UNIVERSITY OF CALIFORNIA AT LOS ANGELES 313 1 THORACIC DISEASES: THEIU PATHOLOGY, DIAGNOSIS AND TREATMENT. BY CALVIN NEWTON, A. M., M. D., Fellow of the Massachusetts Medical Society ; Professor of General and Special Pathology in the Worcester Medical Institution ; also in the Syracuse Medical College: and late Professor of Rhetoric and Hebrew in Waterville College. A N D B Y MARSHALL CALKINS, A. B., M. D., Professor of Anatomy and Physiology in the Eclectic Medical College of Pennsylvania. WITH A BIOGRAPHICAL SKETCH OF THE WORCESTER: PUBLISHED BY D. AND M. CALKINS. 1854. Entered according to the Act of Congress, in the year 1854, BY MARSHALL CALKINS, M. D., In the Clerk's Office of the District Court of Massachusetts. PRINTED BY HENRY J. HOWLAND, WORCESTER, MASS. PREFACE. One object which Dr. Newton had in the preparation of this work, was to sup- ply the increasing demand in the New School of Medicine, for a scientific treatise upon the Pathology, Diagnosis and Treatment of Thoracic Diseases ; and another was to make public the results of his own study and investigation into General and Special Pathology, and the means of Physical Diagnosis. Many new reme- dies, though in general use among the physicians of the New School, yet not in common use by the whole profession, are substituted for those upon which depen- dence has chiefly been placed for the removal of inflammatory diseases. That they are much more efficient, and at the same time less injurious to the constitu- tion, a thorough trial will demonstrate. During nine years, Dr. Newton had giv- en special attention to the study of thoracic diseases, and their treatment, and hence he could reasonably claim ample qualification to execute the task which he commenced. He had formed the plan for the whole work and had written all the general principles of pathology and diagnosis, and also, a particular description of several of the more important diseases of the thorax. Dr. Newton's writing ends on the two hundred and twenty-sixth page, at which place the writing of the Completing Author commences. In the completion of the work, the pathology, diagnosis and prognosis, have been chiefly derived from the best medical author- ities of the age ; and yet, such alterations have been made as investigation seemed to suggest. The treatment recommended, is .substantially that of New School Authors, with such modifications as have seemed necessary, and of practical utili- ty. Being a student of Dr. Newton in 1847 and 1848, and having been since that time associated with him in the practice and teaching of medicine during a limited period, good opportunities have been afforded for learning his peculiar views of the pathology and treatment of disease. From many other medical gen- tlemen of extensive experience much valuable information has been derived, to whom the Completing Author would here express his thanks for the interest which they have manifested in the work, and for their many voluntary contribu- tions to the treatment of disease. In conclusion he would simply say, that he has used every possible effort to make the work valuable for the profession, to which it is now offered, with the hope that it may be the means of alleviating hu- man suffering, and of the advancement of sound medical education. Worcester, July 1854. .3.19731 CONTENTS.' THORACIC DISEASES, 17 PART I. General Considerations, 18 DIVISION I. Pathology, 18 CHAP. I. Fever, discussion of its nature, 19 " II. Inflammation, theories of; its nature ; author's views, 20 34 " III. Congestion, active and passive, 34 35 " ,IV. Serous Effusion, pathology of, 35 " V. The Reparative Process ; discussion of its nature, 37 45 " VI. The Red Corpuscles ; description of, 45 50 " VII. The Formation of Pus ; its kinds, chemical and microscopic char- acter, 50 55 " VIII. Ulccration, 55 " IX. Mortification ; sphacelus, gangrene, 57 " X. Lymphatic Swellings, 58 " XI. Tubercles : their pathology and microscopic character, 59 69 " XII. Carcinoma ; forms of; chemical and microscopic character, 69 77 " XIII. Melanosis ; various forms of, 77 80 " XIV. Xon Malignant Tumors, encysted, hydatids, vascular, 80 82 DIVISION II. Diagnosis : definition, 83 CHAP. I. Symptoms ; divisions of, rational, constitutional, physical signs, 83-85 " II. Topographical terms ; regions of thorax and abdomen, 85 87 " III. Position of patient for physical exploration, 87 " IV. Succussion ; Hippocratic, 89 " V. Palpation, 89 " VI. Inspection, 90 " VII. Mensuration, 91 " VIII. Percussion; sounds of ; cracked pot sound; mediate and imme- diate, 9192 Pleximeters ; directions for their use, 93 95 " Its range of application and utility, 96 " IX. Auscultation, 97 Sec. I. Mode of application, mediate and immediate, 97 Stethoscopes; kinds of; manner of using, 98 103 Sec. II. Healthy sounds of respiration ; (a) tubular ; (b) vesicular, 103108 Varieties of healthy sound, 108 Sec. III. Diseased sounds of respiration ; (a) bronchial ; (b) cavern- ous ; (c) amphoric, 110 112 Varieties of diseased sounds, 115 Sec. IV. Rales; the dry, 116120 " humid, 120124 " V. Adventitious Sounds, 124 " VI. Sounds of the Voice, bronchophony, * pectoriloquy, ego- phony, 126129 CONTENTS. V CHAP. X. Rational Symptoms, 129 Sec. I. Dyspnoea ; causes of; table of causes, 129 132 " II. Cough ; varieties of, 132135 " III. The Sputa ; varieties of, 135138 DIVISION III. General Treatment, 139142 PART II. Particular Diseases, 143 DIVISION I. CHAP. I. Bronchitis, Sec. I. Pathology, 143 Diagnosis ; general and special symptoms, 145 Prognosis and Treatment, 148 " II. Secondary Acute Bronchitis, 149 " III. Chronic Bronchitis, Pathology, Diagnosis, Treatment, 150154 " IV. Bronchitis of Children ; Treatment, 155 " V. Epidemic Bronchitis or Influenza, 156 " VI. Bronchitis of Old People ; Diagnosis and Treatment, 157 158 " VII. General Itemarks on Bronchitis, 158 " II. Pertussis; Pathology, 160 Diagnosis ; general and special symptoms, 161 162 Prognosis and Treatment, 163 165 " III. Asthma; Pathology, 165 Diagnosis, 168169 Prognosis and Treatment, 171 173 " IV. Morbid Changes in the Bronchi, Pathology, 173 Diagnosis, 175 Prognosis and Treatment, 176 " V. Pneumonitis, SEC. I. Pathology, 177 Diagnosis, 183 , Prognosis, 189 Treatment, 190 " II. Asthenic Pneumonitis : Treatment, 192 193 Bilious and Typhoid, 194 *' III. Lobular Pneumonitis, Pathology, 195 Diagnosis, 196 Prognosis, 197 Treatment, 198 " IV. Secondary Pneumonitis, 198 " VI. Pulmonary Emphysema, 199 SEC. I. Vesicular Emphysema, 200 Pathology, 200 Diagnosis, 203 Prognosis and Treatment, 205 " II. Interlobular Emphysema, Pathology, 206 Diagnosis ; Prognosis ; Treatment, 207 " VII. Pulmonary Congestion, Pathology, 208 Diagnosis; Treatment, 209 VI CONTENTS. CHAP. VIII. Pulmonary Apoplexy, 21 1 Pathology,- 212' Diagnosis, 214 Prognosis ; Treatment, 215 " IX. Pulmonary Gangrene, Pathology, 216 Diagnosis, 217 Prognosis ; Treatment, 219 " X. Pulmonary Oedema, Pathology, 220 Diagnosis, 221 Prognosis; Treatment, 222 " XI. Pleuritis^ 222 SEC. I. Primary Sthenic Pleuritis, Pathology, 223 Diagnosis, 230 Prognosis, 237 Treatment, 238 " II. Asthenic Pleuritis, 244 " III. Chronic Pleuritis, 244 Pathology, 245 Diagnosis", 246 Prognosis, 247 Treatment, 248 Paracentesis Thoracis, 249 252 Description of Operation, 253 257 Treatment to prevent its necessity, 257 259 " IV. Latent Pleuritis, 259260 " V. Secondary and Complicated Pleuritis, 261263 " VI. Pleuritis of Children, 264265 " XII. Pneumothorax, Pathology, 265 Diagnosis, 266 Prognosis, 269 Treatment, 270 " XIII. Hydrothorax, Pathology, 272 Diagnosis, 273 Prognosis, 274 Treatment, 275 " XIV. Empyema, ' Diagnosis, 280 Prognosis; Treatment, 281 " Pulsating; Treatment, 282283 " XV. Phthisis ; definition of, 283 SEC. I. Tubercles ; History of their pathology, 284 Pathological characters ; causes of, 286 289 Location ; law of their deposition, 290 292 Forms of; Progress of; Softening of, 293 295 Effects upon the lungs ; Cavities ; Adhesions, 296299 " II. General course of Phthisis, and General Symptoms, 300 Tuberculous Cachexia, 301 Stages of Phthisis, 301 (a) first stage ; Diagnosis, General and Special Symptoms, 301305 (b) second stage ; Diagnosis, General and Spec- cial Symptoms, 305308 CONTENTS. Vll (c) third stage ; Diagnosis, General and Special Symptoms, 308311 Particular consideration of Rational Symptoms, 311 Cough ; Expectoration ; Dyspnoea ; Haemoptysis ; Pain, 311-318 Constitutional Symptoms ; Fever ; Night Sweats ; Emaciation ; Diarrhoea, 319 321 (Edema : Cerebral, Digestive and Sexual Symp- toms, 321-324 Duration of Phthisis, 324 'SEC. III. Varieties. Acute Phthisis, 324 Chronic " 326 Phthisis of Children, 327 Latent Phthisis, 329 SEC. IV. ' Complications, 331 With Ulceration of air-passages, 332 " Disease of Pleura, 333 " Abdominal Diseases, 333 " Disease of Liver, 334 " Fistula in Ano, 335 Differential Diagnosis, 335-338 SEC. V. Causes of Phthisis : Hereditary Predisposition; 339 Influence of Age ; Occupation ; Climate, 341-345 " of Mahria: Inflammation: Contagion, 345-346 " " Intemperance Dyspepsia, 347-348 " " Masturbation: Poisonous Medicine, 349 Prognosis, 350 SEC. VI. Treatment, 351 (a) Preventive and Curative, 351-363 (b) Palliative, 363-368 CHAP. XVI. Pulmonary Cancer : 3(51) Of Mediastinum, 371 DIVISION II. Diseases of the Heart, 373 Their History : General Diagnosis and Prognosis, 373-377 CnAP. I. Examination of the Heart. Position : Size : Impulsion, 377-381 Physical Signs, 382-384 Normal Sounds : Ithythm, 384-386 Abnormal Sounds, 387 Pericardial " the Friction, Creaking Leather, the Churn- ing Sound, 392 Irregularities of Rhythm, 393 Vascular Sounds, bruit de diable, 393 CHAP. II. SEC. I. Pericarditis. Pathology, 394 Diagnosis, 395 Prognosis, 398 Treatment, 401 SEC. II. Chronic Pericarditis. Diagnosis, 399 Prognosis, 400 Treatment, 401 Vlll CONTENTS. CHAP. III. Endocarditis, 405 Pathology, 406 Diagnosis, 408 Prognosis, 110 Treatment, 411 CHAP. IV. Myocarditis, 413 Pathology, 413 Diagnosis, 414 CHAP. V. Hypertrophy, 414 Pathology, 416 Diagnosis, 416 Prognosis : General Treatment, 418 Treatment of Hypertrophy, 421 CHAP. VI. Dilatation of the Heart, 424 Pathology, 425 Diagnosis: Prognosis: Treatment, 426 CHAP. VH. Disease of the Valves of the Heart, 427 Pathology, 427 Diagnosis, 428 Treatment, 430 Varieties of Organic Disease, 431 Atrophy: Softening, 431 Fatty Degeneration : Tubercles, Hydatids, 432 CHAP. VHI. Hydropericardium, 433 CHAP. IX. Functional Disease of the Heart : Palpitation, 433 Pain: Intermittence, 434 Angina Pectoris, 434 Treatment, 435 DIVISION HI. Aortic Diseases, 435 CHAP. I. Aortitis: Pathology, 435 Diagnosis : Treatment, 436 CHAP. H. Aneurism of the Aorta. Pathology, 436 Diagnosis, 437 Prognosis and Treatment, 438 Appendix of Formulae, 440 BIOGRAPHICAL SKETCH OF THE LIFE AXD CHARACTER OF CALYIN NEWTON, M. D. BIOGRAPHIES of medical authors arc seldom found in their works. Their professional appropriations to the science of medicine are their only public memorial. Many circumstances, however, 'make a historical sketch of the life of Professor Calvin Newton desirable, not only by his relatives and pro- fessional friends, but by that extensive circle of acquaintance that he formed during the period of his collegiate teaching, and clerical labors. Calvin Newton was born in Southborough, Mass., on the 26th of No- vember 1800, His father, Mr. Josiah Newton, was a respectable farmer and revolutionary soldier who held many town offices, and the deaconship of the Congregational Church in his native parish. His mother, Mrs. Eliz- abeth Haynes Newton, a lady of benevolence and piety, still lives in Ash- land. His origin was from a family remarkable for longevity and character- ized by a full mental and physical development. In early life he manifested superior powers of mind. At the age of eight years he commenced the study of English Grammar, under the instruction of his older brother, llev. Gideon J. Newton, who says, "he easily comprehended the ideas of authors, so that lie soon was prepared to enter the first class of Grammarians." In the science of numbers, he had few successful compet- itors ; in every study he was thorough, deducing the general from the partic- ular, and easily recognizing the relations of the various branches of knowl- edge. Possessing the " high purpose," " the firm resolve," and " the clear conception," the elements of success in literary pursuits, he improved every opportunity for mental culture, the school vacation, the winter's eve- b X BIOGRAPHICAL SKETCH. ning, the summer's morning. While others sported, he studied, while oth- ers slept the sleep of the sluggard, he sought the society of those golden records written by the genius of every country and of every age. To receive instruction was his pleasure, to impart it, his delight. A youth of sixteen he commenced teaching in a village school, and soon after the study of the classics with the clergyman of his native parish. At Framingham Academy, he completed his preparation for college. In 1820, he entered Brown University, where he remained nearly two years, until the death of his father deprived him of the means with which to complete his collegiate course. The sudden removal of that dear object of filial affection made a deep and lasting impression on his mind. Reflection followed and that most desirable of all moral