, which however is not floo culent and cheesy like the tuberculous, but sanious and often re- markable for its fetor; some lividity of the face, oedema of the feet, and dropsical effusions are common, owing to the frequency of its combination with dilatation of the heart; as these symptoms and this condition of the heart is much more rare in phthisis, Stokes justly affirms that they may assist us in forming a diagnosis. Another point of importance is that it developes itself slowly, and rarely attains such a degree as to prove the immediate cause of death. Again, some one of the characteristic signs of phthisis is generally absent; thus in a case which Louis mistook, there was absence of haemoptysis, hectic fever, pain in chest, and dulness on percussion, but there was emaciation, cough with opaque greenish sputa, and mucous rattle with gurgling under the left clavicle; the case was of ten years' standing, and diarrhoea and night sweats did not set in until the last fifteen days of life ; the face was pale and livid, the legs oedematous, and obscure fluctuation in abdomen. In a case mistaken by Lerminier and Andral there had been oppressed breathing for a year, one attack 10 CONTRACTIONS OF THE AIR PASSAGES These occur in every section of the respiratory apparatus, but present various differences in their extent and proximate causes. As regards the former they may proceed to closure, and perfect obliteration. of haemoptysis, cough, with copious expectoration of puriform and intolerably fetid sputa; during the day the pulse was scarcely frequent, but every evening he had a chill and a burning heat all night, yet he never perspired; emaciation, loss of strength, and diarrhoea for last six weeks ; puerile respiration on the right side, feeble respiration on the left, with great resonance of the voice—the dilatation was on the left side. The physical signs of bronchitis are also more marked and per- sistent than in phthisis. The uniform dilatation is less easily to be mistaken for phthisis, than the saccular variety, but it is extremely difficult to distinguish it from chronic bronchitis ; it occurs most commonly after an attack of pleurisy or pleuro-pneumonia:; its most frequent seat is in the posterior and inferior portion of the left lung; it is always a conse- quence of extensive compression or obliteration of the parenchyma, and hence almost always attended with an evident flattening, or sinking in of the chest over the affected part. It is marked by exten- sive bronchial respiration, not only without dulness on percussion, but with a hollow, tubular sound like that produced when the trachea is percussed; extensive resonance of the voice, almost amounting to imperfect pectoriloquy; a puffing of the breath, and a strong blowing into the stethescope or ear of the observer; in some cases the veiled puff of Laennec, i. e. sensation as if a thin veil or wet membrane was interposed between the column of air and the ear, and vibrated at each breath of the patient. There are no physical signs of cavities. When the dilatation is confined to one or several bronchi, is moderate and nearly equiform, there is an habitual cough, neither very frequent or severe, a moderate mucous expectoration, precisely similar to that in subacute bronchitis, and diffused bronchophony. When many tubes are dilated there is a chronic and persistent cough, in severe and long continued fits, dyspnoea, abundant grayish-yellow, puriform expectoration, the voice and cough resounds under the ear, mucous rattle, a puffing of the breath. Laennec has laid great stress on the abundance of the expectoration, and its great foetor; some of these cases present the symptoms of simple chronic catarrh with copious expec- toration, and may last from ten to fifty years without any of the con- stitutional signs of phthisis. Immediately over the dilated tubes percussion is clear and often distinctly tubular—around them it is clear, of short duration, with increased sensation of resistance of the CONTRACTION OF AIR TUBES. 11 1. Contractions may be occasioned by pressure from without, as in the larynx, and trachea, by an enlarged thyroid gland, in the trachea and bronchi by lymphatic ganglia of unusual size, aneurisms, extensive cancerous deposits in the neck and medias- tinum, large thymus glands, effusions into the chest and cavities of the pleura, &tc. According to King, the left bronchus may be compressed by a dilated left auricle. By these means, the air walls of the chest, owing to the compression and obliteration of the parenchyma. Respiratory murmurs are harsh, bronchial, diffused, and blowing ; the dry and humid rhonchi of bronchitis are present; also bronchophony, or imperfect pectoriloquy ; bronchial cough. In phthisis the symptoms and physical signs are constantly increasing in degree and extent, in bronchial dilatation they often remain unal- tered in both these respects for months and even years. The loss of flesh is rarely so great as in phthisis. In both the equiform and saccular varieties, the external signs of the tubercular diathesis are absent, while those of emphysema and disease of the heart are common. The diagnosis of the saccular variety is much more difficult, and at times almost impracticable, as there is no point of absolute dif- ference between its signs and those of cavities in the lungs. Still the long duration of the disease, the absence of hectic fever, except towards the lastj although haemoptysis may occur, yet if it be fre- quently repeated and abundant, it will almost decide the question in favor of the tuberculous nature of the disease. If the disease have been watched from the commencement, it will be found that the physical signs of a cavity are present without being preceded by dulness on percussion; at a later period, when the neighboring pa- renchyma becomes obsolete, dulness supervenes. In the majority of cases dulness of percussion precedes tuberculous cavities. In large sacs we find cavernous respiration, gurgling, and pectoriloquy, and to add still more to the resemblance to phthisis, they are generally seated in the upper lobes, although, according to Williams, nearer the mammary region than the apex of the lungs. Stokes says the diagnosis can only be made by watching the case ; for in saccular dila- tation the physical signs remain stationary; hence if the extension and enlargement of the cavity be too rapid to be explained by the suppo- sition of a dilated tube, we may at once conclude on phthisis. Stokes has frequently had recourse to this method with success. According to Skoda, when several sacs are strung along one bronchus, and communicate with each other, they may present a characteristic auscultatory sign, viz., loud blowing, dry ringing, interrupted sound, like that made by geese in their flight; when the sac is large and its opening small, a very strong hissing sound precedes this; the expira- tion is attended by hissing or whistling. 12 HYPERTROPHY AND ATROPHY. tubes may be thrust from their natural situation, in various direc- tions ; their volume, as may be seen in contraction of the trachea, may be diminished so as to present mere fissures, either straight or curved, transverse or antero-posterior. 2. Contractions may also result from various diseases of the mucous or sub-mucous tissues, such as hypertrophy, inflammatory swelling, or oedema ; or from the most various excrescences upon, or cancerous deposits about them, or from contraction of cica- trices, after solutions of continuity. The most frequent cause however is bronchitis, especially of the minuter tubes, which fre- quently become obliterated. 3. The volume of the air passages may be diminished, by the entrance of various foreign bodies from without; or from the intestinal canal, through the throat, or abnormal communications; or by the products of various diseases of the mucous membrane and the deeper seated tissues, among which we may enumerate, coagulae of blood, lumps of mucus, bronchial froth, croup mem- branes, pus, tubercular masses, fragments of cancerous deposits, necrosed portions of cartilage and bone.# c. HYPERTROPHY AND ATROPHY. We have already alluded to an hypertrophy involving the mucous membrane of the air passages, the transverse muscular fibres, the mucous glands of the posterior wall of the trachea, and the fibrous sheath of the bronchial tubes, proceeding from catarrh and blenorrhoea of these parts. We must now speak of hyper- * Diagnosis.—According to Walshe, if the contraction be limited to a single bronchus, the respiratory murmur is suppressed over an extent corresponding to the size of the affected tube ; exaggerated and puerile respiration is heard in its neighborhood—sibilant rhonchus is much more common than sonorous, and often is attended with a well-marked and strong hissing; they are heard over the locality of the contraction, while sonorous rhonchus is heard in the neighboring larger bronchi. If the contraction be general and uniform, the respiratory mur- mur will be very feeble, almost inaudible, or quite suppressed on the affected side ; with exaggerated and peurile respiration on the sound. The percussion sound is not as full as in health, but far from as dull as in phthisis. Several of Andral's patients had a feeling of constric- tion at the contracted part, and sensation as if they did not breathe with that part of the chest. HYPERTROPHY AND ATROPHY. 13 trophy of the mucous membrane and the muciparous glands of the larynx and trachea. When existing in a moderate degree, it presents the usual characteristics of hypertrophy of mucous membranes ; but when extreme, it affects in particular the muciparous glands, occasions their enlargement, and attacks those parts most abundantly sup- plied with them, viz., the neighborhood of the superior vocal chords, the ventricles, above the musculus transversus, and the epiglottis. In the trachea we notice the dilated mouths of the excretory ducts of the mucous follicles, situated behind the muscular coat, and gaping open on the swollen mucous membrane of its poste- rior wall. - These glands are enlarged to the size of a hemp seed, pea, or cherry, and are changed either into simple, or sinuous, or imperfectly partitioned sacs, in the cavities of which a whitish, opaque, or transparent glassy mucus is accumulated. In its highest degree, the swelling of the membrane and glands of the larynx becomes a polypous hypertrophy or gives rise to cellular or mucous polypi. When we find the mucous membrane of the air passages and its glands atrophied, especially in the larynx and trachea, there is a diminished secretion of mucus, with simultaneous emaciation of the laryngeal muscles, followed by the dilatation of the larynx, trachea, and bronchi, already described as peculiar to aged per sons. The epiglottis is occasionally the seat of atrophy with relaxation, arising apparently from subacute inflammation ; or from similar causes it may become atrophied, indurated, and variously deformed, so as to allow only an imperfect closure of the glottis. Finally emaciation, and final absorption of the laryngeal cartilages, the tracheal and bronchial rings with their membranes, occurs in consequence of the pressure of various tumors, such as aneu- risms, &cc* * Diagnosis.—According to Williams, when the bronchi are hy- pertrophied, they expand less easily, and hence there is difficulty of inspiration, which is short, quick, and labored, especially on making any exertion; the lungs cannot accommodate themselves by a sup- plementary effort; hence, if pleurisy or pneumonia set in, the oppres- sion of respiration is very great. Expiration is comparatively easy, but both acts are often attended by wheezing; the expansion of the chest is perceptibly limited ; the vesicular murmur is feeble. The signs in fact are those of a permanent and not very severe spasmodic asthma. 14 3. DEVIATIONS IN FORM. Among these belong the acquired deformities of the larynx, trachea, and bronchi, such as flattenings, indentations, curvatures caused by the pressure of enlarged thyroid glands, aneurisms, encysted tumors, &tc, or from cicatrizations after ulceration. The epiglottis in particular presents some remarkable anoma- lies, being frequently found irregularly flattened, its edges unna- turally curled, or its apex curved downwards, or else rolled together like a horn. These malformations are either the conse- quences of contracting cicatrices in its mucous membrane, sub- mucous cellular tissue, or cartilage; or of inflammation of the latter with consecutive softening induration, or emaciation of its substance, and transformation of the same into a rigid fibrous tissue. 4. ALTERATION OF POSITION. These occur especially in the larynx and trachea, which may be forced from their natural position to the right or left side, by partial enlargements of the thyroid gland, by aneurisms, encysted tumors, abscesses, cancerous deposits, or in consequence of wry neck. They may be thrust forward by swollen and inflamed cer- vical vertebrae, by abscesses in the same, by aneurism of the arch of the aorta, cancerous deposits in the anterior mediastinum, &c. The occasional, but very rare dislocation of one of the laryngeal cartilages, may also cause alteration in position. 5. SOLUTIONS OF CONTINUITY. These may be divided into: a. The various injuries of the air passages, from cutting or penetrating weapons, and gun-shot wounds ; fractures and bend- ings of the hyoid bone, laryngeal and tracheal cartilages, from lacerations, blows, and severe pressure; and from the entrance of angular and pointed bodies into their cavities. b. The gradual solution of continuity from absorption and atrophy, caused by the long continued pressure of aneurisms. c. Lastly, the multiform solutions of continuity, the conse- quence of various ulcerative processes, acting from within out- wards, and vice versa. All of these, more or less rapidly, give rise to unnatural com- HYPEREMIA AND ANiEMIA. 15 munications of the air passages with the surrounding cellular tissue, or adjacent cavities and canals ; as with the pleural sacs, blood-vessels, oesophagus; or with abscesses in the lungs, bron- chial glands, vertebrae, and lateral or anterior walls of the chest. They allow, as well the exit of air in various directions out of the passages, as the far more dangerous entrance of blood, purulent ichorous fluids, food or drink, into them. We might here allude to the so-called congenital tracheal fis- tula described by Dzondi, Aschersohn, Serres, and others ; but it requires still farther investigation to form a theory of its mode of formation, and its importance. It is an arrest of develop- ment. 6. DISEASES OF THE TEXTURE OF THE AIR PASSAGES. They occur in all the component tissues of these parts, but the mucous membrane is most frequently primitively affected, and in a greater variety of forms; hence its diseases require the most attention, particularly as they often extend themselves to the subjacent tissues, and cause their destruction. (1.) DISEASES OF THE MUCOUS MEMBRANE AND SUB-MU- COUS CELLULAR TISSUE. a. HYPEREMIA AND ANiEMIA. Hyperaemia of the air passages is a diseased condition of com- mon occurrence. When seated in the minuter bronchial ramifi- cations it becomes combined with hyperaemia of the parenchyma of the lungs. When it occurs in the larger bronchi, trachea, and larynx, it usually exists as an independent and uncomplicated affection. It becomes of more or less importance, in proportion as it occurs either as an active hyperaemia, or a mechanical one, from obstructed circulation ; or as a passive, which is rare ; in either case it may form an independent disease, which finally gives rise to hemorrhage, or under other circumstances to congestion, which may increase to acute or chronic inflammation. The hemor- rhages, may proceed from the bronchial, tracheal, laryngeal, or epiglottideal mucous membranes. When they occur, we find the air passages of the cadaver filled to a varying extent with different quantities of coagulated or fluid blood; the mucous membrane is 16 CATARRHAL INFLAMMATION. dark-red, swollen, spongy, relaxed, and bleeds easily from a greater or less extent of its surface when pressed upon ; we find no other certain source of the hemorrhage, viz., no pulmonary apoplexy, mechanical or ulcerative solutions of continuity, &c. Portions of the pulmonary parenchyma are often spotted of a dark or light-red color, from imbibition of blood, which has settled into the air cells and terminations of the bronchi; this, however, is not peculiar, but occurs in all other forms of hemorrhage in the lungs. Other parts of them are pale, puffed up, and emphy- sematous, as the air cannot pass out, in consequence of the obstruction of the bronchial tubes. These hemorrhages are of an active nature during the evolu- tion of the body, when general plethora is present, and in vicarious discharges for the menstrual or hemorrhoidal flux. They may originate from, and accompany the congestions, which so fre- quently precede and attend the developement and progress of tubercles of the lungs, and may be brought on by violent exertions, either of the whole body, or the organs of respiration. We see them occur from concussion of the lungs, from rapid rarefication of the atmospheric air, but in the vast majority of cases from mechan- ical hyperemia the result of hypertrophy and dilatation of the heart. Anemia of the mucous membrane of the air passages is most remarked in atrophia senilis.