changes, the honest and sin- cere consecration of his talents and acquirements to the service of God. In- timately connected with these events of his life, is another, deserving a pass- ing notice. Of this I have often heard him speak with the simplicity of a child, while the tear of grateful remembrance told the deep emotions of his soul. " I can never speak " says he, " of the benevolent act of Col. Dex- ter Fay, of Hon. Francis B. Fay, and of Hon. Sullivan Fay, in lending me the means with which to complete my collegiate course, without yielding up reason to the guidance of feeling." Freed from pecuniary embarrassment, he returned to Brown University, and there completed his junior year. Subsequently he went to Union College, where he received the degree of Bachelor of Arts in the year 1826, and afterward that of Master of Arts in the year 1829. During his senior year, he taught a high school in Worcester, and at the same time pursued his collegiate studies. The means thus acquired being sufficient in amount, were immediately used for the payment of his borrowed money. While en- gaged in teaching, he was convinced that duty called him to the work .of the Christian ministry. Previously a member of a church in Providence, he then united with the Baptist Church in Southborough, from which he re- ceived a. license to enter upon the duties of the clerical profession. In 1826 he commenced the study of Divinity in Xewton Theological Seminary, and in 1829, received the highest honors of that Institution. During the pur- suit of his theological studies, he frequently preached in the Baptist Church at Bellingham, and in 1828, October 22nd, he was ordained its Pastor. BIOGUAPIIICAL SKETCH. XI While at Framing-ham Academy, he had formed an acquaintance with Miss Millisent Johnson, an intellectual and religious lady. About the time of his settlement in Bellingham, they were married. To him she ever proved a devoted and faithful companion, and although he, on account of her ill- health during the latter years of his life, expected to follow her to the tomb, yet she suddenly deprived of the object of her affection, still lingers on the verge of the grave. In 1832 he was elected to the Professorship of Rhetoric and Hebrew in Waterville College. After remaining there five years, he was elected Pres- ident and one of the Professors in the Theological Institution, first estab- lished at Charleston Me., but afterward removed to Thomaston. He was connected with this Institution four years. Subsequently he be- came the Pastor of the Baptist Church in Grafton, Mass., where he remained about three years, until declining health induced him to change his pro- fession. In early boyhood he manifested interest in the science and practice of medicine ; and although later in life, his moral sense pointed out another path of duty, yet he perceived the necessity for a radical and salutary change in the cure of disease. In the conservatism of tho University, he saw the bias "of antiquity ; in the common sense suggestions of the untutored mind an occasional .gleam of truth ; in the former, the ornament and sym- metry of science, in the latter the practical wisdom of unchained genius. Midway between these extremes bright and safe appeared the course of rea- son, great and enduring the improvements to which it leads. Although ed- ucated at the University at Cambridge and the Berkshire Medical Institu- tion, yet he was uninfluenced by their conservative spirit. Free from prej- udice, not biased by sect or creed, he sought to interrogate nature in the language of science, and to rightly interpret every phenomena which she presents. After the manner of inductive philosophy he sought to deduce from facts some general principle, to guide the physician in the cure of disease. After graduating at the Berkshire Medical College, and his admission into the Massachusetts Medical Society, he commenced the practice of his pro- fession in Worcester. During the whole course of his medical study, he gave special attention to every new remedy and process of cure, which promised to become an improvement. With interest he heard of the dis- Xii BIOGRAPHICAL SKETCH. coveries of that rustic Son of New Hampshire ; how that in many cases his simple vegetable remedies were more successful when prescribed by the hand of ignorance than the common remedies when prescribed by the hand of science. Not believing in all his crudities, he, nevertheless, saw in the simple process of applying medicine, and in the changes in the Materia Medica suggested by Thomson, a germ whose future development, by the fostering care of science would become to the world an inestimable blessing. Opportunities for the administration of the new remedies were improved, in order to test their efficacy, and ascertain the extent of their healing power. Confidence followed experiment, and a firm determination to place their util- ity in a conspicuous position before the world, succeeded the conviction of reason. Following the example of Galen, he sought to combine the practi- cal wisdom of Hippocrates and the rigid logic of Aristotle, and also, to add to their attainments the treasures of modern discovery and invention. He had no blind reverence for the authority of names. " Hereafter," he re- marks, in an address to his classmates of the Berkshire Medical Institution, " it will not be sufficient to refer to authority in support of a particular practice. In the eye of the discerning, it matters not, whether error is old, and has the sanction of distinguished names, or is new and unauthorized. The poisonous draught is none the less bitter for having been already tasted by numbers. It is now becoming fashionable, in the community to bring every thing to the test of experience. We must have the why and the wherefore to sustain any measure ; and, with the greatest reluctance, only can we ad- mit what is incapable of proof, to have science for its basis. Plain common sense comprehending in a measure the nature of disease, and proving by ob- servation and experience what medicines will do, is it not to be put aside by any reference to the history of remedies, and what has been thought in times past to be their action. Many, however, have even up to the present time, seemed to suppose that the authority of names was all the support their practice required ; and with them a reference to Cullcn or Brown, or other distinguished individuals, is of more importance than an overwhelming host of facts. With such persons, in truth, all investigation is proscribed ; whereas we are beginning to learn, that to the test of close scrutiny everything claiming to be science must be brought." With such liberal views of medicine, he entered upon its practical duties BIOGRAPHICAL SKETCH. Xlll Around him on the one hand were the representations of Allopathy, on the other a few pioneers of medical reform. To the progressive party, he mainly looked for sympathy and support, into its ranks he proposed to intro- duce the benefits of scientific study. Himself the recipient of thorough literary culture and medical education, he knew their utility, and realized the benefit that their possession confers. Than himself, in these respects, none were better qualified to lead minds, but imperfectly educated up to higher stations of medical attainment. Why was medical reform generally unap- provcd by the literati, and aristocracy of New England ? Why had its ad- herents such an amount of prejudice, such bitter opposition to overcome ? One reason, doubtless was, the tendency of the human mind to condemn the new, especially when its origin is humble ; another, the manner in which reform was advocated. With it were associated the ideas that every man can be his own physician, that one course of treatment is adapted to every form of disease, that " heat is life, and cold is death." To successfully bring to the notice of the profession a new remedy or new course of treatment, requires its presentation through a certain channel of influence. Had the simple remedies of Thomson and those of other early reformers, and their simple course of medication unconnected with other tilings obnoxious to the general sentiment of mankind, been used and rec- ommended, in some of those foci of influence which glow high up the hill- side of science, long since their merits would have been disclosed, and their benefits have brought joy to the afflicted in all the city streets. The truth of this, Dr. Xewton fully perceived. The remedies were good, a great im- provement upon those in general use, but the fact must be told from portals of science, in order to quickly influence the world. He, therefore, resolved to free if possible, the reform part of the profession from their ignorance, to divest it of the forms of charlatanism, which to some extent it had assumed, and thus to place it on a basis fixed and immovable as the rock of scientific truth. What more useful enterprise, what nobler object could occupy the attention and kindle the zeal of a liberal and educated mind ? To effect sucli a result, to his mind two things seemed necessary : A Medical Institu- tion, and Medical Journal, both conducted scientifically, yet advocating all the improvements that discovery might suggest. Accordingly on the first of January 1846, he commenced the publication XIV BIOGRAPHICAL SKETCH. of the New England Medical Eclectic and Guide to Health. Portions of his editorial address contain the best exposition of his objects and prin- ciples : " Many palhies and isms in medicine are prevalent at the present day Besides allopathy or the old practice, we have homeopathy, hydropathy, Beachism, Thomsonism, fyc. ; and those who are solicited to be our readers, will wish to know, as we suppose, under what colors we intend to sail. In answer to the inquiry, then, we say, Our flag is our own. Our object is the extension of medical truth. We are pledged to sustain no class of physi- cians or mode of practice, except such as we are directed to by reason, sci- ence, and common sense. We belong, indeed, to the Massachusetts Medi- cal Society, and are in fellowship with our medical brethren ; but we, like them, are at liberty to use such remedies in the removal of disease as we judge to be the most efficacious. We are inflexibly opposed to every form of quackery ; but we do not believe that medicine, unlike all other sciences and professions, is incapable of improvement. We believe that much yet remains to be done in developing the principles and carrying out the prac- tice of the healing art ; and, if we can get at truth, we care not from what quarter it springs. We shall never hesitate to adopt any Indian remedy or old woman's prescription, when, its nature and modus opcrandi being shown, we have the evidence, that its good effects must be superior to those of any article now officinal. Time has been when some good thing came out of Xazareth ; and we believe it eminently true in medicine that valuable improvements have arisen from obscure sources. In vain, there- fore, do those who have enjoyed superior professional advantages, say, "We are the people, and wisdom shall die with us." Those who stand at a dis- tance in the outer court of science, are sometimes as genuine and acceptable, if not as exalted worshiped, as others who are permitted to enter the inmost temple ; and we shall try, according to our motto, to ' " Seize upon truth, wherever found, On Christian or on Heathen ground." "It maybe objected, that the tendency of on; 1 Periodical will be to spread oat medical information too broadcast ov-r the community. To this we reply, wa have no wish for the matter? of our profession to be kept, like the mysteries of Egyptian priests, secluded from all but the initiated. We do BIOGRAPHICAL SKETCH. XV not, indeed, accord with Samuel Thomson in the belief, that every man can, with propriety, be his own physician, any more than we believe, that every farmer can, with advantage, be his own carpenter, or blacksmith, or watch- maker. Every man, it is true, can, in a sense, be all these for himself ; but he will certainly be a clumsy performer, so long as he attempts to do a little of every thing, and gains a competent acquaintance with nothing. The science on which the practice of medicine is founded, the knowledge of the human system, the nature and operation of remedies, and the like, are mat- ters not understood, to the degree requisite for the physician, without long and arduous study. Still it is evident, that, to some extent, these matters may be brought distinctly before the minds of the common people, and made level to the capacities of all ; and immeasurably better would it be for chil- dren and the various members of the family circle to employ their leisure hours in becoming acquainted with their physical systems, and with the means of promoting their health, than in dissipating their minds and cor- rupting their morals, with fictitious stories and wild romances. Our endeav- or, therefore, will be the wide dissemination of medical truth ; and, were it possible, we would gladly be jwofcssioitalh/, what one infinitely greater than ourselves was morally and spiritually, a light to enlighten " every man that comcth into the world." " By those of our Thomsonian friends who "go the whole figure," as the phrase is, we