* 1. CATARRHAL INFLAMMATION. This is one of the most common diseases of the air-passages ; it occurs" either as an acute or chronic affection, and in one of the other form most frequently attacks single sections only of the bronchial system. The acute affection however occasionally * Diagnosis.—According to Schoenlein, in simple hemorrhage from the bronchi there are no preceding signs of a congestive stage, no sensation of weight, pressure, or increased warmth in the chest; but the patient merely has a burning sensation in the larynx or trachea, or through a larger or smaller section of the bronchia. To this is added a peculiar irritation and a short paroxysmal tickling cough by which mucus is brought up, which is either saturated or tinged with blood of a bright red color, and sweetish taste. There are hardly any physical signs; nothing peculiar is elicited by per- cussion, and auscultation only affords a moist rattle of unequal sized bubbles, usually larger and more liquid than those of catarrh. CATARRHAL INFLAMMATION. 17 travels over the whole tract of the respiratory tubes, and the chronic form frequently affects their whole extent, the inflamma- tory action being then, however, much more intense in some parts than in others. We distinguish catarrhs of the larynx, trachea, and bronchi, or laryngitis, tracheitis, and bronchitis catarrhosa. ACUTE CATARRHAL INFLAMMATION. This presents the same pathological phenomena in whatever section of the lungs it occurs; viz., various degrees of redness, and relaxation of the membrane, which, according to the stage and intensity of the attack, either secretes increased or diminished quantities of muco-serous, frothy fluid, (sputum crudum,) or of thick, white, or yellow puriform mucus, (sputum coctum,) or finally, of a true purulent secretion, which latter marks the transi- tion into superficial suppuration. The swelling of the mucous membrane and the subjacent cellular tissue is worthy of especial attention, on account of the diminution in the volume of the air- passages which it occasions. It is of the greatest importance when it attacks the lining membrane of the epiglottis, the duplica- tures which bound the rima glottidis, cover the vocal chords and line the ventricles; and also when it affects the mucous tissue'of the smaller bronchial tubes. Acute bronchial catarrh is an important, and, in children, often a dangerous disease, not only from its extent, but from the partial closure and even perfect impermeability of the bronchial tubes, occasioned by the swelling of the mucous membrane, and accu- mulation of its secretions. In children also it is particularly apt to extend to the air cells, causing catarrhal pneumonia. CHRONIC CATARRHAL INFLAMMATION, Occurs with great frequency in certain portions of the air passages, is often remarkable for its great intensity, and is of the greatest importance from its results. These remarks refer particularly to chronic bronchial catarrh. This species of in- flammation is by no means rare in the larynx and trachea, and at times extends over the whole respiratory tract; generally, however, is most intensely developed in some one particular locality. Scarce any other acute catarrh suffers so many relapses,. or so easily becomes habitual; while the chronic variety frequently increases to acute inflammation, or degenerates to a mere 2 18 CATARRHAL INFLAMMATION. blenorrhoea. It presents the general anatomical characters of chronic mucous inflammations, and is a very common cause of swelling in those portions of the larynx, already described as well supplied with mucous follicles, giving rise to glandular hypertrophy, mucous polypi, and condylomatous or cauliflower-like vegetations of the epithelium. In the trachea, and still more in the bronchi, it may cause spongy thickening of the lining membrane. The conditions just mentioned may lead to hypertrophy and relaxation of the sub-mucous muscular layer of the fibrous portions of the vocal apparatus, and of the fibrous sheaths of the bronchi; or they may cause ulcerative loss of substance, especially of the larynx, in the form of a diffuse catarrhal suppuration, or of ca- tarrhal follicular ulceration. Chronic catarrhal inflammation may induce a diminution of the volume of the air passages, sometimes amounting to perfect closure; in the bronchi, adhesion and perfect obliteration is often the result of previous loss of substance by ulceration. At other times it gives rise to dilatation, with hypertrophy and paralysis of the tissues. The quantity of whitish cream-like, or yellow purulent secre- tion, that is effused from a blenorrhoic bronchial mucous membrane, is very great, especially where dilatation is present. Such is the condition of the lung in the so-called phthisis pituitosa, asthma humidum, bronchial blenorrhoea; hence, if it be incised large quan- tities of mucus flow from the divided bronchi, and spread over its cut surfaces, The acute as well as the chronic form may occur as an inde- pendent and idiopathic disease, although they are frequently associated with catarrhs of other mucous membranes. The acute is frequently of an exanthematic character, arising in the course of measles, small pox, and typhus. The chronic form frequently accompanies the most different pseudo-plastic processes upon the mucous and sub-mucous tissues, and is often of a syphilitic, ar- thritic, or scrofulous nature; thus it frequently attends on tubercular phthisis. It may also arise from mechanical hyperaemia, induced by disease of the heart. Gonorrhceal catarrh of the larynx deserves particular mention on account of its sequelae. By metastasis, it attacks the mucous membrane of the epiglottis, the lateral duplicatures of the glottis itself, and the vocal chords, converting them and the subjacent cellular tissue into a fatty-fibrous, white, and resistent texture of considerable thickness, which causes a diminution or narrowing CATARRHAL INFLAMMATION. 19 of the rima glottidis and cavity of the larynx. (Gonorrhceal laryngeal stenosis.} The parenchyma of the lung suffers from a chronic bronchial catarrh in two ways ; it causes emphysema at one time, at another collapse of the air cells, obliteration and consequent atrophy of them. Livor, cyanosis, active dilatation of the right ventricle, and hydro-thorax follow in its train, and it proves fatal either in consequence of these, or by producing asphyxia, or tabes under the form of phthisis pituitosa.* * Diagnosis.—The symptoms of bronchitis vary according as the disease is seated in the larger, smaller, or capillary bronchi. Inflammation of the larger air tubes is rarely attended with* such violent symptoms as when it attacks the minuter ones. Fever and dyspnoea are moderate, cough loud and deep, expectoration scanty and glairy at first, afterwards easy, profuse, and mucous. The per- cussion sound is normal, but the hand applied to the chest often detects rhonchal vibration, especially if intense sonorous rhonchus be present. In the first stage auscultation detects sonorous rhonchus, which when dry is of a grave tone, resembling the prolonged note of a bass violin, or the cooing of a dove; when free expectoration comes on, the sonorous rhonchus is intermixed with mucous rattle of large, scattered, and uneven bubbles. The presence of sonorous rhonchus alone, usually implies that the case is not a dangerous one. The more common form of bronchitis is that in which the larger bronchi, and those of the second, third, and fourth orders, are simulta- neously inflamed. In this variety there is often burning, piercing pain under the manubrium sterni, which commonly extends towards the middle of the sternum, more rarely to the sides of the chest; there is comparatively great oppression of the chest and dyspnoea, but the patient is able to expand the chest fully ; the cough is deep, metallic rino-ing, dry and hard; the expectoration, according to Andral and Watson, is scanty in the first stage, often streaked with small lines of blood, saltish, transparent like the white of an egg, glairy and viscid ; it is stringy and viscid in proportion to the intensity of the inflammation, and at times may be drawn out into threads like those of melted glass. If expectorated after much coughing it will be frothy, with unequal sized large and small bubbles. When the inflammatory fever ceases a remarkable change in the expectoration ensues; the mucus gradually loses its transparency, and becomes mixed with yellowish white or greenish opake masses, which increase more and more until they compose the whole of the expectoration, which is then thick, consistent, muco-puriform, though somewhat viscid and confluent. 20 2. EXUDATIVE PROCESSES (CROUPOUS INFLAMMATION). Under this head belong affections allied to each other from their originating in one general disease, but which differ widely in their local manifestations. These differences, so far as they are the objects of pathologico-anatomical investigation, are con- fined to variations in the physical qualities of the inflammatory products effused upon the free surfaces of the mucous membranes, and to variations in the condition of these membranes themselves, together with their sub-mucous cellular tissue. They occur, Percussion sound remains comparatively clear, and this is of importance; for if, after three or four days of fever, cough, hurried and laborious breathing, we find that the chest sounds clear, the great probability is that the disease is bronchitis, and not pneumonia or pleurisy.—[Stokes.] Auscultation detects sonorous and sibil- lant rhonchus simultaneously, causing a strange medley of groaning and cooing, loud and hoarse sounds intermixed with chirping, whis- tling, and hissing, with sub-mucous rhonchus, and with the natural, gentle, rustling, breezy, vesicular murmur; the less the latter is heard, the more severe the disease ; the more the sibilous rhonchus predominates over the sonorous, the less favorable the prognosis.__ [Watson.] Capillary bronchitis is a more serious disease than pneumonia ; when the capillary tubes are extensively inflamed, the dyspnoea and oppression of the chest is very great, the whole disease is of an intense and severe character, and unless quickly relieved runs on to a fatal termination with great rapidity. According to Skoda, the commencement of the attack is often marked by a very loud, rough vesicular murmur ; this quickly changes to a dry and sharp wheezing^ with sibilant rhonchus, hissing and whistling. According to Graves' when we hear numerous sounds, three, four, or even six or seven in number, proceeding from and audible over a small portion of lung, with wheezing from a great many points close together, we may be sure of capillary bronchitis: these sounds undergo rapid changes during the same inspiration—every moment some of them seem to cease, and to be replaced by new ones. The sibillant or whistling rhonchus depends on inflammation of the minuter tubes, while the sonorous, droning, humming, snoring, or cooing sounds, indicate that the larger bronchi are affected. In bronchitis of the larger tubes the sonorous rhonchus may outroar the vesicular murmur • but generally this is also heard mingling with it; but sibillous rhonchus proceeds from the immediate neighborhood of the air cells and abolishes the respiratory murmur—it does not mask it, but it takes CROUP. 21 especially in true croup, either as primary independent diseases, or as secondary processes, the mere results of a degenerate or chronic affection. True croup, which demands our first attention, is an exudative process, giving out a more or less plastic exudation. It rarely occurs, as a genuine primary process, upon any other than the mucous membrane of the air passages, and appears there under the forms of laryngeal, tracheal, or bronchial croup, i. e. laryngitis tracheitis, bronchitis polyposa vel membranosa. It occasionally extends over the whole of the air passages, progressing from the its place. Sibillous is a more dangerous sign than sonorous rhonchus; when it is heard all over the chest, the whole of the capillary bronchi are affected, and the case is a very serious one.—{Watson.] When the first or dry stage passes away,£rue swft-crepitant rhon- chus is heard; this is a small fine sound, like that heard when the ear is applied near the surface of a liquid slightly effervescing, such as bottled cider or champagne. We are indebted to Louis for estab- lishing the frequency and pathognomonic character of swft-crepitant rhonchus at both bases of the lungs as a sign of capillary bronchitis : the only sound for which it can be mistaken is the crepitant rattle of pneumonia ; but double pneumonia only occurs once in sixteen or seventeen cases—so that, in an immense majority of cases, when a sound approaching the crepitant rhonchus is heard at the base of both luno-s, the case is one of capillary bronchitis and not of pneumonia. __[Walshe.] The only exception to this rule is in the case of new- born infants, in whom double pneumonia is infinitely the most com- mon form ; in 128 cases observed by Valleix and Vernois, both lungs were inflamed 111 times.—[Ibid.] Severe capillary bronchitis of both lungs is remarkable for the rapidity with which collapse and extreme prostration and debility succeed to high fever, extreme dyspnoea, &c. Bronchitis infantilis is very insidious in the beginning; there is common catarrh with coryza, without pain, fever, or dyspnoea, but a frequency and wheezing of the breathing may be noticed, with unusual paleness and depression; cough is frequently, and expecto- ration almost always, absent. The physician often does not take the alarm until extreme dyspnoea shows the imminency of the danger; the pulse then becomes very quick; remissions occur in which the child lies in a somnolent state, without cough, or quick- ness of pulse, but if the breathing continues quick the dyspnoea will return with increased severity, much greater quickness of the pulse, while stupor ensues, the lips become livid, and the little patient dies suffocated.—[Williams.] 22 CROUP. epiglottis to the very minutest branches of the bronchi; at other times it spreads over the throat and pharynx, and even down the esophagus, although rarely. It attacks the mucous membrane either in large continuous sections, or only in small insulated patches which are indented at their edges. Hence the exudation or croup membranes either present the appearance of connected tubular coagulations, which ramify in accordance with the bronchial di- visions, or of irregular patches or layers, as is most common in the larynx. In bronchial croup, the tubular exudations exhibit a thickness which is in inverse proportion to their calibre, being converted into solid cylinders in the minute bronchi. These exudations vary very much in thickness and consistence, some presenting a hoop or ring-shaped or gauze-like coating of the bronchi, while others are a line or more in thickness. In consistence they vary from that of viscid cream to the most compact, leathery, and fibrous false membranes; but even these latter are not of the same density and thickness in all parts, for as a rule they become thinner and softer toward their edges, w hich are creamy and purulent. The layer applied to the mucous membrane is always found softer and looser than the others ; it adheres sometimes very intimately, at others but slightly, as a viscid secretion is often effused beneath it. These false mem- branes are generally of a grayish-white or yellow color, but not unfrequently they have a greenish tinge. On the under surface of the layer, in juxtaposition with the mucous membrane, we occasionally notice red streaks and points, consisting in part of superficially adherent blood, in part of straight or tortuous streams of it, or of roundish extravasations, from which small radiating and branching streams proceed. The membrane itself lying beneath these exudations presents a very various aspect: its redness at times is very dark, even brownish; more frequently it is of a lighter, erysipelatous hue, but occasionally no traces of any injec- tion whatever are to be found; its surface is excoriated, and bleeds from many small isolated spots; the whole presents various degrees of swelling ; at times, however, so slight as to be scarcely perceptible. The sub-mucous cellular tissue is generally, although not always, the seat of serous infiltration. Genuine croup of the air passages occurs most commonly during the years of childhood; rarely, however, before the end of the second year, when the laryngeal and tracheal variety is most frequent. In older persons, viz., during the years of youth and early manhood, bronchial croup is the more prevalent form, and is CROUP. 23 often complicated with pneumonia. Croup of the terminal branches of She bronchi always occurs simultaneously with pneu- monia ; it generally runs an acute course, but may become chronic, the process continuing in a lesser degree of intensity for a longer period, and being subject to paroxysmal exacerbations with re- newed depositions of lymph. It becomes habitual in many per- sons, and bronchial croup in particular exhibits a certain periodicity in its attacks. It is frequently complicated with pneumonia, pleurisy, pericarditis, and at times with meningitis and acute and chronic hydrocephalus. In rare instances it appears on the stomach and degenerates into acute softening of that organ (gastro-malacia). It proves fatal in consequence of the obstruction of the air pas- sages by the effusion, or, as is more commonly the case, by the swelling of the mucous membrane and the sub-mucous cellular tissue, coupled with spasmodic closure of the glottis. Suffocation frequently occurs from oedema of the lungs, or death may result from exhaustion consequent on the profuse exudation. No evident affection of the par-vagum has been found. The other exudative processes deposit a softer and less plastic effusion, which in some cases is almost purulent; or a thin, sero- purulent, gelatinous, discolored, ichorous exudation, wherein the mucous membrane becomes much attenuated, and finally entirely dissolved. The sub-mucous cellular tissue is infiltrated with similar matters, and is rendered friable, easily torn, and diffluent. These affe in most instances secondary processes, arising from the local- ization of some degenerate constitutional affection, such as acute variola, or scarlatina. The collective exudative processes are frequently complicated with similar diseased actions on other mucous or serous mem- branes. They may all degenerate to gangrene, or acute softening of the parts they affect; and from the simultaneous enlargement of the spleen, lymphatic glands, and follicular apparatus of the intestinal mucous membrane, we conjecture their origin in a gene- ral dyscrasia of the blood and lymph. Among such general dyscratic diseases belong apthae of the air passages. They are generally confined to the larynx, trachea, and larger bronchi, rarely extending upon the pharynx. They scarcely ever occur as a primitive disease, but most commonly associate themselves with tubercular phthisis of the larynx and lungs.* * Diagnosis. — According to Dr. Ware, of Boston, true croup 24 3. PUSTULAR INFLAMMATION. The only but most perfect form of pustular inflammation oc- curring on the air passages is the variolous. It is seen when the disease is of very great severity, and attended with profuse erup- tion of the exanthem on the skin. Single discrete pustules are then found upon the mucous membrane of the epiglottis, the ad- jacent soft palate, the larynx, trachea, and occasionally in the larger bronchi; they are soft, easily rubbed off, sometimes con- fluent, and leave shallow, concave, roundish ulcers; the mucous membrane beneath is of a dark red or livid color, and appears excoriated; in the intervals between the pits it is more or less reddened, thickened, and coated with a tough, plastic, mucous, or croupy exudation. At times it is found swollen and, together with rarely attacks children under two years of age; it is commonly gradual and insidious in its approach, for in thirty cases its onset was sudden in two only ; this rule does not apply to it when it occurs as a sequel to scarlet fever, for then it is usually very rapid and almost inevitably fatal. In the simple inflammatory and spasmodic pseudo- croups the attack is almost always sudden, and usually sets in during the first sleep of the child, before the parents have retired to bed: the little patient awakes in great distress—inspiration is attended with great effort, is loud ringing and shrill, somewhat like the inspiration in hooping cough; expiration is comparatively easy and quiet; the voice is hoarse and broken, the cough is loud, hoarse, and barking; such cases almost always give way to an emetic. Catarrhal pseudo-croup is more difficult to distinguish from true croup than the spasmodic variety. At first there are symptoms of catarrh ; in a few days the voice becomes hoarse, the cough croupy ; there is tightness and oppression of the chest, with some approach to croupy inspiration; at times sudden attacks of dyspnoea set in, with loud, shrill, sonorous breathing; but in a few days more the croupy character wears off, leaving simple catarrhal symptoms only. The best diagnostic sign of true croup, according to Dr. Ware is the presence of false membranes, most frequently and sometimes only on the tonsils, sometimes on the palate, uvula, and pharynx. Of thirty-three cases of true croup, in which the throat was examined they were present in thirty-two; in one case there were none on the fauces, but some in the larynx; of forty-five cases of pseudo-croup they were not found in a single instance; in three cases, however there was a thin, starch-like exudation on the tonsils—hence this sign failed only once in seventy-eight times. True croup is compara- tively rare; Dr. Ware met with but twenty-two cases in twelve and a TYPHOUS PROCESS. 25 the sub-mucous cellular tissue, in a state of serous infiltration. A very extensive confluent pustular eruption may bring on a variolous ulceration of the parts. 4. TYPHOUS PROCESS. The typhous process of the air passages presents various pecu- liarities, both in its seat, its relation to typhus fever in general, and to ileo-typhus in particular. It appears in all cases of typhus fever in the form of a pecu- liar typho-bronchial catarrh, attended with a secretion of tough, gelatinous mucus; it is present in a marked degree when the general affection is severe, and in those varieties characterized by predominant affection of the chest. It may occur as a genuine half years' practice ; of these nineteen died. In the same space of time he met with eighteen cases of simple inflammatory croup, all of which recovered ; with thirty-five cases of spasmodic croup, none of which proved fatal; and with fifty-six cases of the catarrhal variety, without a single death. In pseudo-croup the cough is often much louder and more violent in the beginning than in those which ultimately prove more alarm- ing. In the less dangerous cases the breathing is generally loud, harsh, and suffocative from the commencement, and attended with great efforts, much loud coughing, creating great alarm, and calling for immediate relief; but in the commencement of true croup the breathing is comparatively quiet and unobtrusive; there is only a little more effort in drawing in the air, and a little more force exer- cised in its expulsion ; soon there is a slight dilatation of the nostrils at each inspiration, and a slight whiz or buzz at the rima glottidis, heard by placing the ear on the back of the neck, or upon the larynx. In the latter stage the symptoms are more formidable and urgent than in the first stage of the less dangerous varieties: they are too well known to require a full detail. According to Dr. Ware, the recovery from membranous croup is slow and unequal; the natural cure is brought about by a suppurative inflammation which commences in the trachea, beneath the false membranes, which are thus loosened and finally thrown off; it ad- vances slowly about the glottis. The progress of the cure is attended with copious expectoration of pus, with or without pieces of false membrane, which often become dissolved by the pus; expectoration may also be mixed with blood — voice may not return for weeks. These accidents never occur even after the severest cases of simple inflammatory croup. 26 TYPHOUS PROCESS. or degenerate typhous process ; in the first instance being either a primary or secondary affection, in the latter always a secondary. Its seat is at times upon the bronchial, at others upon the laryngeal mucous membrane. On the former it frequently presents itself as primary bfoncho-typhus, which is a disease of great importance ; on the latter it occurs as laryngo-typhus, which is always, at least with us in Vienna, a secondary affection. a. The genuine typhous process upon the bronchi almucous membrane always appears in the form of an intense diffused con- gestion ; the membrane itself is of a dark red, almost violet color, spongy and swollen ; a gelatinous, and at times a dark, blood- streaked mucus is secreted, often in large quantities. It is most common in the bronchial ramifications of the inferior lobes of the lung, and is always limited to the stage of congestion ; never giving rise to the visible production of those ulcerations which occur in such immense numbers in the follicular apparatus of the intes- tine, in abdominal typhus. In primitive broncho-typhus, the typhous process localizes itself upon the bronchial mucous membrane, avoiding all others, even that of the intestine, for which it in general shows the most decided preference ; although it is true that, even on the latter, we in many instances notice an evident, though comparatively tri- vial, secondary enlargement of the intestinal follicles, in which the neighboring mesenteric glands also take part. In such cases it is often a very difficult matter to recognize the presence of typhus fever in the above described affection of the bronchial mucous membrane; still the peculiar congestion of the spleen and of the greater cul de sac of the stomach, the remarkable tumefaction of the former, the well-known cherry-juice appear- ance of the blood, and the affection of the bronchial glands, will generally suffice to mark its typhous nature. The bronchial glands present similar diseased appearances to those of the mes- entery in ileo-typhus: they are swollen, enlarged to the size of a pigeon or hen's egg, and at first of a dark bluish-red color; at a later period reddish-blue, soft, friable, and infiltrated with the marrowy typhous product. Like the mesenteric glands they may become the seat of sudden and tumultuous changes, leading to in- flammation of the adjacent mediastinum and pleura, with or without perforation of them. It is frequently combined with pleuro and pneumo-typhus, and is undoubtedly the basis of the exanthematic and contagious form of this disease, and may also be present in the Irish and North American typhus, which, in a majority of TYPHOUS PROCESS. 27 cases, seem to run their course without any intestinal affection. Broncho-typhus is rare with us in Vienna ; at least, it cannot be compared in point of frequency with ileo-typhus. Genuine secondary bronchial typhus presents the same morbid phenomena as the primitive, only it is rarely developed in so severe a degree. The degenerate form is still more rare, gener- ally occurring as a species of bronchial croup, or as diffused gangrene of the bronchial mucous membrane. b. Laryngo-typhus is with us in many epidemics an unusually frequent and extremely unfavorable phenomenon. It perhaps never occurs as a primitive, independent affection, but is always secondary, and dependent upon and growing out of various anomalies in the intestinal typhous affection. Its seat is in the laryngeal mucous membrane, above the musculus transversus, and towards the posterior extremities of the ventricles (a situation for which, as we shall subsequently see, almost all the, pseudo-plastic processes have a peculiar predilec- tion). Next it is most frequent on the epiglottis, towards its lateral edges ; at times, however, it attacks both of these places simultaneously. It no doubt frequently occurs in a genuine form, but it is very rarely that we have an opportunity of seeing the typhous infiltra- tion in its crude state, or while in the process of softening; we usually find ulcers similar to, but much smaller than, those of the intestine. Far more frequently laryngo-typhus presents itself in a degen- erate form, as an exudative or croupous process, or, what is more frequent, as a superficial gangrene. The latter, after the slough has fallen off, leaves an ulcer which cannot be distinguished from other degenerate typhus ulcers, so that from the cadaveric appear- ances alone we can form no correct idea of their origin. These ulcers are of a circular shape, of the size of a lentil or pea; at times discrete, at others confluent from the coalition of two, three, or more. As we have already intimated, they are seated upon the posterior laryngeal wall and the lateral edges of the epiglottis, in both of which situations they occur as linear ulcers ; while on the inferior surface of the epiglottis they always present a more or less circular form. They have all an atonic character; are lax, discolored, with black edges, and eat gradu- ally into the musculus transversus, the ventricles, the vocal chords, the cricoid cartilage, and that of the epiglottis, in all of which they occasion softening, or necrosis, and exfoliation. Upon the 28 INFLAMMATION OF THE SUB-MUCOUS CELLULAR TISSUE. posterior laryngeal wall we not unfrequently notice abscesses of a larger or smaller size, in which the necrosed cartilages are found bathed in a brownish ichor. At times they perforate into the pharynx. The whole forms a typhous-laryngeal-phthisis. Laryngo-typhus is frequently complicated with pneumonia, and with secondary broncho and pharyngo-typhus.* e. INFLAMMATION OF THE SUB-MUCOUS CELLULAR TISSUE. Besides the share which the sub-mucous cellular tissue takes in the inflammations of the mucous membrane of the air passages, it may also be the primitive seat of this affection. It is of rare occurrence, however, and when it does appear it is usually the * Diagnosis. — According to Andral, broncho-typhus is more frequently latent than any other disease of the lungs, and it may lead to brown or livid softening of the parenchyma, before this is suspected to be the seat of any disease. It is most apt to supervene in the third or fourth week of typhus fever, and is only marked by a sudden increase of the prostration of the patient; the pulse becomes much more frequent and often extremely feeble, although occasionally hard; the features change, and the cheek bones present a livid redness, which contrasts strongly with the livid paleness of the rest of the face. There is often no appreciable difficulty of breathing, neither cough or expectoration; the patient will sink rapidly, apparently from mere nervous weakness, yet after death the bronchial mucous membrane will be found in a state of intense inflammation. At other times the disease is only marked by hurried breathing, without cough or expectoration; sometimes auscultation discovers nothing unusual; the respiratory murmur seems normal, but if the pa- tient be compelled to cough strongly, or to make several forced and deep inspirations, the auscultator will frequently be astounded at the number, variety, and intensity of the bronchial rales.—(Stokes.) Whenever a sudden increase of debility sets in in a fever patient, it is a common practice among experienced auscultators to examine the chest of the patient at once and carefully, especially its posterior and inferior portions; dulness of percussion there is often the only sign which marks the existence of splenization, i. e. livid or brown softening of the base of the lungs, for the induration of the paren- chyma is often not great enough for bronchial respiration to be formed. If bronchitis be present it is generally marked by the presence of dry and moist bronchial rales. It is of the utmost importance frequently to percuss and auscultate persons laboring under bad fevers, however exempt they may appear from any affection of the chest.—(Andral.) ULCERATIVE PROCESSES. 29 result of a metastasis, and hence is particularly apt to run into suppuration and mortification of the cellular tissue and superin- cumbent mucous membrane. These inflammations are generally confined to the region of the larynx, though they occasionally extend to the neighboring pharyngeal and aesophageal tex- tures, or to the intermuscular cellular tissue of the neck. When chronic they are apt to cause hypertrophy, thickening, callous induration of the tissues affected, and consequent diminution of the volume or calibre of the larynx.