may be thought not sufficiently strenuous for Botanic principles. Some may even impugn our motives, and charge us with CXUDO- 11 i/lo O OO between different parties for the sake of gaining favor with all. To such we put the question of Nicodcmus of old. " Doth our law judge any man, be* fore it hear him, and know what he docth V" Or, again, we reply in the language of one of C;osar's procurators, resident at Ccssarca, " It is not the manner of the Romans to deliver any man to die, before that he which is accused meets the accusers face to face, and have license to answer for him- self concerning the crime laid against him." If the Eclectic is not essen- tially orfhodox, even in the judgment of the most radical Botanic, then, anil not till then, let us be condemned for heresy. If, indeed, any expect of us a constant warfare with diplomatized physicians, they are destined to disap- pointment ; for we do not believe, that, by that medium, much medical truth is, or can be communicated. Were we, or any member of our family, dar_- XVI BIOGRAPHICAL SKETCH. gerously ill, wo confess, that we should prize a plain description of the dis- ease, with the means of recognizing it, and the mode of applying such rem- edies as would speedily effect a cure, far more highly than even the most el- oquent tirade or phillipic against the errors of the schools. And, besides, we must plead, in our own behalf, the peculiarity of our phrenological devel- opment. Our organ of comlativeness is not large, and it is extremely dif- ficult for us to be pugnacious. We think it better to love even our enemies; and to trust to the correctness of the maxim, " Truth is great, and will pre- vail." Very few, at the present day, we believe, will sympathize much with a neighbor of ours who calls himself a doctor, and who recently avowed to a friend, that " an educated physician and an educated minister are good for nothing ; and that, if we would have a good physician or a good minister, we must take a man directly from the plough." We would not conceal the truth, that we like to have physicians and ministers, as well as mechanics, merchants, and others, educated for their respective employments ; and we cannot help thinking, that the fable of the fox that lost his tail, has its moral in the case of the neighbor referred to. True it is, that in medicine, as in every thing else, one may be taught error ; and, under erroneous instruc- ions, he may have his mind misdirected, and his judgment perverted ; but, this affords no argument whatever against a correct education. It is the error inculcated, and not truth, which works the evil. The medical student has only to take the path marked out by reason, science, and common sense ; and then, the farther he advances, the better practitioner will he be. Ac- cording to our views, empiricism, whether in or out of the regular profes. sion, diplomatized or not, has its foundation in ignorance and error. It is the lack of true professional knowledge, and not a redundancy, which makes the empiric, and sacrifices human life. Our watchword to every man who would be a good physician, will ever be, Onward, onward, in the path of truth. In this way, and in this only, will you honor your profession, and benefit your race. The time has come in which, to gain the confidence of the people, the medical practitioner must place himself on the platform of sound professional principles." Such were his ideas of medicine, liberal, philosophical, reasonable. To diffuse them in the profession, and to impress them upon the minds of stu- dents, he ever labored. BIOGRAPHICAL SKETCH. XV11 In the same year the inceptive step for the establishment of a Medical College was taken. At a Convention of the friends of reform, a Board of O Trustees was chosen, and Dr. Newton was elected Professor. An unsuc- cessful application to the Legislature for a charter, made it necessary for the Institution, in order to grant degrees, to act under the protecting aegis of the Botanico-Medical College of Georgia. At the end of the first course of lec- tures, debts had accumulated, which he and his co-laborer in reform, Dr. J. A. Andrews, generously paid. The next course of Lectures in 1847, commenced, and progressed under circumstances somewhat more favorable ; and although efforts were yearly made, no charter was obtained until the year 1849. Before a special com- mittee appointed by the Senate, Dr. Newton presented the claims of the Wor- cester School, in opposition to the appeals made by a committee from the Massachusetts Medical Society, consisting of Dr. John Ware, Dr. Jacob Bigelow and Dr. Henry G. Clark, in order to prevent the legal existence of the Worcester Medical Institution. Dr. Newton, however, was successful in the accomplishment of his object. In 1847, the Eclectic took the name of the Journal, under which title it was published until the time of his death. For its support he yearly contrib- uted his editorial services, and even made pecuniary sacrifices to keep it in existence. In 1850, a College building was erected by the friends of the enterprise on Union Hill in the city of Worcester. For this, Dr. Newton freely con- tributed. " To the welfare of the Institution," he remarks " my heart and my life, are, and shall be unremittingly dedicated ; and, when I go the way of all the earth, I hope to leave behind me, not merely a pecuniary legacy, that will supply some of the Institution's future wants, but a richer legacy of professional literature and science, embodied in medical works and in- stilled into the minds of hundreds and thousands of the profession." The Institution from this time seemed more prosperous. The sessions of 1852 and 1853, were better attended and hope seemed more than ever be- fore to inspire the heart of its founder. The establishment of a State Society was another object whose accom- plishment seemed necessary to the success of medical reform. For this pur- pose, Dr. Newton, in 1850 was chosen chairman of a committee, by his c IVlll BIOGRAPHICAL SKETCH. medical brethren to draft a constitution for the Massachusetts Physo-Medical Society. Rules and regulations were established, and regular meetings held, at which addresses were delivered, and topics of professional interest dis- cussed. In 1852 he attended the National Eclectic Medical Association at Roch- ester, N. Y., and was elected its President, and one of a committee to pre- pare an address for the next annual meeting at Philadelphia. At Rochester he formed, while attending the Convention, many pleasing acquaintances with his medical brethren ; he won their respect and proved to them amidst conflicting interests a nucleus of union. His election to the chair of General and Special Pathology in the Syracuse Medical College, induced him still more to labor for the production of harmonious action among the reformers of New York. By the friends and students of the Syracuse Medical College, his Lec- tures were very highly approved, and many expressions of regard and af- fection were mingled with the sadness of the parting farewell. A want of medical literature was another incentive exciting to action the mind of Dr. Newton. No works were extant written in a style purely sci- entific containing the treatment of reformers adapted to the pathology of the schools. He, therefore, retired from general practice, also resigned his chair at Syracuse and devoted his time exclusively to writing. After the completion of his work on Thoracic Diseases, he had formed the determina- tion to visit Europe, in order to better qualify himself for the authorship of a work on Theory and Practice. But the room of the student was not his most healthful element. The bright sunlight of day, its toil and strife were far less injurious to his active and vigorous frame. From physical exer- cise his mental drew too much of his attention. The nervous system suf- fered. In the words of Prof. Reuben, " The insidious foe was lurking in the very springs of life, loosing the delicate affinities, and cutting off at their fountains the streams of vital force." In the private relations of life, Dr. Newton was respected and honored. By the citizens he was elected one of the Common Council, a member of the Board of Aldermen, and was Secretary of the Board of Trustees of the Worcester Academy. A full enumeration of all the places of trust which he has occupied, and the little incidents connected with the fulfilment of his BIOGRAPHICAL SKETCH. XIX official labors, would be interesting ; but such is not my present purpose. A brief consideration of the more important points in his character will suffice. In doing this, I am well aware of the difficulties to be overcome, of the bias of friendly acquaintance. To love and reverence a teacher and friend, how pleasant ! To analyze his character, how repugnant to the warm glow of af- fection ! And yet the public weal demands an analysis of the characters of leading men, in order that their virtues may be imitated, and their faults avoided by those who succeed them on the changing stage of life. Dr. Newton was a powerful man physically, a man of a large mould, a great body, and a great brain ; his frame vigorous and well proportioned, every part alive with active, vital force. What a chest was his ! what large pulmonary and digestive organs, those two factors of physical and mental power ! From thence was derived his constant impetus to corporeal exertion, the fuel supplying the bright flame of thought. His personal appearance was not indicative of ornament, but of that physical strength and mental energy and decision which press right onward to their destined purpose. His intellect was strong and active. The forms of intellectual action may be divided into three modes : the Reason, Understanding and the Imagination ; the Reason, dealing with uni- versal laws, the philosophic power. The Understanding, with details, the practical power. The Imagination, with beauty, the Poet's gift. Of Reason, Dr. Newton had a larger share than of the other intellectual endowments. He was a man of philosophic ideas, ever seeking to deduce from facts a law, general and universal. To generalize was his ambition, to strike out like Bacon, some new and shorter course to scientific improve- ment. His power of comprehension was uncommonly large. And hence, from his mind original ideas proceed. Originality may be divided into two kinds ; originality in applying in a novel manner the knowledge of others, and that originality which brings forth the new principle, the new idea. This latter is not so dependent upon others' thoughts; it has a creative power of its own ; within the boundaries of genius is the field of its labor. View- ing things subjectively, it moulds into its own likeness the external world. In its ideal creations are newness, and freshness, are forms of utility unseen by common minds. Traveling in untrodden paths, pursuing its diverse way into the dark labyrinths of the unknown, there from a spark of intellec- XX BIOGRAPHICAL SKETCH. tual agency it kindles the radiant flame of science. Of this latter kind Dr. Newton possessed the more, of the former the less. His ideas of disease were neither those of Allopathy, nor those of Thomsonism or Bcachism ; they were peculiarly " his own." He organized new associations of physicians, and moulded a system of successful medical empiricism into the form of sci- entific knowledge. His Understanding was less than his Reason. Although he acquired readily and retained well, his perception was less acute than that of many minds inferior to his own. In adapting means to the accomplishment of an end, his large hope sometimes caused him to overlook many of those minor contingencies which mould and fashion results. The secret of his success, lies mainly in his reason, in his comprehensive views of the subjects of medical study, in his indomitable perseverance, in his devotion to one object, in his spirit of self-sacrifice. To science he seems to have paid much attention, more than to general history and liter- ature. I cannot claim for him large imagination. His eloquence lacks the poetic charm, the beauty which makes luminous the page, and touches the heart of humanity. Two or three short poems are all that his poetic faculty has left. One on Superstition, has the following excellent lines : " Hail ! Sacred knowledge. Freedom's purest Friend, The richest boon which Heaven to earth could send, llesplendent Orb, but late thy dawning ray, Hath broke the horrors of a sunless day, Soon may thy power, our languid spirits fire, And Franklin's sons to classic heights aspire, An Attic genius stamp our growing fame, And wrest the Laurels even from Grecian name, Then Superstition from the earth be cast, Not least of evils, though to die the last." His style was simple, the style of a strong, logical thinker. His theologi- cal writings, though sometimes dull, addressed to the reason, at times swell into beauty, and touch the conscience. When contending for some princi- ple or for personal interests, his opponents often felt the keenness of his re- buke, and feared again to call forth his withering, caustic words. In his writings as in his life, there were no artful flourishes of rhetoric, nothing but the language of a naturally frank and honest hearted man. BIOGRAPHICAL SKETCH. XXI