* d. ULCERATIVE PROCESSES. These with rare exceptions are seated upon the larynx and trachea, and commonly result from affections which commence in * Diagnosis. — According to Howship, boils may suddenly stop discharging, and uneasiness in the throat come on : in a few days respiration will be impeded, from some cause evidently seated in the larynx ; extreme difficulty of breathing ensues, features exhibit great anxiety and distress, death follows, and suppuration of the sub-mucous cellular tissue of the larynx will be found. The exact diagnosis of this rare affection is not yet known, but Johnson says such cases are not rare : they commence as simple sore throat, but soon the symp- toms become severe beyond their apparent cause, and the expression of distress is disproportioned to it. Stricture of the larynx, from thickening of the mucous and sub- mucous cellular tissue, is, according to Schoenlein, not uncommon in persons who have lingering, badly treated, or suddenly suppressed gonorrhoea. It has permanent and paroxysmal symptoms. Paroxysmal.—Suddenly the patient has a sensation of contraction of the larynx, and cannot expand the chest sufficiently : inspiration long, with a shrill, trembling sound; trachea is stretched as far as possible, hence the neck is thrust forward; the eye is dull; pulse small, weak, and quick; the patient grasps hold of every thing, has intense anxiety, and beckons for aid. Such paroxysms are sponta- neous and generally occur at night, but they may be induced by hasty speaking and eating; they last from fifteen minutes to many hours. Permanent.—A remarkable alteration of voice, rarely a dull, bass tone, but more of a fistulous and hoarse one, with a peculiar snarling speech; the breathing conveys the idea that the air forces itself through a contracted place, which becomes more evident when the ear is placed over the larynx; constant difficulty of breathing; con- stant want of more air; a peculiar sensation in the chest, induced by the small quantity of air in the lungs; inspiration is long, because 30 ULCERATIVE PROCESSES. the mucous membranes, which they destroy from within outwards. We have already referred to the catarrhal suppuration ; to the sloughing ulcer, which with the apthous are degenerate exudative processes ; to the variolous ulcers ; to the typhous ulcers in general, and to suppuration with gangrene of the mucous membrane, aris- ing from a primitive affection of the sub-mucous cellular tissue. We have yet to treat of suppuration of the perichondrium with necrosis of the laryngeal cartilages, and to tuberculous and can- cerous ulcerations. Here, however, we only propose to treat of syphilitic ulcera- tion of the air passages. The epiglottis is the favorite seat of this affection, which frequently spreads to this organ from the soft palate and root of the tongue. They present the well known characters of secondary chancres, and often occasion entire destruction of the epiglottis and the adjacent mucous membrane of the glottis. This destructive process generally confines itself to these localities, leaving after cure a more or less considerable deficiency of the epiglottis, which is covered by thick, hard, white, tendinous and cord-like cicatrices, crossing each other in various directions, causing diminution in size and deformity of the affected parts. In single rare instances they extend to the larynx and trachea, causing sloughing and apthous ulceration of the mucous membrane, contraction of the sub-mucous tissue, brittle- ness and friability of the cartilages. The walls of the air passages may be ulcerated from without; this occurs most frequently in the bronchi, owing to their neigh- borhood to softened tubercles and tuberculous abscesses.* but little air enters the lungs; expiration is short, because there is too little air there; remarkable sensation .of weakness and prostra- tion ; skin cool; pulse weak and contracted. At a later period ema- ciation comes on; difficulty of swallowing ensues, as the epiglottis becomes swollen, so as not to close the larynx; hence a portion of food or drink often gets into the larynx, where it excites cough, by which the foreign matter is again forced out, often through the nose. Frequent inclination to cough, cough dry and croupy at first, with lividity of the face; afterwards it becomes moist with glassy expec- toration, streaked with blood at times. This disease almost always proves fatal, sometimes in five or six months, at others not for years- most common in men about thirty years old; death ensues during a paroxysm, which may seem allayed, but it returns suddenly and treacherously, and the patient quickly dies of suffocation. * Diagnosis.—It is well known that, in an immense majority of 31 e. CEDEMA OF THE AIR PASSAGES. It is most frequent in the larynx, and there also attains its greatest intensity, and is followed by the most serious consequences. It has attracted the particular attention of pathologists, under the name of oedema glottidis. In rare instances it extends to the mucous membrane of the posterior tracheal wall and upon the pharynx. This disease, in those cases which strictly belong under this head, consists in an infiltration of the sub-mucous cellular tissue and the mucous membrane with a colorless or pale yellow serum. The seat of oedema glottidis is in the mucous membrane of the epiglottis, of the aryteno-epiglottic folds, of the vocal-chords, and ventricles. When fully developed, a transparent pale yellow fluctuating swelling is formed, which, according to its size and extent, diminishes or entirely closes the aperture of the glottis. CEdema of the glottis may occur either as an acute or chronic affection, and is associated not only with all the previously men- tioned inflammatory diseases of the laryngeal mucous membrane, but also with many irritations of this and the adjoining parts. It also arises as a sequel of catarrhal inflammations, more fre- quently from those of an exudative or exanthematic character, and from inflammation of the sub-mucous cellular tissue. It follows the typhous and all other ulcerative affections of these parts, such as the tuberculous, cancerous, &ic. It is important to be prepared for and to be able to diagnose those cases, for they arise from unknown exciting causes during instances, ulceration of the larynx is of a tuberculous nature, and secondary to more or less extensive tuberculosis of the lungs. Yet Schoenlein admits a rheumatic inflammation and ulceration of this organ, comparatively frequent in those much exposed to cold and wet, such as washerwomen, &.c.; the pains are said to be more fre- quently piercing. Also, a laryngo et tracheo-phthisis hysterica, most common in females who have frequently suffered from globus hystericus ; in this the pains are commonly contracting. When the ulcers are seated high up in the larynx, there often is a flaming red- ness of the fauces and tonsils ; when the vocal chords, ventricles, or arytenoid cartilages are ulcerated, there is hoarseness, alteration, or complete loss of voice ; the larynx is not often painful to pressure, except an ulcer is seated on the crico-thyroid ligament; when the posterior surface of the larynx is ulcerated, difficulty and pain on swallowing is experienced. The cough is peculiar and characteristic; 32 GANGRENE. the progress of the above mentioned affections of the laryngeal mucous membrane, of the soft palate, tonsils, and neighboring tissues, quickly attain a high degree of development, and cause rapid suffocation, though the primitive disease may appear very slight. It is important to distinguish the sero-purulent infiltration from simple oedema glottidis, as the former is always the result of an intense inflammatory affection of the sub-mucous cellular tissue.* /. GANGRENE OF THE AIR PASSAGES. It occurs in two distinct forms: 1st. As a circumscribed eschar of the mucous membrane of the air passages, which im- mediately attacks the subjacent cellular tissue, in which, however, it may also occur primitively. 2d. As diffused gangrenous col- liquescence of the same tissues. It arises under conditions simi- lar to those causing gangrene of the lungs, and is at times asso- it does not come from the depths of the chest, but is a tussis laryn- gea, being effected by the muscles of the throat and larynx only; cough may be absent, and its place supplied by a mere hawking up of pus and mucus; cough, however, may come on in violent paroxysms, in which the rima glottidis becomes contracted, with violent con- tracting pain in throat, a croup-like paroxysm, and danger of suffo- cation. The root of the tongue is often thickly coated on one side only, viz., on that corresponding to the seat of the ulcer ; this coating may extend in a broad stripe from the root to the tip of the tongue; when present it is characteristic. * Diagnosis.—The symptoms of oedema glottidis are so similar to those of croup, as to have led some physicians to believe that this latter disease is not so rare in adults as is usually supposed. Cruvel- hier thinks that it is always preceded by and attended with inflamma- tion and tumefaction of the throat, and fever ; the voice becomes remarkably rough; patient complains of difficulty in the throat, and of the entrance of air during inspiration, while expiration is effected with comparative ease ; in the course of the disease respiration be- comes extremely difficult, rapid, and hissing ; dyspnoea with extreme danger of suffocation set in; voice is extinct, or else hoarse, sharp, and croupal; by auscultation we hear a shrill, trembling, and whistling sound, as if the air met with an obstacle in its passage throuo-h the larynx. If the finger be passed rapidly and dexterously through the fauces, a roundish, painless, but soft swelling will be felt. Asphyctic paroxysms ensue ; the face becomes swollen and livid ; the eyes pro- ject from their sockets, and the patient often dies suddenly of suffo- cation.--(SCHOENLEIN.) PERICHONDRITIS LARYNGEA. 33 ciated with it. It generally occurs in a tissue in some way pre- viously diseased, being however an accidental rather than a necessary termination. We have said that the circumscribed form arises in the train of inflammation of the perichondrium, from tuberculous laryngeal phthisis, typhous ulceration, and laryngeal croup. The diffused variety is far more frequent in the mucous membrane of the bronchi. In it, we find the membrane con- verted in various places into a soft, moist, shaggy, friable tissue, of a dirty brownish-green color, giving out the peculiar odor of gangrene, and occupying either a large extent of surface, or only spots of various dimensions. The bronchi are filled with a simi- larly discolored, frothy, foetid, sero-ichorous fluid. It most com- monly accompanies gangrene of the lungs. b. DISEASES OF THE CARTILAGINOUS SKELETON OF THE AIR PASSAGES. a. INFLAMMATION OF THE PERICHONDRIUM OF THE LARYNGEAL CARTILAGES (PERICHONDRITIS LARYNGEA). We occasionally have opportunities of noticing in the cadaver a peculiar form of ulceration of the larynx, which without doubt is the consequence of an inflammation primitively seated in the perichondrium, which is detached either in single circumscribed spots, or more frequently from both surfaces of the whole car- tilage ; a quantity of pus is found collected in a membranous sac both anteriorly and posteriorly between it and the cartilage. The cartilages are rough, shreddy, necrosed, and perforated, and either laid bare by circumscribed abscesses, or else they lie entirely free, detached, discolored, attenuated, softened, either entire, or crumbled into several small pieces, the whole being situated in a large purulent cavity. This abscess may open and discharge its contents into the larynx, pharynx, trachea, or through the skin. The disease attacks the cricoid cartilages by preference; it is generally considered of a rheumatic nature, and has been described as a rheumatic laryngeal phthisis. Still it may follow the acute exanthems, especially variola, or may arise from an abuse of mercury. b. INFLAMMATION AND SOFTENING OF THE EPIGLOTTIS. The epiglottis occasionally becomes the seat of chronic 34 OSSIFICATION OF CARTILAGES. inflrmmation, by which this organ is transformed into a dense, rigid, fibro-cartilaginous tissue, a change always attended by con- traction and deformity. In contrast with this, softening may occur, similar to that which affects the yellow coat of the arteries, and which possibly may be also the result of inflammation. In this condition, the epiglottis loses its elasticity, becomes soft and brittle, assumes a dirty yellow color, and wastes away. C OSSIFICATIONS OF THE CARTILAGES. In the later years of manhood, the cartilages of the larynx, in the male, almost always become ossified; hence this change only deserves particular attention when it commences at an unusually early period, is finished in a short space of time, or extends itself to parts not usually its seat. They ossify in the following order: 1st, the thyroid; 2d, the cricoid ; more rarely and at a later period the tracheal, and finally the bronchial rings. This ossifi- cation is a true transformation of the cartilages into bone, not a mere deposition of osseous particles into their tissue. It occurs either spontaneously, or may be induced by, an inflammatory vascular activity of the perichondrium, and is frequently noticed in and about the seats of ulcers, especially those of a tuberculous character. Fracture and injuries of the cartilages often prove exciting causes of the deposition of osseous callus. The new bone, when developed in the course of laryngeal phthisis, may become the seat of caries and necrosis; it then frequently hap- pens that fragments of bone may be coughed up,- which however can be readily distinguished by their peculiar structure from cal- careous concretions. In rare instances not only do the most minute bronchial car- tilages become ossified, but even the walls of the smallest terminal twigs. We then find rigid tubes passing through the lungs, which do not collapse when cut across; and if the finger be passed over the incised surface, it detects prominent, sharp, sand- like granules. This condition only occurs in very aged persons. The epiglottis is never truly ossified, but is sometimes, though rarely, the seat of bone-earthy concretions, especially when in consequence of inflammation it loses its normal structure and becomes changed into a fibrous tissue. These concretions necessarily cause various kinds of deformity. POLYPI OF AIR TUBES. 35 d. HETEROLOGOUS FORMATIONS OF AIR PASSAGES. These become of especial importance when they project into the cavity of the air passages in the form of broad or pediculated vegetations, causing different degrees of diminution in their cali- bre. These vegetations occur almost exclusively in the larynx, and, under the common head of laryngeal tumors, are generally divided and treated of according to their external characters. Taking their internal structure as our guide, we shall reduce them to the following species, which are also found in the substance of, or beneath, all other mucous membranes. 1. Epithelial Formations. These occur in the form of rounded cauliflower-like or warty vegetations, varying in size from that of a hemp seed to that of a hazel-nut, or even larger. They are attached to the mucous membrane by a short neck, have a laminated structure, and con- sist almost wholly of exuberant epithelial cells, and prolongations of delicate vessels from the mucous membrane. Their favorite seats are the vocal chords and arytenoid cartilages ; still they have been found attached to the inferior surface of the epiglottis and to the cricoid cartilage. As they may spring from a cancerous basis, they are frequently of a malignant nature; but they also occur in a benign form in persons of various ages who have suffered from frequent attacks of catarrh or croup. They are the most com- mon of all laryngeal tumors. 2. Cellular or Mucous Polypi and Condylomatous Excrescences. These generally grow upon, or by the side of previously ex- isting ulcerations, though they may also arise from healthy mucous membrane. They form hard, spongy, bluish-red bodies, of the size of pins' heads, hemp seeds, or peas; lying side by side, and covering large sections of the laryngeal mucous membrane, par- ticularly that which clothes the vocal chords. They are in all probability of a syphilitic origin, and when, as occasionally hap- pens, they arise in connection with tubercular laryngeal phthisis, they lead us to suspect a combination of the syphilitic with the tubercular dyscrasia. 36 CANCER OF AIR PASSAGES. 3. Erectile Tumors. Erectile tumors occur in the form of soft, broad-based, dilatable vegetations, or as morbid growths from the free extremities of mucous polypi. The first variety not unfrequently springs from a cancerous basis. 4. Fibrous Tumors. These tumors are very rarely found in the sub-mucous cellular tissue of the larynx, but are of more frequent occurrence in that portion of the pharyngeal mucous membrane which covers the posterior laryngeal wall. In this situation they are met with not only of their usual inconsiderable size, but at times are distin- guished for their great volume, and by their adhesion to the perichondrium, reminding us of the large pharyngeal polypi that grow from the sub-mucous periosteum at the back of the throat. 