All bombast in language felt the keen edge of his -sarcasm, and of his judgment. No high sounding words could captivate his approval. In his lectures he was familiar, his illustrations simple, adapted to give the idea, rather than please the fancy. Dr. Newton was a conscientious man. To the guidance "of the Supreme Intelligence he intrusted all his interests. In every condition of life he was trust-worthy, never deceiving with subtle tongue, nor flattering the gross prejudice of the vicious and ignorant. Rather than resort to the duplicity which every where prevails around us, he chose to be deprived of many ad- vantages which an unmanly policy often affords. Honest, open-hearted and unsuspecting himself, he sometimes gave his confidence to those not worthy of its reception. lie was ambitious to excel, ambitious to occupy that station for which his education and talents best fitted him. Would he have served under the banner of those who were his inferiors in qualification ? would he submit to be transformed into an instrument whose use would elevate ignorance and quackery above himself? Dr. Newton's dignity and self-respect, could not be thus degraded. And if to exercise those qualities, is to be ambitious, then he may prove guilty to the charge. Such an ambition is worthy of all honor, and respect. That ambition which never feels, moves, acts, never makes humanity rejoice. His .ambition then was one of the qualities which fitted him for the performance of the duties devolving upon the station which he occupied. Its results have added to the interests of progressive medi- cine, and, therefore, let reform be thankful that a shining light has illumined its rising pathway to usefulness and honor. His affections were strong. When once entwined around their object, they were enduring and constant. He loved strongly, loved the qualities which make up the ideal of perfection, and in whomsoever these shone brightest and most constant, thither his affections were directed. Relatives and friends, neighbors and citizens loved him, for in him the good found en- during friendship. lie never sought to betray for policy, nor loved to sac- rifice the interests of others for personal aggrandizement. With him the just and good found sympathy. But the vicious, base, and jealous enemy, no regard and favor. " Lofty and sour to those that loved him not, But to those that sought him, sweet as summer." XX11 BIOGRAPHICAL SKETCH. He was a cheerful man, and loved to make company lively by the inter- change of wit. His mirthfulness was peculiar, breaking out in that explo- sive hearty laugh, which will long be remembered' by his friends and ac- quaintance. Philanthropy was one of his qualities of mind. He heard the cry of the poor, and from his heart went forth the bright stream of sympathy and re- lief. Charity often entered his open purse, and took away that which ava- rice would hold with relentless grasp. He was a religious man, a Christian in the highest sense of that word. For its external form, its pomp and show, he had less regard than for its inner life. His soul had been renewed, and away in the gloom of futurity, he saw the golden gate open for its reception. In all his actions he recog- nized an overruling Hand, and willingly submitted to Supreme dictation. In fine, his whole life shows that he had a large development of those relig- ious faculties which join the hearts of the good to the Infinite God. To principle more than to forms and ceremonies he was religiously devoted. For some benevolent purpose he labored, not for mere worldly gain, but for the purpose of gaining the approval of a smiling humanity. Having no children upon whom to bestow his care, he considered the Institution whose corner stone he laid, as worthy of his parental love and affection. That he had faults no one will deny, and -yet even for these there were many palliating circumstances. If he attempted too much, it was because he sought to rear a fabric of medical reform, and to complete the entire structure by the force of his own energy and genius. If he did not sym- pathize with all the ideas and customs of reformers, it was partly owing to his different culture, and different habits of thought. Very few are the men whose faults are so few, whose virtues so many. The clay may be long ere another, so faithful to principle, integrity and to science, will descend from seats of honor, to labor in an unpopular cause for the sake of doing good to the world. A magnanimity of soul far transcending the little petty jealousies that divide the ranks of reform, is plainly shown by the events of his life. At first we see him an ambitious and honest youth, obtaining the prize of intellectual valor at the common school ; now teaching with one hand, with the other studying the classics, and now entering the University, and at the BIOGRAPHICAL SKETCH. XX111 end of two years, returning to his homo to bid an affectionate father a last farewell ; now cheered by the benevolence of his neighbors, now exulting in the joy of that hope which is as an anchor to the soul ; then teaching a high school in Worcester, and next returning from Academic halls laden with the honors of science ; now entering the theological seminary and devoting his talents and acquirements to the service of God, and now the village pastor ; next the college professor, then the theological teacher, again a pastor, after- ward a student of medicine, a practitioner, a professor and founder of a medical institution, an author; and finally we see him, " The hale and strong, who cherished Xoble longings for the strife, By the -wayside fall and perish, Weary -with the march of life." Born November 26th, 1800, he died of typhoid fever August 9th, 1853, died in the midst of useful labors, at a time when victory over difficulties was just before him. But his life was not in vain ; it was marked with achievements in the field of utility. He wrought a work which humanity will bless, for he labored for the interests of man ; a work which heaven approves, for he sought to extend the religion of Christ. He had induced tho student to press on in the path of knowledge and virtue ; he had elevated the groveling ideas of youth, and had pointed them to the benefits of thorough mental culture in order to insure success in the practice of a profession ; he had taught them to exercise their own faculties of mind, to think and investigate for them- selves, rather than to depend upon the authority of others ; he had taught the physician the importance of possessing an unblemished moral and relig- ious character. Of these labors he began to receive the reward. His ideas of medicine began to enter the walks of the higher circles of society, induc- ing legal protection and securing popular favor. Before his decease, he had seen these indications of the speedy and final triumph of medical truth over prejudice and conservatism. If he did not complete the entire fabric, he formed and fashioned the plan, laid the corner stone and reared thereon the central pillar. The consciousness of having done so much for the good of mankind, must have lighted with joy the last moments of his existence. Life to him was desirable for its opportunities to do good to others, and his XXIV BIOGRAPHICAL SKETCH. regret was, that a disease should take him away from a field of labor in which he was conscious of conferring a lasting benefit upon the world. Prophetic omens of the sad event had appeared. I was with him at Syr- acuse, his room-mate and colleague, and often heard him remark " My work is nearly done adhere to me, carry out my plans." Death came though scarcely welcome. A few faithful friends and medical attendants gathered around him ; upon them he called for aid, but for the cold touch of death there was no healing balm. His strength failed, delirium stirred up his brain, and again he hopefully talked of his College, his Journal, his Book. Finally, the silver cord was loosed and his soul rising to newness of life was calm and peaceful in the bosom of God. Such washis life ; his physical, vigorous, and energetic ; his intellectual, in its onward flow constructs a more accessible pathway to scientific truth ; his moral and religious, like a cone its apex at the earth, its base in the light of eternity is ever expanding, ever progressing in the bright sunbeams of the Pure Intelligence. He is no longer a citizen of earth ; but There is a happier clime, A larger and a purer life, unknown to earth and time, A clime with light ineffable, unveiled by midnight gloom, Beside whose living streams the fairest flowers perennial bloom ; A clime beyond the circling stars, the floating cloud, the sky, All radiant with its glowing hues ; there all beneath it lie, There with the loved and lost of earth, undestined more to sever, In their glad presence shall he dwell, in blessedness forever. THORACIC DISEASES. Any classification of the diseases to which the human body is subject must necessarily be, to an extent, artificial and imperfect. Both advantages and disadvantages attend every arrangement which ever has been, or ever can be adopted. In what I may say in this volume, and in others which I intend (Deo volente] to succeed it, I shall employ, in the main, a topographical divis- ion. As the subject of this volume I have selected THE VARIOUS DIS- EASES BELONGING TO THE CAVITY OF THE THORAX ; but, passing down the cervix to exclude cervical diseases, where shall I begin my reckoning of thoracic ? It best suits my convenience to com- mence at the bifurcation of the trachea, that is, at the origin of the right and left primary bronchi. I pause upon that separating muscle, the diaphragm. Having, however, bounded the field of my observation, I find myself at a loss in examining the objects within. Some of the diseases here observed are of such a nature as to exist only in this locality: others imply an affection common to the thorax and other parts of the body ; while others still are only local manifes- tations of a morbid influence pervading the whole system. In my classification, I shall embrace all those affections which are quite prominently exhibited in the thoracic cavity. 18 THORACIC DISEASES. PART I. GENERAL CONSIDERATIONS. Before proceeding to a particular description of the several dis- eases appertaining to the thorax, various abstract principles and preliminary matters require some illustration. On such topics as are but remotely connected with these diseases, or are readily un- derstood, the medical reader must be left to inform himself from other sources ; and the following pages take it for granted, that, as far as these topics have a bearing on the primary subject of this work, the labor of proper investigation has already been performed. Other topics, however, of the first importance, are of such a nature as to demand here a somewhat full discussion. DIVISION I. PATHOLOGY. Pathology treats of whatever relates to the physical system in a state of disease. In its most limited application, it implies a de- scription of altered structures or morbid conditions. In a more enlarged sense, however, it involves, besides this consideration, an explanation of the processes by which the existing condition is produced, also, of the causes by which those processes have been established, and of the consequences of that condition, or the symptoms occasioned. My present purpose does not require nor allow an extensive discussion of pathological principles. I limit myself to such mat- ters as are quite intimately connected with diseases of the thorax ; but, in illustrating them, I am obliged to dwell a little on some considerations which are in themselves strictly physiological. FEVER. 19 CHAPTER I. FEVER. The term fever, in its original application, as is evident from the import of the corresponding word in Latin and in several modern languages, signifies heat. From this sense, however, a wide de- parture has long since been taken. When the nosological system of classification universally prevailed, the term was used to indi- cate a certain collection of symptoms, such as an abnornal degree of heat in the body, an accelerated pulse, a furred tongue, and a generally impaired state of the corporeal functions. Inasmuch, however, as very different pathological conditions may produce these symptoms, Cullen, at a somewhat later period, chose the the term pyrexia to mark these constitutional disturbances when arising from some local cause ; and he limited the former term to the designation of similar symptoms, when the cause is some general and not well understood influence upon the physical system. It would be well now for the interests of medical science, if the pro- fession would favor this distinction. At any rate, to avoid confu- sion of ideas, it is indispensible to remember, that the term is em- ployed to indicate symptoms which arise from very dissimilar causes. When the cause is inflammation or any local disturbance, what- ever, I call the constitutional excitement symptomatic fever, or pyrexia. On the contrary, when the cause is the existence of mor- bific matter in the current of the circulation (, whether this has been introduced from the atmosphere without, or by means of mal-assimilation within the system), I designate the disturbance as idiopathic fever, or fever more properly so called. In the former case, that of pyrexia, the term employed is nec- essarily applied to the manifestations of disease ; and, when the cause is purely imnammation of some part, the constitutional man- ifestations of that cause are sometimes characterized as inflamma- tory fever, the phrase being used in a sense somewhat more limit- ed than that of symptomatic fever. In the sense of idiopathic 20 THORACIC DISEASES. fever, the term should be understood to involve more immedi- ately certain pathological conditions as giving rise to that consti- tutional excitement which manifests those conditions. If this distinction should be rigidly observed, the term fever would distinctly characterize a class of diseases, pathologically considered ; and all controversy, in regard to the recuperative ef- forts of nature as constituting fever, would be forever at an end. In this sense, however, the term embraces an extensive and im- portant subject, one which, though concerned, to some extent, with thoracic diseases, yet more appropriately belongs elsewhere, and which I design to discuss at length in another volume. In the sense of symptomatic fever orpyrexia, as the subject only in- volves directly the manifestations of existing local disease, it does not require any separate discussion. CHAPTER II. INFLAMMATION. Inflammation is a term derived immediately from inflammatio, a Latin word, the root of which is injlammo, to burn or inflame. It is applied to a local disease, one prominent characteristic of which, is an abnormal degree of heat. That some things, connected with the nature and manifesta- tions of this disease, are complicated, and have, till of late, been involved in intricacy, I freely admit. In its most prominent fea- tures, however, it is exceedingly simple ; and one cannot avoid the emotion of wonder, that numerous pages and even volumes have heretofore been written with little effect, except to make gross darkness the more visible. In the theories of medicine, in- deed, as in those of theology, much talent has, on different topics, been wasted in dreamy speculations. The more acute have been the intellects employed, the more delicately, it is true, have hairs been split, but the less has been the amount of practical common sense exhibited. We need not historically come down to the days of Hahnemann, and of sugar globules, represented to possess power in proportion as they approach an infinitesimal division. INFLAMMATION. 21 Homoeopathy may be, indeed, the quintessence of professional nonsense ; but that which is, at least, double-refined, has existed from an earlier period than any portion of the present century. This lamentable truth has been made more evident on no sub- ject than on that of inflammation. More than one hundred and fifty years since, Boerhaave taught the luminous doctrine, that inflammation is caused by viscidity of the blood, and an error loci of its particles, together with a morbidly acrimonious state of the fluids. Next come the fanciful and frivolous notions of Stahl and Hoffman respecting the influence of the nervous system in pro- ducing inflammation. Passing forward to the middle of the eighteenth century, we find Cullen maintaining the theory, that, in inflammation, there is an obstruction of the blood, produced by ''spasm of the extreme arteries, supporting an increased action in the course of them." Hunter, who was nearly contemporary with Cullen, supposed, that, when inflammation exists, there is "a dis- tracted state of parts, which requires another mode of action to restore them to a state of health." This other and necessary mode he considered inflammation to be. Of course, in his opin- ion, it was a recuperative and not a morbid process. Of late years, considerable controversy has been raised, by two conflicting and almost opposite opinions on this subject. One of these opinions makes inflammation depend on "increased action of the capillaries of the part;" the other, on "weakened action of the same vessels, and increased action of the trunks." In support of the one or the other of these opinions, English physicians, no less distinguished than Dr. Thomson, Sir Everard Home, Dr. Wilson Philip, and others of equal professional rank, have adduced their own experiments on living animals; but these experiments, though convincing to their authors, do not, as they are now viewed, establish either of the opposing theories. Dr. George Hay ward of Boston, late "Professor of the Princi- ples of Surgery and Clinical Surgery," in the Medical Depart- ment of Harvard University, has been accustomed, in his Medical Lectures, to define inflammation to be "a diseased action of the capillary vessels, attended by redness, swelling, pain, and heat." In this definition, the Professor has certainly manifested talent, lying in one direction. In other words, he has shown ability to 22 THORACIC DISEASES. speak with such vagueness, that, while he seems to utter an im- portant sentiment, he really says nothing definite or of moment. Except those who embrace that absurd Hunterian notion, that inflammation is a process of recovery or increased physiological action, none, of course, can doubt, that, in it, there is an abnor- mal condition of the capillaries, and that redness, swelling, pain, and heat are phenomena attending the local disturbance ; but What is the disease of the capillaries? and What is the proximate cause of those phenomena? These, and like questions, the only ones of importance in the case, are left wholly untouched. Be- sides, the same high authority has uniformly taught the medical students of the University, that, in the healing of a wounded part, the first recuperative process established is inflammation, and that, without this, neither an adhesion nor healthy granulations can be formed. In other words, the language, if I understand it, says, that, where, from any cause, there is a solution of continuity in any of the tissues, the first part of the curative process is a par- ticular morbid action. So much for medical philosophy and con- sistency ! Having thus remarked upon the absurdities of those medical opinions which have, at different times, been entertained for nearly two centuries past, and having done this to show what inflamma- tion is not, it becomes me now to attempt an illustration of what it is. I, therefore, immediately define inflammation to be a state in which the capillaries of the part affected are interrupted in their proper function, are morbidly relaxed, and are over-distended; and, in which the blood that is passing through them is first abnormal- ly excited and chemically changed, and then stagnates and coagu- lates. This definition supposes a pathological and not a mere symptomatic view of the disease. Its symptomatology would merely say, that it consists in redness, swelling, pain, and heat, as these are the phenomena immediately attending it. Here I would remark, that the nosological classification of dis- eases, formerly adopted by the profession, contemplated them, almost exclusively, as different groups of symptoms. The symp- toms at any time existing, collectively considered, were called the disease. The causes of these symptoms were divided into proxi- mate and remote. The proximate were what we now call the INFLAMMATION. 23 disease itself, that is, the pathological condition giving rise to the symptoms. The remote causes were sub-divided into excit- ing and predisposing. The exciting were those which, by their immediate action, developed the pathological symptoms. The predisposing were all such influences as prepared the system to be affected by the action of immediate agencies. In illustrating the disease now before me, I propose to consider its inherent nature, its causes, and its effects. In regard to the first of these particulars, I remark, that, when, for any cause, the nerves connected with the contractile fibrous tissue of the capilla- ries lose their power, the tension of the coats of the vessels is not preserved, and, as the consequence, the relaxation is immediately manifested by those vessels' becoming abnormally filled. This, I suppose, to be the usual way in which capillary congestion is ef- fected. The relaxation is primary, and the over-distention secon- dary. The process may, however, and sometimes doubtless does, commence in the opposite direction. Arterial excitement, by in- creasing abnormally the current of the blood, may mechanically force open the capillaries, and the relaxation may occur, seconda- rily, as the effect of over-distention, in destroying the innervation. The former of these modes Dr. C. J. B. Williams calls that of congestion ; the latter, that of determination of the blood. Both causes, may, indeed, exist at the same time. The vessels may morbidly relax and arterial excitement may occur simultaneously. But, in whichever manner the fulness or congestion of the capillaries takes place, it can seldom be allowed long to remain without producing the characteristics of inflammation. There may, however, for a season, be capillary congestion without in- flammation ; but there cannot be inflammation without capillary congestion, as a primary part of the process. Capillary conges- tion is not inflammation, but inflammation is capillary congestion and something more. In the commencement of inflammation, as the capillary vessels are beginning to be clogged, the onward current of blood is, of course, partially obstructed, and perturbation follows. When the part concerned is microscopically examined, the white globules and the red corpuscles are seen passing, for a time, in different directions, onward, backward, and obliquely. Soon the white 24 THORACIC DISEASES. globules, which pass not so centrally in the current as the red corpuscles, begin to adhere to the walls of the capillaries. As the disease advances, the relaxed vessels having become distended to their utmost, by the stagnated blood, doubtless sometimes suffer a portion of it to be effused or extravasated into the circumjacent areolar tissue. When this takes place, that which has left the vessels soon coagulates and becomes foreign matter. Indeed, its coagulation is the same as that of blood drawn into a 'cup, in ordinary venesection. But the blood within the vessels is the only portion of special importance to be considered; and this is the subject of very pe- culiar and interesting changes, worthy of a more minute descrip- tion. The functions of secretion and nutrition, in connection with the part affected, being partially or wholly arrested, it would seem, that the nervo-vital power usually employed in those func- tions, is not supplied, or passes in another direction; and the elec- tricity, set free by the union of carbonic or proteine matter in the capillaries with the oxygen contained in the red corpuscles is ex- pended within the current itself. In this process, the fibrine is immediately increased. Probably this is due to an arrest of secretion and nutrition, not merely in the part inflamed, but, to an extent, sympathetically throughout the system. That there is such a general arrest is evident from the symptomatic fever or constitutional disturbance which takes place. The white or lymph globules, too, are soon found in an abnor- mal quantity. Chemically, these globules consist of the deutox- ide of proteine. Their organization, however, seems to involve a degree of vitality. They are spheroidal bodies of gelatinous consistency; and, indeed, have clearly the characteristics of large and crudely formed cells. At any rate, they are made up of gran- ules in such a way as, in their more perfect state, if not in every instance, to possess nuclei and cell walls. They have a strong disposition to adhere to one another and to the walls of the ca- pillaries. Hitherto physiologists have supposed these globules to be the red or blood corpuscles .in a forming condition. In my judgment, however, they are entirely distinct,. are formed in a different way, INFLAMMATION. 