5. Cancer. As has already been remarked, this morbid change not unfre- quently forms the basis of exuberant epithelial formations and erectile tumors. In addition it may occur in the fibrous form in the larynx, in the medullary form in the sub-mucous cellular tissue, and, what is extremely remarkable, cancerous degeneration of the arytenoid cartilages occasionally takes place. These tumors project into the laryngeal cavity in the form of knobby, rounded protuberances of various sizes, and diminish its volume to a greater or less degree. They for the most part prove fatal while yet in their crude state, but at times pass into the stage of softening and degenerate into cancerous ulcers. Cancer may also occur in the trachea and bronchi, but only as a secondary disease. Thus in rare instances large medullary cancerous masses open their way from the neck into the trachea, or from the posterior mediastinum into the bronchi, into which esophageal cancer may also perforate and grow. We occasionally notice a malignant degeneration of the fibrous bronchial sheath, which at times extends from a bronchial trunk to a greater or less extent along its ramifications. We then find the walls of the bronchi thickened and rigid, their volume diminished, their inner surface tuberous and uneven. This degeneration seems to spring from a primitive affection of one or several bronchial glands. TUBERCULOSIS OF AIR TUBES. 37 6. Tuberculosis. Tubercles are of very common occurrence in the air passages, but are not equally frequent in all parts. They are most frequent in the larynx, extremely rare in the trachea and larger bronchi, and again become frequent in the terminal bronchial twigs.- By their softening they cause tuberculous ulcerations of the affected tissues, and according to their seat they produce laryngeal, tracheal, or bronchial phthisis. a. Tuberculosis of the larynx is so rarely a primitive independent disease, that its occurrence as such has been positively denied. It is developed in the train of tuberculous disease of the lungs, and generally only when the latter has progressed into pul- monary phthisis. The seat of the tubercles is almost constantly and exclusively confined to the mucous membrane and sub-mucous cellular tissue above the musculus transversus, and the adjacent arytenoid cartilages; still in exceptional cases they are met with upon the epiglottis and in other parts. The tuberculous matter is either deposited in the sub-mucous cellular tissue in the form of gray granulations, or is infiltrated into the mucous membrane as a yellow, cheesy, friable substance; in both instances, but espe- cially in the latter, it passes rapidly into softening and ulceration. The softened gray granulations form little ulcers of the size of a mustard seed or lentil, with thick and hardened edges; they then coalesce and form secondary, irregular ulcerations with in- dented, serrated edges, and a cellulo-callous base, both of which may become the seat of a secondary deposition of tubercles. The yellow, cheesy infiltration softens in and together with the mucous tissue, forming larger, extremely irregular, gnawed, and, as it were, fissured ulcers. These are attended with evident inflammatory reaction, viz., redness, injection, swelling, oedema of the sur- rounding tissues, and apthous exudations in their immediate neigh- borhood. .These ulcers enlarge in consequence of the softening of secondary tubercular depositions in their edges, bases, and imme- diate neighborhood. They increase in depth as well as breadth, and gradually extend over the whole larynx, viz., upwards to the epiglottis, beyond it upon the soft palate and root of the tongue, and downwards into the trachea, causing suppuration and morti- fication of all the fibrous tissues and cartilages. They may even perforate the larynx from within outwards, and open into the sur- rounding cellular tissue, thus causing universal emphysema. 38 TUBERCULOSIS OF TRACHEA. Secondary tubercular ulcerations at times assume a peculiar aspect from a condylomatous development of the mucous mem- brane of their edges, or of those of the muco-membranous insular patches which frequently remain on the bases of the ulcers during their enlargement. It is not improbable in these cases that the tuberculous dyscrasia is complicated with the syphilitic. These ulcers may heal up in rare instances, when favored by the necessary general conditions, but always leave more or less callous, misshapen cicatrices, proportionate in size and depth to those of the previous ulcerations, and cause a greater or less de- gree of contraction and deformity -of the larynx. We must be on our guard, however, not to imagine every cicatrix existing in the larynx or trachea adjacent to true tuberculous ulcerations to be the remains of similar ulcers. b. Tuberculosis of the trachea is extremely rare, for the laryngeal affection scarcely ever extends itself, even upon the superior portion of this tube. In laryngeal phthisis, however, nothing is more common than for us to find small ulcers upon the tracheal mucous membrane, often, too, in such numbers that they become confluent and cover the whole of its surface. It is to these cicatrices which we just now referred, when we warned against mistaking them for the scars of tuberculous ulcers. They are small and shallow, generally of an oval, occasionally of a linear form, with concave bases, and often so very superficial as only to be observed when the light is thrown obliquely upon them. They are either clean or covered with a cream-like, dis- solving exudation of a croupy character, and are surrounded either by a fiery redness or a sharply circumscribed, red areola. They are seated for the most part on the posterior tracheal wall; frequently they extend into the bronchial trunks, being found in greater numbers on the right or left side of the trachea and cor- responding bronchus, according as one or the other lung is pre- dominantly or exclusively the seat of tubercular disease. They also occur with considerable frequency in the pharynx and upon the mucous membrane of the mouth, but are in no wise connected with'tuberculous ulcerations, and may be at a glance recognized as exudative apthous ulcers, which, however, frequently associate themselves with florid laryngeal phthisis. When the tuberculous disease is stationary, or makes actual retrograde movements towards a cure, these apthous ulcers heal, leaving delicate, white, shining, radiated, star-like cicatrices. c. Bronchial tuberculosis occurs in the mucous mem- BRONCHIAL TUBERCULOSIS. 39 brane of the tubes, which may be infiltrated with yellow, fatty, cheesy, tuberculous matter to such a degree as to seem almost entirely converted into it. The tube itself becomes enlarged, its cavity gradually and completely filled with tuberculous matter, while its fibrous sheath undergoes a fatty infiltration and becomes callous and thickened. This variety of degeneration is at times a secondary process ; it is then developed in those bronchi which open into tuberculous vomicae, and is dependent on pulmonary phthisis. Primitive bronchial tuberculosis is a more important disease. As we have already mentioned, it is an affection of the terminal bronchial twigs, arising in these originally, and from them spread- ing along those of a larger size. Like pulmonary tuberculosis it occurs most frequently in the superior lobes, but unlike it is often found in their periphery. At times it attacks a large portion of the bronchial tree, and should we then make a section of the lung, we find the parenchyma traversed by numerous thick-walled, dilated bronchial tubes, which are filled with cheesy, tuberculous matter. Bronchial tuberculosis is often complicated with a fatty gelati- nous, or fatty, cheesy, tuberculous infiltration of the parenchyma of the lungs ; sometimes, on the contrary, it is a perfectly uncom- plicated and independent disease. In the latter case the obstruc- tion of the tubes is followed by obliteration of the air cells, and atrophy of that portion of the pulmonary parenchyma supplied by them with air. If we then make a section of the affected part, we find the obstructed bronchi contracted into the form of ribbons, which ramify through a dense elastic tissue. The tuberculous matter softens, destroys the bronchial walls, and creates abscesses in the adjoining pulmonary parenchyma. These abscesses, the first step of which is the destruction of the bronchial walls, are by no means so frequent as those arising from the softening of pulmonary tubercles. This mode of soft- ening is most frequent when simultaneous tuberculous infiltration of the lung exists. Another, but a rarer change is, the transfor- mation into chalky concretions. This metamorphosis is most fre- quent when the tube has been entirely obstructed with tubercu- lous matter, and the parenchyma of the lungs, to which it leads, has in consequence become atrophied. Under favoring constitu- tional causes, the matter is changed into a cheesy pap, which, instead of softening, begins to thicken, and is finally changed into a chalky mass, around which the bronchial tube contracts, and becomes atrophied. 40 FOREIGN BODIES, ETC. Bronchial tuberculosis occurs as a primitive disease during the years of childhood ; is generally associated with the tuberculosis of the other tissues peculiar to this period of life, but most fre- quently with the disease of the bronchial glands. It presents many resemblances to tuberculous deposits on the fallopian and uterine mucous membranes.* 7. Foreign Bodies in the Air Passages. Under this head we must consider: 1. The various diseased products of the entire mucous membrane of the air passages, such as blood; various quantities, often very great, of mucus of different qualities, viz., gray, pearl- colored, transparent, colorless, watery, tough, glassy, cream-like, whitish, yellow, and purulent; actual pus, membranous concretions or croup-membranes, ichorous fluids, tubercles, tuberculous pus, necrosed fragments of cartilage, ossified bronchial cartilages, &;c. * Diagnosis.—Tubercular ulcerations of the larynx are more com- mon in males than females ; from Louis's statistics we learn that in eighty cases of phthisis in females they were found nineteen times, or in about one-fourth ; while in one hundred and thirteen cases in males they were found forty-four times, or in about two-fifths. It is not sufficiently known that in some cases the affection of the larynx forms not only the first evident commencement of phthisis, but so masks the disease of the lungs that cough, dyspnoea, haemoptysis, emaciation, and hectic fever, seem to spring from it, and not from the lungs, which are apparently sound to the mere symptomatologist. But nothing is more uncommon than laryngeal phthisis independent of pulmonary phthisis. In upwards of five hundred non-tuberculous subjects dying of various chronic diseases, Louis did not find one example of laryngeal ulceration ; as chronic laryngitis with ulceration is found in from one-fourth'to two-fifths of all cases of consumption the conclusion is irresistible that in an immense majority of instances this affection is but a part of consumption. If we find a case of chronic laryngitis with emaciation, hectic, &.c, the probabilities amount almost to certainty that there are softened tubercles in the lungs. Louis says that moderate pain of limited duration in the region of the larynx, coupled with more or less marked alteration of the voice, signifies superficial ulceration of the larynx; whereas severe and continuous pain with persistent loss of voice results from deep ulceration. But this affection is generally painless ; commonly there is but a little heat and constriction in the part, coupled with more or less hoarseness or loss of voice. According to Andral ul- cerations of the mucous membrane lining the ventricles and covering FOREIGN BODIES, ETC. 41 2. The products of diseases external to the air passages, and which enter either through natural or artificial channels : as blood in various but generally very large quantities, from the bursting of an aneurism ; bronchial froth, composed of serous and frothy fluids from the parenchyma of the lungs ; pus and ichor, flowing from abcesses of the pulmonary tissue, bronchial glands, or vertebrae. In consequence of the direct corrosion of a bronchial trunk, pus may be discharged from the cavity of the pleura; the same may happen with an hepatic abscess ; cancerous ichor, from malignant disease of the esophagus; tuberculous matter; bone-earthy and stony concretions, including chalky transformations of tubercles; catarrhal mucus ; acephalocysts, which, according to Portal, get into the air passages from the lungs, liver, and thyroid body. 3. Foreign bodies which, a. Enter into the air passages from the pharynx, esophagus, or even from the stomach and intestinal canal, through natural or unnatural communications. Among these belong fluids which the chordae vocales often cause an alteration of the voice, which is not greater than when these parts are red and slightly swollen : a hoarse and rasping voice generally depends upon a considerable tumefaction of the mucous membrane of the ventricles : the destruc- tion of one chorda vocalis may cause either hoarseness or loss of voice ; of both, always complete aphonia. Fixed pain at the upper part of or immediately above the thyroid cartilage, difficulty of swal- lowing, and escape of drink through the nose, announces ulceration of the epiglottis, provided the throat and tonsils be healthy. Apthous ulceration of the trachea is commonly attended by no special symptom ; in a single instance only did Louis observe a slight feeling of" heat and obstruction behind the sternum. It is not known if the successive crops of apthae upon the trachea occur simultane- ously with those which take place so frequently in the mouths of phthisical patients. Tuberculosis of bronchial glands.—According to Rilliet and Barthez, serious results from pressure of enlarged bronchial glands occur less frequently than might have been expected: complete obliteration of a bronchus from the same cause is also rare ; but compression of the trunk or branches of the pneumo-gastric nerve is common, and is attended with a spasmodic cough resembling hoop- ino- couo-h, alteration of the voice, even total aphonia, and very dis- tressing attacks of asthma. When enlarged bronchial glands com- press the superior vena cava, they may occasion, 1, oedema of the face ; 2, dilatation of the veins of the neck; 3, a livid color of the face ; 4, haemorrhage into the cavity of the arachnoid. By compressing the pulmonary veins, 1, haemoptysis; 2, oedema of the 42 FOREIGN BODIES, ETC. flow into the cavities by ulcerated or cicatrized openings, or from strictures; ascarides, which sometimes find their way into the pharynx and thence into the glottis, and are said to have caused death by suffocation. b. Articles of food, pieces of gristle, tough meat, which be- come wedged into the glottis in consequence of inflammation and degeneration of the muscular parts of the pharynx, of swelling of the tonsils, haste and inattention during the act of deglutition, especially in idiots, or when coughing, laughing, sneezing, &c. These accidents are still more apt to occur when atrophy, rigidity, deformity, and consequent insufficiency of the epiglottis, are present. c. Foreign bodies which accidentally obtain entrance into the glottis without an intentional act of swallowing, and which fall, or are forced into the trachea or bronchi. Among these we have articles of the most various kinds, fruit-pits, coins, pins, natural lung may result. By compressing the bronchi, they occasion, 1, loud, very persistent, sonorous rales, which are sometimes very sin- gular in their tone and character ; 2, feebleness, or absence of respiratory murmur in parts of the lungs ; 3, they will convey sounds which are found in the bronchi in their normal condition, but not transmitted to the ear, such as prolonged expiration, bronchial res- piration, &c, although the lung may be almost or altogether healthy ; 4, if pulmonary lesions exist, their stethescopic signs will be ex- aggerated—thus, crude miliary tubercles will give rise to bronchial or cavernous respiration, or to pectoriloquy ; and if they have begun to soften, or are attended with slight bronchitis, distinct gurgling may be heard; 5, the sounds arising from an affection of one lung may be transmitted to the sound side, and thus excite a suspicion of a double lesion. These stethescopic phenomena are heard especially at the upper and posterior part of the lungs; they vary very much: thus, bron- chial respiration will be heard one day, and give place on the next to simple prolonged expiration, while on the 'third cavernous respi- ration may be present; in fact, feeble respiration, prolonged expi- ration, bronchial breathing, cavernous respiration, pectoriloquy, gurgling, and mucous rhonchus, may alternate with, or succeed each other, without any regularity. This changeableness of the stethe- scopic signs, if attended with persistent dulness of percussion be- tween the scapulae, render it almost certain that there is tuberculosis of the bronchial glands ; if cough, emaciation, fever, and sweats, are also present in a child from three to four years of age, scarcely a doubt can exist as to the nature of the disease.