25 and for very different purposes. The red corpuscles are much larger than the white globules, are different in form and in struc- ture. The former are discoid in shape and have no nuclei. Be- sides a proteine compound, they contain iron and the various incidental and stimulating elements of the blood ; and their spec- ial office seems to be to convey oxygen from the atmosphere to the capillaries, to create animal heat, set electricity free, and, by a stimulating effect, give rise to vital action. They have their ori- gin in the blood-vessels, and, in these vessels, serve their purpo- ses, and perish. The white globules, on the contrary, are evidently formed from liquid fibrine, by the oxidizing process which makes a solid deu- toxide. Fibrinization, we know, commences at the lacteals, and increases throughout the course of the lymphatics, till the current of united lymph and chyle is passed into the venous system, at the terminus of the thoracic duct. Fibrine is polarized or partial- ly organized albumen. To my own mind, there seems good rea- son for the belief, that the elementary granules of vital being have their origin in the lymphatic glands, and pass with and as a part of the fibrine, into the current of the blood; so that fibrine, not merely is chemically organized, but has the first traces of vital organization. If a portion of chyle or any nutritious matter enters the blood, as it would seem that it does, by venous absorption, and without passing through the lymphatic system, this may aid in the chemical formation of the red corpuscles, or it may be vi- talized, by the power of the elementary granules, while in the blood vessels. Be the truth, however, in regard to these latter speculations, as it may, it is now certain, that, in inflammation, white globules exist, in abnormal amount, in the capillaries of the part affected, and they are actually formed in those capillaries. It is, also, cer- tain, that these globules adhere to one another and to the walls of the affected vessels, thereby producing partial or entire stagnation of the blood. During the process of the chemical change, the circulation of the blood is disturbed and the motion of its parti- cles is quickened. As soon, however, as the vessels are fully obstructed, the current necessarily ceases, and the blood coagu- lates. When this takes place in some of the capillaries, the sur- 4 26 THORACIC DISEASES. rounding ones receive the current by the anastomosing vessels. and, of course, are subjected, for the time, to an increased circu- lation ; but, in their turn, they are liable to be obstructed, and be- come the recipients of stagnant and coagulated blood. This disposition of the white globules to adhere to the walls of the capillaries has been ascribed to the existence of vital at- traction ; but, probably, it is only the result of that physical prop- erty of adhesiveness which belongs generally to solt solids com- posed of glutinous materials. At any rate, whatever may be the immediate cause of the adhesion, the effect is, at length, to arrest all vital action in the part, and produce coagulation. As for the red corpuscles, during the process of obstruction, they remain for a season free, passing tortuously in the midst of surrounding white globules. At length, however, they have no longer space to move, and are so crowded into the interstices of the white globules, that the whole vessels concerned contain a large accumulation of them. The liquid fibrine and serum pass on, or are literally filtered out. The CAUSES of inflammation may be divided into predisposing and exciting. The predisposing are the influences which prepare the system, or some particular part of it, to take on inflammatory action. They are exceedingly various, and their specification, in this connexion, is entirely unnecessary. The exciting causes demand a hasty consideration here. They are mainly contusion, friction, heat, cold, venous compression, and the absorption, into the blood, of morbific matter. Contusion becomes a cause of inflammation by an exhaustion of nervous energy, or a destruction of nervous fibres, and an in- terference with their action; so that the vessels readily assume a morbidly relaxed and over-distended condition. In this condition there may be effusion; or the cause may even rupture a portion of the vessels, and afford unnatural outlets to the blood. This is called extravasation ; and it often attends inflammation, when resulting from the cause now under consideration. The operation of friction is similar to that of contusion. The nervous energy is exhausted or the nervous fibres are impaired, and the capillary vessels are weakened, so as to prevent their proper action in passing the blood along to the veins. The INFLAMMATION. 27 effect, of course, is congestion ; and, if long continued, inflam- mation. Excessive heat, applied to a part, produces inflammation there, much after the manner of contusion and friction, hy overcoming the nervous energy and impairing the action of the capillaries. Local inflammation, in a remote part, however, may be produced by such an application of heat as affects the constitution generally and creates arterial excitement. The balance between the flow of blood into the capillaries and that from them being destroyed, over-distention and morbid relaxation, with the various character- istics of inflammation, follow. Cold, philosophically considered, is a mere negation the ab- sence of heat; but, in common language, when the temperature of the atmosphere is moderate and becoming less, we speak of an increase of cold. Using the term, thus, in the popular sense, I speak of the effect of an excessive, local application of cold as im- pairing the nervous energies of the capillaries, and, as in the pre- ceeding instances, giving rise to supervening inflammation. Cold, so applied as to act constitutionally, may inflame a remote part, by destroying, as in the case of excessive heat, the balance of the circulation. The immediate effect of the compression of a vein is congestion of that vessel, in the part through which the blood is approaching the point of compression; and, if the congestion is continued for any length of time, an effusion of serum into the circumjacent areolar tissue ordinarily follows. Sometimes, however, the com- pression, and, more especially, the obliteration of a vein, extending a congested condition back to the capillaries, and disturbing vital action, gives rise to inflammation. But the most fruitful and important source of inflammation, is a depraved condition of the blood. The absorption of morbific matter, of almost any kind, so renders the circulating fluid an un- healthy stimulus to the nerves, that inflammation supervenes, as the consequence. It would seem, that, owing to some chemical or other affinity, on the part of different ingredients in the blood, for different tissues or organs, the localities of the inflammation created are varied according to the nature of the causes. In gen- eral, however, it will be found, that, when local inflammations 28 THORACIC DISEASES. take place as the effect of an abnormal condition of the blood, that blood is too rich in fibrine absolutely, or, at any rate, in pro- portion to the amount of corpuscle's. Thus, while inflammation uniformly gives rise to an increase of fibrine, a quantity abnormally great, already existing in the blood, favors the local development of inflammation. The fibrine, in connexion with the primary granules which ac- company, and perhaps elaborate it. is that part of the blood which supplies the natural waste of the tissues, and repairs those tissues, when wounded. The red corpuscles, on the contrary, supply the nervous ganglia with electricity, or the material necessary for those ganglia to employ, in creating nervo-vital fluid. The fibrine evidently affords the base for the formation of that deutoxide compound called the white globules. These globules, therefore, though in part, perhaps, a chemical combination, are yet in part, at least, vitally organized, the vital power, it would seem, being supplied by the products of the lymphatic glands. The red corpuscles, on the other hand, being too abundant, in any case, in proportion to the fibrine, we seldom have inflammation in any part, but the patient is liable to congestion of the veins, to their rupture, and to a consequent hemorrhage. This liability especial- ly exists in regard to the brain. Hence the frequency of apoplexy with plethoric persons, or those having an excess of red corpuscles in the blood. The nervo-vital fluid being increased, is adapted, in itself, per- haps, to give additional strength to the arteries. Still, in inflam- mation, there is arterial fulness; and this is evidently produced di- rectly by the capillary obstruction checking the onward current, or by the constitutional excitement increasing the arterial circula- tion. The exciting effect of the corpuscles, on the contrary, is, like the external irritation of the atmosphere, a mere chemical and not a vital influence, and is, therefore, in undue proportion, debili- tating and not strengthening. The fibrine and primary granules, when not abundant, being used up, to a considerable extent, at the capillaries, the red corpuscles, especially if forming too large a proportion of the blood, afford an abnormal irritation to the veins, weakening their energy, and causing their over-distention. Among the EFFECTS of inflammation I rank, in the first place, the INFLAMMATION. 29 various phenomena by which it has been nosologically character- ized. The redness is owing to an increased amount of blood in the congested vessels, with what is sometimes around them. The different shades of the redness result, partly, from the different proportions in the amount of arterial and venous blood in the ca- pillaries, and, partly, from the different conditions of the same kind of blood. Ordinarily the color is somewhat scarlet, because it is mainly arterial blood which fills the capillaries. This is especial- ly true in scarlatina, rubeola, and other eruptive diseases. In the active form of superficial erysipelas, we have a similar condition. Indeed, much that is ordinarily called erysipelatous inflammation, is rather erysipelatous congestion, the blood remaining in the re- laxed capillaries, and not being coagulated, nor having undergone the chemical changes characteristic of inflammation. In this condition, the color of the part effected is a bright scarlet ; but, as the congestion passes into inflammation proper, the color be- comes essentially that of ordinary inflammation. After considera- ble exposure to violent cold, the part becomes congested, and the color is then purplish. This is because the venous portion of the vascular system, lying more superficial than the arterial, the blood in the former is so stagnated as to crowd into the capil- laries and give the darkened shade. Of course, if inflammation proper becomes established, the same characteristeric measurably remains. In general, while the inflammation is in its active state and there is considerable constitutional excitement, the hue is flo- rid ; but, after the blood has been, for some time, stagnant, the color becomes deeper. The presence of the white globules, how- ever, tends to render the tinge lighter, than is the usual tinge of simple congestion. In all cases, when the blood has been coagu- lated for a considerable time, the color becomes darker, in conse- quence of the change in the coagulated material. The swcllim? of inflammation is the result of the accumulation o of blood in the part affected ; and it is proportioned to the abnor- mal amount detained in and sometimes around the capillary vessels. Of course, the increase of the part is essentially the same before and after the blood has coagulated. In connection with the en- largement by inflammation, there may be and often is a farther en- 30 THORACIC DISEASES. largement by other means, as by oedema, by a congestion of the lymphatic vessels, or by a collection of pus; but, in general, these different effects are easily discriminated. Different tissues, it is true, are capable of very different degrees of swelling by inflam- mation; but this is due to the difference in the vascularity of their structure and in their capacity to receive blood. Mucous tissues, for instance, are more vascular than serous, and are, con- sequently, capable of more accumulation of blood. The same is true of the cutaneous tissue. Hence the very appreciable amount of swelling shown in the skin, in different eruptive diseases, mod- ified, however by some of the other circumstances already referred to. But to the muscular, the areolar, and the glandular tissues, from the character of their structure, we are more especially to look for the greatest amount of enlargement, when the part is in- flamed. In these the swelling is, sometimes, not only considera- ble, but very great. The pain of inflammation is produced, partly, by the tension of the tissues or the pressure made on the nerves of the part affected : and, partly, perhaps, by an exaltation of the sensibility created by the temporary arterial excitement, or determination of blood. It is different in different portions of the system, being varied by the degree of innervation and other circumstances, under the influence of the same immediate cause. Let the natural sensibility of the part be acute, the arterial excitement considerable, and the pres- sure strong ; we then have the severest pain, as in inflammation of the sheath of a nerve, the pulp of a tooth, &c. Indeed, when the natural sensibility is not great, the other circumstances com- bined may give distressing pain ; as, for instance, when the lining of an osseous canal is inflamed. The strong determination of blood to the part and its confinement by pressure may so exalt the sensibility, though in health it is not great, as to render the pain most excruciating. The inflammation may be so located and the tissues concerned may be of such a character, that but little or no pain is experi- enced, except when the part is pressed, or its tissues are somehow put upon the stretch. This condition, which is called tenderness, exists commonly in enteritis, sometimes in pleuritis, and indeed in various affections. There are, under peculiar circumstances, other INFLAMMATION. 3 1 modifications of pain which are commonly called feelings of sore- ness, of smarting, of tingling, of heat, &c.; but which need no special illustration here. They are the pain of inflammation, uni- ted with sensations produced by connected causes. The heat of inflammation presents a problem which, till of late, has not been well solved. Animal heat is maintained by a process of combustion or oxidation. In the lungs, in the act of inspiration, a portion of the blood is evidently oxidized, by the oxygen inspired, and caloric is evolved ; so that arterial blood pro- ceeding from the lungs is one or two degrees warmer than the venous which enters them. A part, too, of the inspired oxygen is taken up, " and is carried, by the agency of " the red corpuscles, or li a compound of iron, to every part of the body." In the ca- pillaries, oxidation again takes place, by a union of oxygen with either effete portions of tissue, or those portions of the circula- tion which are not in a condition to be appropriated to nutrition, properly so called. The adipose tissue of the animal body, we know, is only the non-azotized elements of the food (,or such as will not form the other tissues and nourish the system), organized (,when the oxygen present is not sufficient for their immediate combustion), and deposited, to be used for oxidation, when after- wards needed; and, "in the herbivorce, a great part of the com- bustion which yields the animal heat is carried on at the expense of those parts of the food which cannot form blood ; namely, sugar, starch, or gum, fat, &c." Besides the oxygen which en- ters the circulation through the lungs, a considerable quantity is, also, received into the system by absorption, through the skin, and mucous tissues ; and this is, in like .manner, used for the ox- idizing process. The immediate result f this process is the for- mation of carbonic acid and water, which are disposed of mainly by the lungs and by the tegumentary tissue. The effect of ac- tive exercise is to quicken the respiration, and the circulation, thereby impelling more blood and carrying more oxygen into the capillaries of the surface, as well as elsewhere. The result of this is iticreased oxidation, it is true; but a portion of the acid and the water, formed by the invigorated action of the perspiring fol- licles, passes upon the surface, in the form of perspired matter. 32 THORACIC DISEASES. The evaporation of this matter, in obedience to a well known chemical law, promotes coolness at the perspiring part. Now, in inflammation, the perspiring follicles are not invigora- ted by an increased power of the nervous tissue. On the con- trary, that power is weakened or destroyed, the perspiration is checked or prevented, and the cooling effect is diminished or lost. At the same time, the oxidizing process is not diminished but is increased. It does not appear, that the matter of the tissues be- comes more rapidly effete. On the contrary, it would even seem, that, to an extent, the process is, with that of nutrition, suspen- ded. But, while the nervous power is not used in the ordinary secretions and excretions by which the system is nourished and changed, that same power is evidently diverted from the nutritive to the excito-motory branch of the nervous system. Hence arises the constitutional excitement, which always, to an extent, attends inflammation. The respiration and the circulation are quickened ; the materials for an increased oxidation in the capillaries of the inflamed part are supplied ; and, through the local irritation, an unusual process of oxidation, within the capillaries, is set up. It is that already described, in which the white globules are abnor- mally multiplied. This process, from the nature of chemical laws, must evolve heat ; and I suppose it to be the principal source of the increased heat of inflammation. The fact, that, under constitional excitement, the blood, heated at the lungs, passes more rapidly to the inflamed part, has, doubt- less, a slight influence in creating the local heat ; but that the cause is principally local, is evident from the simple consideration, that, occasionally, the affected portion has a temperature of 102, 104, and even 106, or more degrees of Fahrenheit. In explaining the phenomena by which inflammation reveals itself, other effects have already been referred to. One of these is the interruption of the functions of secretion and nutrition. In health, the fibrine, with the primary granules, is constantly being applied to the regeneration of the tissues, as the matter of those tissues is constantly losing its vitality and becoming effete. But, in inflammation, it has been already said, the interruption of the nervous action suspends this process, in the inflamed part; and it INFLAMMATION. 33 would seem, that, by sympathy, it is, also, in a great degree, sus- pended throughout the system. Hence, another consequence is, that Jibrine accumulates in the blood, increasing, from less than three parts in a thousand, not unfrequently to five, and, sometimes, even to seven or eight. I ascribe to this cause the increase of fibrine characteristic of inflammation, rather than to any peculiar cause existing exclusive- ly in the part affected. That the white globules are elaborated mainly in the part affected is evident; but their elaboration is an oxidation of existing fibrine, which is a vitalized compound. The increase of fibrine is proportioned to the extent and duration of the inflammation, in the active state ; but so, also, are the con- stitutional disturbance and the suspension of the secreting and nutritive processes. That the blood in the inflamed part contains more fibrine than in others, may be true; but, if so, as the ordi- nary vital processes are more interrupted there than elsewhere, this may afford an explanation of the cause. Again, the effect of the suspension of the nutritive function is, that there is no sense of want in the system, in other words, no appetite; and the taking of food, under the circumstances, only imposes a burden upon the powers of nature. Here I may remark, in passing, that, if the process by which effete matter is thrown off, is a vital act, and governed by laws similar to those by which a new deposit is made, then it must cease, substantially, when the other process is suspended. If, on the other hand, it is a mere chemical process, such as attends all decay of animal matter, then it will not be effected by the con- dition of the vital functions. Some facts, it seerns to me, strong- ly commend the former view ; and, among these, the compara- tively slight diminution of the azotized tissues, when, by reason of constitutional disturbance, the appetite is destroyed, and little or no food is taken for a considerable length of time. In that condition, it is true, the adipose tissue is used up in creating ani- mal heat ; but it is the consumption of that tissue, mainly, which produces any occurring emaciation. I have already alluded to the suspension of superficial perspira- tion as an effect of inflammation. This needs no farther illustra- tion than to say, that the matter seems to be governed by a law 34 THORACIC DISEASES. in common with that which controls the replenishing and the de- trition of the tissues. There are other effects of inflammation; but, being more re- mote and constitutional, they do not require discussion here. CHAPTER III. CONGESTION. I have spoken of inflammation as commencing in a congestion of the capillaries. When, however, we speak of congestion, as a disease, we mean an excessive fulness of the larger vessels, and commonly the veins. From the veins, when lying superficially, in connexion with mucous tissues, there seems sometimes to be an effusion of blood as a whole, or a hemorrhage, without any apparent lesion of the vessels. This is illustrated in ordinary cases of hematemesis, and in some cases of hemoptysis. It may, however, be reasonably questioned, whether, in these cases, there is not an actual rupture of the delicate coats of the smaller veins. Be that as it may, ordinarily at least, when blood leaks from the veins, it is because of a rupture of their coats ; that is, it is hemorrhage by extravasation. This rupture, of course, is the effect of pressure and over-distention. But it is veins, and not capillaries, that are the subject of lesion ; and the constitutional effects of the hemorrhage are very different from those of inflam- mation. When the hemorrhage is produced upon the brain, the result is apoplexy, and not brain fever; when produced in the lungs, it is the disease, pulmonary hemorrhage or pulmonary apo- plexy, and not pneumonitis. In short, whatever disturbance it may produce in the system, it does not give rise to such an amount of constitutional excitement or symptomatic fever, as in- flammation. Inflammation is liable to be caused by an abnormal increase of fibrine. Hemorrhage often results from an excess of red corpuscles ; or it may be produced by a weakness of the vessels, or by an obstruction; but it always has congestion as its immedi- ate antecedent. SEROUS EFFUSION. 35 Congestion is divided into active and passive, or, as some prefer, into active, passive, and mechanical. Suppose, then, that the vis a tergo (, whether consisting in the heated and expanded condition of the blood in the lungs, or in the action of the heart), or suppose, that some abnormal irritation of the arterial muscular coat, or various influences combined, are hastening the current through the arteries, while, from the capil- laries onward through the veins, it is not hastened, the invariable effect must be congestion. This is sthenic or active congestion. Again, suppose the veins to be weakened, arid the circulation through them to be consequently checked, the current from the heart coming on with its normal rapidity, then, of course, conges- tion must follow as before. This is asthenic or passive congestion. I am of the opinion that a weakened condition of the muscular coat of the veins, together with a weakness in the power of the valves, is not imfrequently the principal cause of congestion. The veins not having tonicity enough to support the current, are morbidly relaxed; and, the valves not affording the proper resis- tance, the power of gravitation, when the position of the patient favors, occasions congestion. Still, again, suppose the blood to be impeded, in its return to the heart, by some obstruction in the course of the veins, so that it accumulates in a portion of the venous system. This is what Dr. Watson calls mechanical congestion; but it may, with equal propriety, be called passive congestion. It is the result, not of increased, but of obstructed and diminished action. We have an instance of it, in the case of cording the arm for venesection. The veins, lying nearer the surface than the arteries, are mechan- ically obstructed, and the blood accumulates. CHAPTER IV. SEROUS EFFUSION. There are two methods under which the serum of the blood is separated from the other portions, and is collected either in are- olar tissue or in shut sack. The one of these methods which I 36 THORACIC DISEASES. call secretion, will be considered in another connexion. The other which is effusion, requires to be illustrated here. The for- mer supposes an active condition of secreting organs. The latter implies merely a passive, or relaxed and over-distended state of the coats of the larger vessels, ordinarily, if not always, the veins. Compress any of the veins, as when a ligature is applied to the arm preparatory to venesection, and let the compression remain for a considerable time ; oedema of the surrounding areolar tissue will invariably take place. That is, the serum of the blood will be effused or passed through the coats of the veins. The fibrine and the red corpuscles being vitally and chemically organized, of course, their proximate elements occupy an appreciable space ; whereas the serum, being without any distinct traces of organiza- tion, is made up of elements in a different condition. These elements will readily pass through interstices too small to allow the passage of the fibrine or of the red corpuscles. In all cases, in which the course of the blood in the veins is materially ob- structed, for any length of time, the consequence is a serous effusion. Hence, according to the position of the obstruction, arise different forms of dropsy. It has been supposed, that capillary obstruction, holding back the arterial current and causing over-distention in the arteries, sometimes, produces effusion through the arterial coats. In re- gard to the systemic circulation, I think this is not so. Cer- tain I am, that in general, serous effusion takes place from the venous, and not from the arterial system ; and it would seem to be owing to the fact, that venous blood contains a less proportion of fibrine than arterial, and, consequently, has a less amount of vi- tality. Two considerations favor this supposition. The first is this. The circumstances of the lungs are peculiar. The pulmonary arteries circulate the purple or venous blood; and, when, in pneu- monitis, there is an obstruction of the capillaries by the inflamma- tion, besides the blood effused at the capillaries, there is, also, a degree of serous effusion. It would seem, that this takes place, through the pulmonary arteries, from the blood which has not yet acquired the arterial character, and that it is owing to the dimin- ished amount of vitality in the purple blood. THE RKPARATIVE PROCESS. 