—[Rilliet and Barthez.] FOREIGN BODIES, ETC. 43 or artificial teeth, nails, pebbles, pieces of glass, &;c. In favora- ble cases they are soon ejected by coughing; in others they remain, causing not only inflammation of the air passages them- selves, but pneumonia, suppuration of the lung, injuring the walls of the tubes in various ways, and occasionally penetrating through them into adjacent canals and blood-vessels. Here we may be permitted to refer to the following rare case: A little boy acci- dentally sucked an arrow from a blow-gun. It was drawn with its feathered portion downwards into the trachea, and from thence into the left bronchus. In consequence of hemorrhage from the lungs, he died in twelve days with symptoms of pneumonia. Bronchitis, especially of the left side, and hepatization of the left inferior lobe, were found after death. The arrow was lying loose in the left bronchus ; its point upwards, and to the right. Near the junction of this bronchus with the trachea was a very small incised opening, and from this the perforation extended into the adjacent arteria innoninata. This nrischief was caused by the point of the arrow being forced during the paroxysms of cough- ing against the right side of the trachea, which of course lay opposite in the axis of the left bronchus. Key states an interesting and important fact, namely, that the majority of these foreign bodies fall into the right bronchus, owing no doubt to its greater size, the more obtuse angle at which it is given off from the trachea, and to the greater force of the current of air flowing into it at every inspiration. We are here reminded of the circumstance of the right lung in new-born children be- coming more quickly and perfectly inflated than the left.* * Diagnosis.—According to Hawkins and Ryland, in by far the greater number of cases the foreign body continues to be movable in the trachea ; it may be distinguished from laryngitis by the absence of fever at first; by the very sudden manner in which the symptoms come on ; by the intermissions in the difficulty of breathing, which sometimes continue an hour or two; by the noise which is heard occasionally when the foreign body is impelled against the vocal chords; by the excessively violent cough which follows this occur- rence; but more particularly by the chief difficulty of breathing beino- during the time of expiration, while in laryngitis the chief difficulty is in inspiration. When it is located in the larynx below the glottis—in the situa- tion of the cricoid cartilage, the severe paroxysms of coughing are aDsent—hoarseness may be wanting in two cases out of three, but in all there is a sense of soreness and uneasiness [in the spot where the foreio-n body is fixed; a noise is heard either during expiration 44 II. ABNORMAL CONDITIONS OF THE PLEURA. 1. DEFICIENCY AND EXCESS OF DEVELOPMENT. The pleural sacs are absent when there is a perfect deficiency of the organs of respiration; the thoracic cavities then being filled with a dense fibro-cellular tissue. A partial deficiency of the pleura exists when, owing to the absence of the diaphragm, its serous membrane is continuous with that of the peritoneum. Excess of development always occurs in the form of duplica- tion of the costal pleura, except in the case of double monsters, in which the cavities of the chest are found double in a greater or less degree, and when both lungs are found seated in one large common cavity. It is extremely rare, especially when contrasted with the frequency of congenital duplications of the peritoneum. On account of its rarity, as well as the conditions under which it or inspiration, or both, and in all the patient asserts that something has been swallowed. When a plug of mucus obstructs a bronchus there may be a feel- ing as if something was lodged there, with a sense of great heat at the part; the clot may be large, weigh an half ounce, be yellow, opaque, viscid, and of a consistence intermediate between usual mucous sputa and false membrane : after its expulsion the sense of warmth at the spot maybe changed to a painful heat, which may last many hours. When a plug of mucus obstructs a bronchus we all at once cease to hear the normal vesicular murmur, or the rales if bronchitis be present; the part of the chest above the obstruction retains its sonorousness; at the same time the patient is seized with greater or less dyspnoea ; after a violent fit of coughing the plug may be expelled, the dyspnoea cease, and the respiratory murmur return; in rare cases the difficulty of breathing increases, suffocation becomes imminent, and patient dies of asphyxia.—(Andral.) In one of Andral's cases the patient, in the midst of a violent fit of coughing, was seized all at once with extreme difficulty of breathing. The remainder of the day and all the night he had orthopnoea and almost continual efforts at coughing. The following morning there was imminent asphyxia, his face was swollen and violet; extremities livid, and pulse nearly extinct: with difficulty and panting he en- treated them to relieve him of an enormous weight which he said he felt on a level with the right mamma, and which was smotherino- him. The sonorousness of the chest was not diminished—from the clavicle to below the breast, both before and behind, neither respiration nor rale was heard, although the chest was elevated with force; on op- posite side there was exaggerated, puerile respiration. HYPEREMIA OF PLEURA. 45 arises, we may be allowed to allude to an increase of the right pleural sac, which as yet has not been noticed or described by any previous observer. This extends in the form of a fold from above and outwards, downwards and inwards, its free edge embracing the arch of the vena azygos, and lying in a supernumerary fissure, which divides the superior lobe of the lung into two parts. 2. ANOMALIES IN SIZE AND FORM. The size or capacity of the pleural sac is always proportionate to the congenital or acquired volume of the lung ; thus large lungs have spacious pleurae, those of a less size have smaller ones. Li emphysema, dilatation of the serous membrane takes place; in atrophy, diminution of it occurs. The pleural cavities may be enlarged to various extents by accumulations of gaseous or liquid fluids in them, and be lessened by an increase in size of the peri- cardium or peritoneum; also by heterologous deposits in the mediastinum and by deformities of the walls of the chest. The form of the pleura is regulated by that of the bony thoracic walls ; hence we must refer our reader to what has been said concerning anomalies in the shape of the thorax. 3. DISEASES OF THE PLEURA. a. Hyperemia. A continuous increased flow of blood according to its extent occasions either a local or general opacity, also thickening or hypertrophy of the pleura, or finally the development of anom- alous cartilaginous and bony substances in its texture or that of the sub-serous cellular tissue. Congestion may also cause increased secretion, which, accord- ing to its character and the condition of the blood in general, may result in the transient or permanent accumulation of various quantities and qualities of serous fluids in the chest. [Hydrops pleurce or hydrothorax.] In rare instances it may lead to hemor rhage in the pleura or haemo-thorax. 6. Inflammation of Pleura. Pleuritis, Pleuresia. This is the most frequent disease of the pleura: it generally appears as an idiopathic and primitive disease, and most frequently 46 INFLAMMATION OF PLEURA. is of a rheumatic nature. It may arise in consequence of injuries, or concussion of the chest, from exposure of the pleura to con- tact with atmospheric air, pus, gangrenous ichor, &c, which may reach it from within through the air passages ; from the extension of inflammation and other affections of the neighboring tissues and organs, especially the lungs ; or finally it occurs as a secondary or metastatic disease, and is often associated with inflammations of other serous membranes, particularly the peritoneum and peri- cardium. In general it bears a marked croupous or exudative character. Pleurisy is either general, and then the disease for the most part is least severe upon the pulmonary pleura, or it is partial and circumscribed. It may also in either case be acute or chronic. As every thing' which has been said of serous membranes in gen- eral holds good with regard to inflammation of the pleura, we shall here confine ourselves to the consideration of important peculiarities. The exudations occur in all the varieties already described, two forms of which, the purulent exudation (Empyema) and the hemorrhagic, are of very frequent occurrence and of great im- portance. Acute, but more particularly chronic pleurisies deposit an exudation, the quantity of which is increased paroxysmally; when the inflammation is general it often becomes enormous, the fluid portions weighing as much as eight, ten, sixteen, and even twenty pounds and over. The thorax in these cases becomes dilated in a more or less striking manner; the intercostal spaces are enlarged from paralysis of their muscles, and the depressions so evident in the healthy state are completely effaced. The dia- phragm is pushed down into the abdomen, the mediastinum and heart are thrust to the opposite side, and this way diminish its capacity. The lung itself is compressed in proportion to the quantity of fluid present; if no old adhesions exist to prevent it, it is always forced upwards and inwards, toward the mediastinum and spine; it may be reduced to one-fourth, sixth, or even the eighth part of its normal volume ; it loses its natural arched form, and becomes like a flattened cake. Its substance is of a pale- reddish, or bluish-brown, or leaden-gray color; it is tough, leath- er-like, and destitute of blood and air. Its external surface is covered with a plastic effusion, which extends over the lung from the adjoining costal pleura; thus the lung is, properly speaking, shut out from the cavity of the sac formed by the pleuritic exu- dation. If adhesions already exist as the remains and conse- INFLAMMATION OF PLEURA. 47 quences of previous inflammations, then these will, in proportion to their nature and the tenacity of the tissues of which they are composed, prevent in some measure the above described disloca- tion of the lung. In partial pleurisies, thig dislocation and com- pression of the lung is prevented in a degree and manner propor- tionate to the situation and extent of the adhesions. A purulent exudation most frequently is found in weak cachectic individuals, and in those having a peculiar predisposition to the formation of pus. From the intensity and frequent renewal of the inflammation, it quickly leads to general debility and pyogenous admixture of the blood.. The effused pus not unfre- quently degenerates to ichor with disengagement of gas, so that from its decomposition a pneumo-thorax is added to the purulent effusion. Occasionally, suppuration of the walls of the chest with or without caries occurs, leading to a spontaneous discharge of the contained fluids, &c, by an external opening; or, on the other hand, this same process may take place on the surface of the lung, opening into and causing suppurative inflammation of the bronchial tubes, and giving rise to ejection of purulent matter from, and entrance of air into, the pleural sac. Among the partial pleurisies, we may mention those occurring near the apices of the lungs in consequence of pulmonary tuber- cles, those in the lower sections of the pleural sac and pleura diaphragmatica, those of the mediastinal lamina, and finally those occurring in the interlobular fissures of the lungs. Plastic exudations, the result of simple inflammatory pro- cesses, either acute or chronic, are transformed into cellular tissue of varying density or to cellulo-serous or fibrous texture, present- ing various peculiarities as to their form and extent, When they are the product of general pleurisies they coat over the whole of the costal and pulmonary pleura ; occasionally, however, they are only found in single spots of various sizes, in the form of circum- scribed insular patches, surrounded by healthy serous membrane ; they may, or may not, adhere to the opposite pleura. This cel- lular tissue of new formation appears either as dense and rigid, or as long, lax, movable, filamentous adhesions, according as a greater or smaller quantity of liquid effusion was present either originally or during their organization. They exist in the form of general cellular adhesions, when the whole cOstal and pulmonary pleura are attached, or as partial ones when only a portion of them adheres. They may become the seat of fresh inflammatory processes ; but, as Laennec has remarked, they generally circum- 48 INFLAMMATION OF PLEURA. scribe and limit subsequent pleurisies. In general dropsy, or in the hydropic diathesis, they may become the seat of a serous infiltration. This tissue is at times met with in the form of delicate flocculi or bundles, scattered over the costal and pulmonary pleura with- out forming adhesions, or even corresponding in situation. In most instances, however, previous cellular adhesions appear to have been torn asunder by the motions of the lungs and chest, and we then find cellular patches on both pleurae, which corres- pond in position and shape ; they may rise conically from a broad base, or extend into long string-like prolongations. If, during the organization of the plastic exudation, a watery effusion was present in the pleura, sufficient in quantity to prevent the two layers from coming in contact, then the cellular tissue receives a serous coating, and the pleura is found covered with a second more or less perfectly adherent serous membrane of new formation. If the exudation, under the same circumstances, was of some thickness, it will be converted into a smooth, bluish-white, fibrous lamella, which either covers the whole pleura or is only attached to it in single places, in the form" of sharply circumscribed tendi- nous patches, with either thick and abrupt or sloping and shelving edges. Even in the first case these lamellae are not of a uniform thickness in all parts, but present an areolar, perforated, and sieve- like appearance. Under such circumstances, it at times happens, after the quantity of the fluid effusion has diminished, that the lungs push through the parts where the false-membranes are thinnest, and project through their meshes in the form of teat-like * vesicular appendices. Chronic inflammation of the pleura, especially when it creeps slowly among the organizing exudations, occasions very important metamorphoses of the substance of the pleura and of the pro- ducts of inflammation. It gives rise with great frequency to profuse hemorrhagic or serous effusions at the same time that it deposits remarkably thick and solid coagulae, which are gradually transformed into very dense resistant fibrous swathes. Besides dilatation of the thorax, corresponding in degree to the quantity of fluid effused, and the already mentioned dislocation and com- pression of the lung, we have, as a result of general pleurisy, thick pseudo-membranous pleural sacs of new formation. These adhere both to the costal wall and the lung ; but the parietal laminae is generally the thickest, often measuring four, six, eight, ten lines, or even an inch in thickness. CONTRACTIONS OF THORAX. 49 If under such circumstances a quantity of the serous effusion be absorbed, then the lung, by reason of the thickness and resist- ance of its covering of fibrous false membrane, is completely pre- vented from recovering its former size, or may do this only very slowly and gradually. In the latter case the two lamellae of the fibrous exudation approach each other by degrees, and after the complete absorption of the serum may come together and coalesce. The thorax in such cases, as Laennec has already shown, becomes permanently contracted ; this contraction varies in degree from a scarcely perceptible flattening to a very evident ditch-like depres- sion, and exerts a very marked influence upon the shape of the body. In these latter cases the greatest sinking in takes place as a gen- eral rule in the neighborhood of the sixth, seventh, and eighth ribs, and the lateral wall of the chest presents a concavity from the axilla to the edge of the ribs. The thorax appears contracted as well in its periphery as in every one of its diameters ; the ribs sink in to such an extent as to touch, or even overlap one another. The thoracic muscles are found emaciated ; the intercostals in par- ticular are contracted to an extent proportionate to the degree and continuance of the paralysis they have undergone, and finally are transformed into a cellule-fibrous structure. The dorsal spine inclines from its normal position, with a lateral curvature towards the healthy side ; the shoulder of the affected side sinks down in proportion to this curvature. The lumbar portion of the spine forms a curvature proportionate to that of the dorsal, but towards the opposite side, and hence the pelvis of this side assumes a higher position, occasioning an apparent shortening of the cor- responding leg; then the form of the hips and buttocks and the carriage of the body attains some similarity to that which occurs in coxalgia. There are various causes for this contraction of the thorax: among these are, the pressure of the atmosphere on the chest, coupled with incapability on the part of the lung of returning to its former size with a rapidity equal to that of the absorption of the serous effusion, owing in part to the binding down of the organ by the fibrous swathe, but principally to the loss of its elasticity and power of expansion, from the long continued pres- sure it has endured. There is also a predisposition on the part of the costal lamina of the fibrous exudation to contract and increase in density, and a similar inclination to contract on the part of the cellulo-fibrous tissue which has taken the place of the atrophied intercostal muscles. 4 50 CONTRACTIONS OF THORAX. Contraction of the thorax may, even when the result of general pleurisy, affect only one portion of the chest, as the upper sec- tion, the lower remaining either absolutely dilated or only rela- tively so when compared with the contracted part. Thus it may happen, for instance, after a partial absorption of the effusion, that adhesions may take place superiorly, while below this is prevented, and the lamellae are held apart by the remainder of the effusion which gravitates between them. Partial contractions of the thorax are generally the consequences of partial and circum- scribed pleurisies, as seen in the clavicular regions from effusions about the apices of the lungs when pulmonary tubercles are present; and in contractions of the lower section of the lungs, from inflammations about their bases. Ossification of the fibrous lamella, more particularly of its parietal portion, occurs sometimes before, but more generally after, the absorption of the serous effusion. Deposition of bony matter generally takes place in the thickest portion of the exudations, in the form of compact knobby strings and plates. In rare instances, the whole pseudo-membranous pleural cone, with the exception of the thin layer covering the lungs, passes into ossification ; and should this take place before the entire absorption of the effusion, then the relics of this remain permanently inclosed in a bony sac. As several of the causes of thoracic contraction are present in pleurisies followed by other forms of exudation, such contrac- tions are frequently noticed to take place in them, though gener- ally in a minor degree. Thus a slight degree of shrinking of the chest follows even when the pulmonary layer of the exudation has become an extensible, yielding, cellular tissue, and the lungs have re-attained their normal size ; but then the costal lamina of the effusion is transformed into a thick fibrous sheath, which, from its condensation and shrinking, gives rise to the contraction. We see it take place after pleurisies with inconsiderable plastic effusions, but with profuse ones of pus ; it is then caused by paralysis and atrophy of the lungs from long-continued pressure, and by paralysis and alterations of the tissue of the intercostal muscles, as these keep equal pace with the intensity and continuance of the inflam- mation and the quantity of the effusion. Inflammations at times occur in both pleurae, and may be either simultaneous in their occurrence or not. Pleurisies with persisting effusions may produce cachexia, general dropsy, hydrothorax of the opposite side, hyperemia and GANGRENE OF PLEURA. 51 oedema of the lung of the affected side, asphyxia, dilatation of the right side of the heart, various degrees of venous congestion and atrophy of the lungs, and may lead to the eradication of already existing tuberculosis. Typhous pleurisy in its strict and proper sense is perhaps always associated with typhous pneumonia. In addition to the suppuration of the pleura, already mentioned as one of the terminations of empyema, a similar destructive pro- cess may arise, originating either within the parenchyma of the lungs or from without, somewhere in the circumference of the thorax. Simple or tuberculous abscesses, especially when seated upon the sternum or its neighborhood or on the spinal column ; softening encysted exudations from the peritoneum-diaphragmati- cum ; perforating hepatic or splenic abscesses ; ichorous or can- cerous deposits, may all prove exciting causes of pleural suppura- tion. Perforation of the costal pleura is not unfrequently pre- vented by the presence of thick resisting layers of false mem- brane, the result of previous pleurisies which have effected such intimate adhesions of the lungs that an abscess cannot open into the cavity of the thorax; sometimes, however, it is perforated, and ulcerous destruction of the lungs themselves ensues. Gangrene of the pleura arises when the serous membrane is laid bare by collections of pus or ichor in the lung or walls of the thorax, occasioning its transformation into yellowish-white, or more frequently into black or greenish-brown, soft, deliquescent eschars, coupled with superficial gangrene of the lungs. It is easily distinguished from the acute black softening, which the pleura-diaphragmatica undergoes from the stomach, or which the left mediastinal layer is subject to from its contact with the esophagus.* * Diagnosis.—Acute manifest pleurisy is marked by the occur- rence of a chill followed by fever, with quick and hard pulse, stitch in the side, dry cough, difficulty of breathing, dulness on percussion, absence of respiratory murmur, at times aegophony, and by dilatation of the affected side. The stitch in the side is regarded as one of the most constant symptoms of pleurisy, but Louis asserts that it is more frequently absent than present. When present, it may be slight and wandering for several days, apparently seated in the muscles of the chest, and then without farther exposure it becomes suddenly exasperated ; more commonly it sets in suddenly as an acute, penetrating stitch 52 DIAGNOSIS OF PLEURISY. 1. Secondary Formations. We pass over the cellular and cellulo-serous formations to the consideration of anomalous fibrous and cartilaginous tissues and bony substances. They occur with great frequency upon the in the side, as if a knife were thrust into it at each inspiration, mo- tion, or cough. Excessively acute pain is regarded by some as diag- nostic of hemorrhagic pleurisy. Pain is thought to be most frequent on the left side, although Chomel states that two-thirds of all cases of pleurisy are, like pneumonia, on the right side. Laennec states that it is not unusual for the pain to shift from side to side without a transference of the disease; it was already noticed by Stoll that the pain may be on the right side, and the disease on the left. If the posterior mediastinum is the particular seat of the disease, the piercing pain is often located between the scapulae, and is much in- creased by motion of the dorsal portion of the spine, while the difficulty of breathing is slight, and the increase of pain from inspi- ration comparatively so. According to Schoenlein, pleuritis postica is often mistaken for lumbago, as the pain may be felt in the lower dorsal and lumbar regions only, or there may be violent drawing pain in the small of the back extending to the sacral region, increased by touch and motion, attended with a feeling of tension in ab- domen, and with crawling or numbness in one or both legs; if, as is commonly the case, the membranes of the spinal marrow become simultaneously affected, there is pain exactly in the centre of the spine, which is stiff, and very sensitive to touch and motion; para- lysis of the legs and bladder may come on suddenly. Pleurisy of the anterior mediastinum is marked by sharp pain under the sternum, and supervention of dulness on percussion.—[Andral.] Pain along the cartilaginous border of the ribs, extending into one or both hypochrondria and flanks, marks diaphragmatic pleurisy. But in the great majority of cases the pain is felt a little below the nipple, although the seat of the disease is often elsewhere; this is as much of a mystery as the pain in the top of the shoulder in liver-complaint, and that in the knee in disease of the hip-joint. The pain is often so sharp and lancinating at each inspiration as to impart a peculiar expression of anxiety and suffering upon the countenance of the patient, which is almost pathognomonic to the eye of the observant physician. Respiration is often marked by a peculiar nervous hurry ; it is short and jerky ; it is also low, as the chest cannot be fully expanded on account of the increase of the pain at every attempt to do so: this is a valuable diagnostic sign from pneumonia, in which respira- tion is high, as the volume of a hepatized lung rather exceeds that of one fully expanded. DIAGNOSIS OF PLEURISY. 53 costal pleura, and exhibit two varieties in their origin and seat. In the one case, they are the products of inflammation, which, as above stated, have become transformed into fibrous or cartilagi- The cough is short and dry, and attended with a thin mucous and very scanty expectoration ; if sputa are more abundant we should suspect a complication with pneumonia, or bronchitis; cough is usually infrequent and moderate, and may be so slight as not to attract attention. The pulse is frequently peculiar; it is frequent and hard, instead of being full, large, but compressible as in one variety of pneumonia, or small, soft, and frequent (one hundred and ten to one hundred and thirty) as in another variety. As the pleuritic effusion begins almost simultaneously with the commencement of the pleurisy, dulness on percussion is quickly found to be present; it is usually first noticed at the base of one or the other lung behind ; it is attended with a great feebleness of the respiratory murmur, or entire absence of it at the dull part. When the effusion is very copious from the commencement, we may find dulness over a large portion of one side of the chest at the very first examination, and entire absence of vesicular murmur which has taken place so rapidly, equably and completely, that no effort of inspiration can render it perceptible—the extension of the dulness in pleurisy is usually much more rapid than in pneumonia. Rattling in the air passages is heard much less frequently than in pneumonia—a rattle with numerous bubbles renders it far more probable that the disease is not pleurisy. If the lung be adherent to the diaphragm, or to the back part of the chest, it cannot be forced upwards and inwards towards the roots of the lungs and spine, but will be flattened against the back or the side of the chest; the air-cells will be compressed, but the bronchi remain pervious, hence there will be dulness on percussion and bronchial respiration, so that the case may be mista- ken for the second stage of pneumonia. But the bronchial respira- tion has not been preceded by crepitant rattle, and in some part of the chest there will be dulness on percussion, with feebleness or entire absence of vesicular murmur, without bronchial respiration. Alteration of the percussion sound from a change in the position of the patient, is frequently put down as one of the diagnostic signs of pleuritic effusion, but we have the great authority of Laennec and Skoda for stating that it generally happens that the patient cannot change his position ; or if he be able .to do this, and a portion of the lung be already completely compressed by the effusion, he cannot retain his new position sufficiently long to allow the fluid to leave its first place and occupy another so as to compress other portions of the lunor. Increase of dyspnoea from change of position is a more important sign of effusion. Patient generally lies on the affected 54 DIAGNOSIS OF PLEURISY. nous tissues, and from thence to bone-earthy concretions, which assume the form either of plates or strings. They are always seated inside the costal pleura, to which they have intimately side; in pneumonia, he prefers lying on his back, or on the sound side. The grazing variety of friction sound is much more rarely heard in the commencement of pleurisy than at a later period, when most of the serous effusion has become absorbed, and a portion of the pulmonary pleura rubs, at each inspiration and expiration, against a corresponding part of the costal pleura, both being coated with plastic exudation. Under such circumstances the friction sound may become rubbing or grating, as if two pieces of new leather were rubbed together; the sensation may even be felt by the patient who is thus enabled to point out the exact spot of its location. Dilatation of the affected side is a valuable sign ; Laennec has found it well marked as early as the second day of pleurisy; an in- crease of six lines, or half an inch, is very obvious to the sight. ^Egophony is at best but an uncertain sign of pleurisy ; Chomel heard but eight times out of nineteen ; in six cases the voice was transmitted without being broken or tremulous, or its pitch raised; in five cases there was no approach to 33gophony. When the effusion is great, the heart is usually forced to the opposite side; but occasionally it happens that dulness may extend quite up to the clavicles, and yet the heart retains its position. Chomel says when the heart is forced aside the danger is great, and death very probable ; he prides himself upon the cure of two cases of pleuritic effusion with displacement of the heart, occurring during the course of the same winter; both recovered he says, " which is very rare." When the effusion is copious on the right side, the liver is pushed down, and, as it then projects below the ribs, it may be mistaken for enlargement of the liver. Jaundice and vomiting of bilious matters may be present, owing probably to a simultaneous inflammation of the convex surface of the liver; at least Hasse has drawn attention to the frequency with which adhesions of the liver to the diaphragm have been found, when extensive adhesions of the right pleura are present: we too have found this coincidence in at least twenty cases. When the effusion is copious th§ natural vibration of the chest when the patient coughs or speaks is lost.—( Reynaud.) Acute latent pleurisy.—It is not generally known how frequently acute pleurisy is latent; we have already quoted Louis, who states that acute pain in the chest is more frequently absent than present. It is best illustrated by an example; young Dr. Jackson, durino- his stay in Paris, observed that one of his young friends looked rather DIAGNOSIS OF PLEURISY. 55 coalesced. In the other case, these fibrous or cartilaginous tissues are developed without any inflammatory process, merely in con- sequence of a hyperaemic state of the sub-serous cellular and unwell, rather more so than is common from a slight catarrh, which was all he complained of; Dr. Jackson called to see him again at night; they laughed and talked together for some time, he appearing pretty well, and referring his complaint to a slight bronchitis. Dr. Jackson examined his chest, not expecting to find any thing, so slight were the general and local symptoms; auscultation and per- cussion, however, detected a considerable pleuritic effusion. In another case recorded by Dr. Jackson, a woman had been sick for fifteen days; she had had a chill but no heat, pain, loss of appetite, acceleration of the pulse or dyspnoea; there was slight cough only— yet a pleuritic effusion filled the lower half of the left chest. The frequency in which pleuritic adhesions are found after death without there having been any manifest pleurisy during life, speaks strongly for the frequency of latent pleurisy. Acute latent pleurisy is very apt to occur towards the end of chronic diseases ; sudden prostration with increased difficulty of breathing are often the only signs which mark it; the patient sinks apparently from mere debility, yet after death extensive pleuritic effusion may be found. Acute double pleurisy is almost always latent; it is rarely at- tended by the acute, circumscribed, characteristic pleuritic pain ; as the dulness and dilatation of both sides may be equal, inspection of the chest and percussion may throw no light upon the affection, as no comparison between them can be made. It may however cause death before effusion takes place, on account of its extent and the extreme dyspnoea it occasions. If it take place rapidly it is generally fatal. Diaphragmatic pleurisy.—According to Andral, risus sardoni- cus which was regarded as characteristic of this disease by Boer- haave, Van Swieten, Dr. Haen, &,c, is not even common in it; when present, however, we should think of diaphragmitis. Andral regards a remarkable degree of anxiety, sudden alteration of the features, acute pain in one or both hypochondriae, extending along the edges of the false ribs to the flank; complete immobility of the diaphragm; absence of abdominal respiration, with presence of costal; almost constant orthopnoea, with inclination of the trunk forwards, as by far the most characteristic symptoms; hiccup, nausea, vomiting, and convulsive movements of the face, especially of the lips, may be present, but are often absent. It is best exem- plified by a case : A man was seized with a slight shivering, followed by a burning heat; two days after, an acute pain was felt in the left hypochondrium, along the cartilaginous edge of the ribs ; consider- 56 DIAGNOSIS OF PLEURISY. fibrous layers of the pleura, or of the serous membrane itself. We first notice a white, more or less circumscribed opacity and thickening of the serous tissue, which becomes converted into a able oppression of the chest; sleepless, restless, occasional hiccup ; on third day, pain continued, dyspnoea increased, and cough became frequent; patient was found sitting up in bed, with body bent for- wards, his hand constantly applied to his side, where the slightest pressure caused him to scream aloud; he pronounced a few words in a broken, interrupted voice, and with difficulty; inspirations were short and frequent, and effected by the elevation of the ribs only; the diaphragm was fixed and immovable ; cough frequent; no ex- pectoration ; pulse very frequent and hard; skin burning hot and dry; auscultation and percussion normal; some remission of the symptoms during the day, aggravation of them and delirium every night; on the fourth day convulsive movements of the face set in ; on the fifth, almost continual nausea; pressure on the epigastrium induced hiccup and nausea. Death on the sixth. Chronic pleurisy may occur either as a primitive affection, or as one secondary to an acute attack. In the latter case the severe symptoms moderate and partly disappear ; the skin loses its burning heat; there is no dyspnoea, except from unusual positions, exertion, or excitement; a slight acceleration of the pulse alone remains : patient complains of weakness only, and fancies he is on the eve of convalescence. At a still later period pulse is no longer frequent; strength returns ; walking, talking, or excitement no longer produce the least dyspnoea; yet the chest may be half full of fluid, only to be detected by means of physical signs [Andral] ; this may be the case although the acute attack have lasted but four or five days. It is rare, even in the mildest cases, for the effusion to be absorbed in less than a month, commonly not under two or three months. [Laennec] Dilatation of the chest is the most obvious sign which meets the eye of the physician; the affected side is more full and prominent than the healthy one, although the enlargement seldom exceeds an inch and a half; the intercostal depressions are not only obliterated, but their place is supplied by an intercostal bulging; while the ribs and cartilages remain permanently as far apart, or even farther than during the fullest inspiration. When this dila- tation of the chest is coupled with extreme dulness on percussion, and with entire absence of respiratory murmur, or excessive feeble- ness of it, no doubt can remain as to the nature of the affection. When bronchial respiration supplies the place of feeble or extinct vesicular murmur, the lung is generally adherent to and compressed against some part of the chest; in such cases, however, dilatation dulness, and feeble or extinct respiratory murmur, will generally be found opposite to the situation of the bronchial respiration. DIAGNOSIS OF PLEURISY. 57 smooth or rough elastic patch, or into a group of fibrous or fibro- cartilaginous granulations, or into masses with irregularly rounded angles, of the size of a pea or larger, and which finally ossify. According to Laennec, primary chronic pleurisy is generally latent, or at least extremely insidious; the stitch in the side either does not exist at all, or it is obscure and momentary, only felt at long intervals; a slow fever creeps on by degrees; cough, with mucous or even puriform expectoration, is much more common than in the acute variety ; it may come on so suddenly and profusely as to lead to the apprehension that an abscess has burst, or that pus has made its way from the cavity of the pleura into the air tubes; more or less rapid emaciation ensues, and many of the symptoms of tubercular phthisis present themselves, such as night sweats and diarrhoea; the mere symptomatologist cannot distinguish them. Formerly an accu- rate diagnosis between the two affections was a matter of little mo- ment, as both were nearly equally and certainly fatal. Broussais saved but one case out of eighteen, and Laennec regarded a cure as a rare accident; but Stokes has saved twenty cases in succession with hydriodate of potash and blisters; while Hope has cured thirty-five cases running with mercury and blisters. Hope insists strongly upon the danger of mistaking the febrile irritation from anemia which attends this disease, for inflammatory fever; Townsend, Broussais, and Laennec made this mistake, and kept their patients on low diet; Hope, however, allowed strong broths, animal food, and porter, durino- the intervals of the most violent hectic fever, occurring in two daily tremendous paroxysms; the pulse was running from 120 or 130, to 150 or 160, with what patient terms internal fever, thirst, craving for cold drinks, dryness and heat of skin, &,c.; even when the dyspnoea, faintness and danger of suffocation was most urgent, Hope relied on the prompt use of mercury, and states that it was quite common, and happened in fact in the majority of cases that the fluid descended one-third or even one-half, within forty-eight to sixty hours, relieving the extreme dyspnoea and danger of impending dissolution. It must not be forgotten, however, that dilatation of the chest and pushing down of the diaphragm may take place to such a degree that air will again enter the upper portiors of the lung, although the quantity of fluid be not diminished. In the great ma- jority of cases an attrition murmur, or pleuritic rubbing sound, will be heard as the fluid becomes absorbed ; this is always best heard along the line of the margin of the lungs from the heart, curling backwards to the base of the lower lobe. The longer this rubbing sound is heard the better, as then the adhesions are more apt to be loose and elongated, and the lung will generally recover its full size, marked by full resonance on percussion, and complete restoration of respiratory murmur. But if rubbing sound last for a few days only, 58 TUBERCULOSIS OF PLEURA. These latter are always seated beneath or without the serous membrane, and are covered over by it. The two varieties may be easily distinguished. The fibrous exudations clothe the whole costal as well as the pulmonary pleura, but they only ossify upon the costal layer. The sub- serous new formations occur almost exclusively upon the costal and diaphragmetic pleura, and are frequently found in the inter- costal spaces. They sometimes become detached in the form of rounded, knotty masses, which fall into the cavity of the chest as free cartilages. 2. Tuberculosis of the Pleura. Tubercles of the pleura occur in all those forms common to serous membranes, namely: a. As perfect or partial and rapid conversion of a pleuritic exudation into tuberculous matter. This is most common on the costal pleura. b. As tubercular deposits in organizing, or more or less organ- ized pseudo-membranous exudations, i. e. tuberculosis upon or in cellular or cellulo-fibrous tissue of new formation. c. As primitive, acute, miliary tubercles. The second variety of tubercular formation is frequently com- plicated with secondary inflammation of the false membranes in which the tubercles are seated, and is very frequently attended with a hemorrhagic effusion. Tubercles of the pleura are generally the result of a marked tuberculous dyscrasia already evinced by the production of tuber- cles in other organs. They are mostly associated with tubercu- losis of the lungs and bronchial glands ; still they occasionally occur as the first in order of the successively developing tubercu- the adhesions become so close and universal that expansion of the lung cannot take place, and patient may remain more or less delicate for eighteen or twenty-four months, or even for life.—[Hope.] Acute pleurisy is generally regarded as a dangerous disease; but Louis states that recovery almost always takes place when the disease attacks a previously healthy person ; he estimates the deaths at not more than one in one hundred, as he did not lose a single case out sixty-eight. Chomel also states, that the pleurisies which occur so often during the course of consumption, rarely increase the fatality of the disorder, even when attended with effusion ; resolution appears to take place as promptly as in ordinary simple pleurisy. TUBERCULOSIS OF PLEURA. 59 lar depositions. They often complicate stationary or even retro- grade pulmonary tuberculoses, and are then to be regarded as evidence of a tumultuous re-crudescence of the general disease, and from that time forward they are generally associated with profuse tubercular depositions in many organs. Tubercles of the pleura frequently soften and deposit tubercu- lous pus in the various pseudo-membranous tissues in which they are seated ; the abscesses thus formed may perforate the pleurae and thoracic walls, with or without being attended by caries of the ribs.* * Diagnosis.—But little is known of the diagnosis of tubercles of the pleura, and it is of comparatively little importance, as tubercles of the lungs are almost always simultaneously present. They seem to be more common in children under fifteen than in adults : thus in one hundred cases of tubercular disease in adults, Louis found the pleura affected only twice; while Papavoine found tubercles of the pleura seventeen times in fifty cases in children; and Rilliet and Barthez, in three hundred and fourteen children with tubercular deposits in various organs, found them in the pleura one hundred and nine times. Circumscribed pleurisy is so common in phthisis that we can derive no assistance from the presence of pain in form- ing an opinion whether tubercles are seated in the pleura or not; in fact, fixed or movable, transient or permanent, slight or severe pleuritic pains, are so common in the dorsal region, between the scapulae, or beneath either of the clavicles, during the course of consumption, as to form a valuable diagnostic sign of the presence of tubercles in the lungs; but these pains in the majority of instan- ces arise from circumscribed, simple pleurisies, which lead to partial adhesions of the pleura. According to Barth and Roger, when tubercles are deposited under the two serous laminae of the pleura, and form resisting prominences on the surface of these, they may give rise to manifest friction sound ; yet, according to Fournet, cir- cumscribed pleurisies at the apex of the lung are the most common cause of the grazing variety of friction sound, and indicate the pro- gress of tuberculization towards the surface of the lungs ; hence it is evident that in the majority of cases we can only conjecture the existence of tubercles in the pleura. When present in pleuritic pseudo membranes, they increase the existing irritation and sustain the secretion of fresh quantities of fluid and plastic exudations, while they offer a permanent obstacle to the complete absorption or organization of those which have already been thrown out; hence when pleuritic pains and irritation exist for months in succession, it is probable that they are kept up by the irritation of tubercles. 60 CANCER OF THE PLEURA. 3. Cancer of the Pleura. This is far less frequently met with than tubercles; it never occurs as the first in order of the successively developing cancer- ous formations, but is always the result of a cancerous dyscrasia, which has already localized itself in other parts. It is frequently found in company with cancer of the breasts, mediastinum, or even of the bones, and is common when numerous cancers are present in many organs ; most commonly it arises simultaneously with cancer of the lungs, especially after the extirpation of large cancerous masses in the breasts. The pleura may be perforated from without inwards by adjacent cancerous deposits, which, after they have involved it in their ulcerous destruction, project themselves into its cavity in the form of knotty protuberances; or else it appears originally upon the smooth internal surface of the pleura, in the form of flattened, roundish, knobby, fatty, marrowy bosses of the size of a hemp seed, egg, or fist. They are either loosely or intimately attached to the serous membrane ; in the latter case they always attack the tissues of the pleura itself, and generally prove to be medullary cancer. Their presence always occasions the accumulation of various quantities of serous fluid in the pleural sacs. 4. Abnormal Contents of the Pleural Sacs. Besides the anomalous contents of the pleural sacs which we have already mentioned, and those to which we will subsequently allude, we must speak particularly of the presence of air and serum, forming the so-called pneumo and hydro-thorax. Accumu- lations of various kinds of air and gas have many sources distinct from those arising from the entrance of atmospheric air from without or through the bronchial tubes, in consequence of pene- trating wounds of the chest or of injuries of the lungs. Pneumo- thorax may recur under the following.circumstances : a. In consequence of the opening of a tuberculous abscess before adhesion of the costal and pulmonary pleura has taken place. This is the most frequent source of pneumo-thorax. b. In consequence of the rupture of a superficial gangrenous eschar of the lungs. c. From the softening of the so-called metastatic depositions PNEUMO-THORAX. 61 which perforate the pulmonary pleura before reactive hepatiza- tion can take place in the lungs. d. From the opening of a pulmonary abscess which commu- nicates with one or more of the bronchi. c. From the disengagement of gas from decomposing purulent and ichorous exudations (empyema). f. In rare instances a small quantity of air is found as a product of inflammation, in connection with a benign pleuritic effusion. g. In consequence of corrosion of the pleura and of one of the bronchi by purulent or ichorous exudations. h. In consequence of rupture of one or several pulmonary vesicles in vesicular emphysema, or from rupture of the pleura in interlobular and vesicular emphysema. i. From perforation of the diaphragm or mediastinum in con- sequence of acute softening of the stomach and esophagus. If the disease giving rise to the pneumo-thorax is not in itself fatal, as is always the case in softening of the stomach and esophagus, then the accumulated gas causes inflammation of the pleura, and exudations which vary according to the source of the gas, its nature, composition, and that of the other substances which are precipitated into the thorax simultaneously with it. Pneumo- thorax causes compression of the lungs and hydro-thorax. Hydro-thorax is a very rare disease, except when it occurs as a result of general dropsy, and even then it is scarcely ever the first in order of successively occurring serous effusions, except when it occurs from disease of the heart and lungs. It may occur as a consequence of hyperaemia of the pleura, and the longer it continues the more it is associated with swelling and hypertrophy of the same. It attends cancerous vegetations on the pleura, but arises especially from diseases of the heart and large vessels, pericarditis, catarrh, bronchial dilatation, indurated hepatization, and pleurisy. Finally, it occurs in the general dropsy which follows exhausting diseases, such as typhus, puerperal fever, phthisis from tubercles and cancer, brights disease, &tc. The lungs are compressed and forced from their situation in hydro-thorax in the same way that we have seen them in pleuritic effusions. It should be carefully distinguished from those serous effusions which occur as the product of a pleuritic process. The beginner may find some difficulty in distinguishing it from those pleurisies which deposit exudations with scanty plastic product, forming the 62 EXCESS AND DEFICIENCY OF THE LUNGS. so-called active dropsies. He is particularly liable to be taken when these effusions hav*