61 The other consideration is the effect of repeated acts of vene- section, or of hemorrhage from an accidental cause. As the blood loses its proportion, not merely of red corpuscles, but finally- of fibrine, and becomes more serous, a dropsical effusion sets in and increases. CHAPTER V. THE REPARATIVE PROCESS- Those who embrace the notions of Hunter, that inflammation is a recuperative, and not a morbid action, seem to confound togeth- er two processes, which are almost as unlike each other, as the hardening of clay by the presence of heat, and the hardening of water by the diminution of heat. Not only, indeed, are the two processes very dissimilar, but any considerable amount of inflam- mation, in any wound, will, at any time, utterly prevent the pro- cess of reparation. It is probable, however, that the frequently close succession of the one process to the other has aided in be- traying pathologists into an important error in regard to the nature of inflammation, and in giving rise to such language as " wounds uniting by adhesive inflammation," " granulations formed under the influence of a healthy inflammation," and the like. The truth is, the reparative process is entirely distinct from that of inflammation, and, in almost every particular, unlike it. In the former, there is nothing of the redness, swelling, pain, or heat which characterize inflammation. There is not, to any ex- tent, a morbidly relaxed and over-distended condition of the capil- lary vessels ; nor is there an effusion or extravasation of blood into the circumjacent tissue, as sometimes occurs in inflammation. Indeed, the two processes have scarcely a single phenomenon in common. The reparative process, taking place after a lesion has, by any means, been produced, is but little more than an increased and slightly modified condition of that action by which the system is being constantly repaired, i. e., by which the place of effete matter removed is supplied. The lesion may be the result of an 31 97P1 38 THORACIC DISEASES. incision, of contusion, of inflammation itself, or of some one of various other means ; but the process of cure is substantially the same, in all cases. This process of repair is not under the control of any indepen- dent power, that is properly entitled to some distinctive name, such as vis medicatrix naturce, vires vitce, or the recuperative power of nature. The process is simply one controlled by law, established in the system and at all times existing. The results, of course, diifer, according to the existence of different conditions, the law remaining the same. Under the circumstances of ordi- nary decay, the function of nutrition is performed at such a rate as just to meet the demands of the waste. When that same function needs to be executed more rapidly, the circumstances are such that more nervous stimulus is afforded; but it is all in obedi- ence to an unchanged law. The lesion, through the afferent nerves of the nutritive branch of the nervous system, impressing its condition upon the nervous centres of that branch, the increas- ed exciting influence returns through the efferent nerves of the same branch, and more rapid nutrition is the necessary effect. It is by this reparative process, that the parts of a wound, being brought together, unite, if under favorable circumstances, by what is called adhesion, or union by the first intention; if, under other circumstances, generally by the formation and appropriation of interstitial matter. Dr. Carpenter, however, considers the pro- cess to take place in three different modes; and, evidently, there is, occasionally, a modification of manner, slightly different from the two now named. I cannot, however, wholly endorse the views of Dr. C. According to him, the three modes are as follows. The first is "the adhesion of the sides of a wound by a medi- um of coagulable lymph, or of a clot of blood." The second is "reparation without any medium of lymph or granulations, the cavity of the wound being filled by a natural process of growth from its walls." The third is "reparation by means of a new, vascular, and organized substance, termed granulations." By the first of these modes is meant to be designated what " is ordinarily termed union by the first intention." But, in this mod- ification of process, no "clot of blood" performs any vital part. Blood, when clotted, becomes dead animal matter, and can never THE REPARATIVE PROCESS. 39 be again applied to vital purposes. This is just as true, when the blood remains in the tissues and in the capillaries, as when drawn into a vessel. If, by coagulable lymph, however, is meant the hyaline fluid, then the expression contains the truth. This fluid is employed in forming cells and producing the adhesion of the sides of the wound ; but the term is a bad one, as it suggests the notion of coagulated blood or a clot; and, indeed, seems to have been used, by Dr. C., as synonymous with the phrase, "a clot of blood." The process of union by the first intention is really a simple one. In the first place, liquor sanguinis is secreted (,not effused), on the edges of the wound, those edges being placed in juxtapo- sition. This fluid and the red corpuscles compose the blood ; but the red corpuscles remain in the circulating current. That portion of this fluid which is scarcely vitalized, is composed mainly of al- bumen and water, and is called the serum. The more watery part of this is evaporated or absorbed. The other probably re- mains; and, with the fibrine (, containing the primary granules), takes on a smooth and glassy appearance. Hence, the whole is called the hyaline fluid. It is, also, termed blastema and cyto- blastema; because it is "the basis of every forming structure of the human body;" in other words, because it contains the first buddings or cell-buddings of new growths. When this fluid is examined by the microscope, it is seen to contain regular, though minute, spheroidal cells ; besides which, there are innumerable graniform bodies of still smaller size, appearing merely as specks or dots in the blastema, and these latter are elementary or primary granules, the very beginnings of the spheroidal cells. These appearances, the fully developed cells, especially, have sometimes been called exudation corpuscles. The name, however, is an un- fortunate one, as they are entirely distinct from the red corpuscles, and must not be confounded with the latter. Though the hyaline fluid is itself vitally organized, in a de- gree, yet it is only the granules and the formations from them, which exhibit the traces of full or perfect organization. Every fully developed cell has a triple organization, a nucleolus or nu- clcoli (.for there are sometimes two or three within one cell), a 40 THORACIC DISEASES. nucleus, and a cell-wall or investing envelope. These nucleoli are really an aggregation of the primary granules. As the reparative process advances, these nucleoli multiply, and the blastema assumes a greater opacity. Molecules aggregate around one or more of these nucleoli, and a nucleus is formed. To complete the cell, however, a transparent and most delicate membrane, composed of proteine, invests the whole, and consti- tutes the wall. The blastema, in which the cells float is albumi- nous matter, with only the faintest traces of organization, while the fluid contents of the cell the medium interposed between the nucleus and the cell-wall are more distinctly fibrinized being attracted within, and, in the process, becoming changed, by the vital power of the nucleus. The nuclei, becoming the parents of other cells, are sometimes called cytoblasts or cell-germs, the name being designed to indi- cate the peculiar function. A nucleus, with its nucleolus or nu- cleoli, being an aggregation of granules, each one of which is capable of being developed into an independent cell, new cells may be completely formed within a primitive one ; or the primi- tive one may rupture and scatter its contents into the surrounding blastema, where they, in turn, may assume the characteristic triple organization, producing and reproducing new cells, indefinitely. Again, cells may form, in the blastema, in an isolated manner from pre-existing granules, when these granules are in contact with living tissues. In this case, each granule attracts to itself, assimi- lates, and organizes a portion of the nutritious fluid, forming it into the cell- wall and the contents of the cell. Cells, as first found, are generally spheroidal in shape; but they become variously modified, in forming the several different tissues. Sometimes they become elongated, sometimes flattened, fusiform, prismatic, polyhedral, or caudate, according to the purpose to which they are devoted. In the formation of new tissue, the cells arrange themselves in longitudinal lines, the proximate surfa- ces of the cell-walls disappear, and a tubular cavity is made. In this way, according to the form which the cells assume, and the matter with which they become filled, the muscular, the nervous the osseous, and all the various tissues are formed. There are other modifications of circumstances under which THE REPARATIVE PROCESS. 41 cells appear. Some float in the blastema, independently of each other; and, hence, arc called isolated cells. From their ephemer- al nature, also, they are called transition cells, in opposition to those which form an integral part of the more permanent tissues, and are, therefore, called permanent cells. The transition cells have their own purposes to serve. For instance, they are em- ployed in the formation of the epidermis, the nails, the epithelial mucous membrane, and, in general, those tissues which are rapid- ly thrown off and formed anew. Those of the epidermis and the epithelium seem to originate in molecular granules, which are diffused through the substance of the basement mem- brane. While cells are developed under such varieties of circumstances as have now been considered, it is, to my own mind, sufficiently clear, that elementary granules exist in the current which circu- lates in the lymphatic system, and which is composed of lymph and chyle united ; and these elementary granules, as well as the more organized portions of cells, are centres or poles, from which emanate ncrvo-vital influences, to carry on the purposes of vitali- ty and organization. To return now to the case of an incised wound, suppose new cells, as they are formed, to arrange themselves in order one upon another ; suppose this process to commence on both edges of the wound simultaneously ; and suppose, moreover, that those edges are in juxta-position, that is, are as nearly in contact as they can be conveniently arranged. No sooner does the longitudinal ar- rangement of cells commence from each edge, than the outermost ones meet, and, by assimilating a portion of the blastema, unite, the circulation becomes established, nervous influences pass from one edge to the other, and the wound is healed. This is the sim- ple process of union by the first intention. A clot of blood, in this case, can do no more than to keep off the atmosphere and other irritating agencies from without, by filling the interstices, where the parts are not entirely in apposition. It is, from this kind of protection, that benefit is secured, by dressing a wound, in the blood, as the phrase is. The incised edges, by being im- mediately shielded from deadening influences, remain in a condi- tion to take on the healing process. Of course, as soon as the (i 42 THORACIC DISEASES. cells, accumulating upon one another, meet from the two edges, the parts unite and the wound is healed. The SECOND MODE in which Dr. Carpenter considers the repara- tive process to be effected, Dr. Macartney c;]ls the modeling process. In this case, " the surfaces of the wound do not " im- mediately " unite by vascular connexion." The edges take on a smooth and rather red appearance, much like mucous membrane. They seem also to be slightly moistened with a thin fluid. This is usually considered as a case of natural growth from the walls of the wound, till the parts finally become united. This mode of union may, by care, be effected, where otherwise the process would be accompanied by granulations and suppuration. The means to be employed are the exclusion of air and of other irritating causes. Now, in my view, the difference between this mode and that of union by the first intention is exceedingly slight. The parts not being in juxta-position, there must be an evident accumula- tion of cells one upon another. Transition cells form an epithel- ial covering to the growth from permanent cells ; the accumulation continues ; and, when the parts meet, the epithelium disappears, and union is effected. The increased accumulation of cells, and the existence of epithelium, during the growth, constitute essen- tially the whole difference between this mode and that first con- sidered. Indeed, when a wound is said to unite by the first in- tention, often interstices are first filled by coagulated blood, or are, in some way, protected ; and the case is, in part, as really one of the modeling process, as any which are ordinarily regarded as such. Dr. Carpenter's third mode of reparation is one in which gran- ulations are employed. These are formed under the unfavorable circumstances of irritation or continued inflammation. The gran- ulation structure is a special one formed for a temporary purpose. It is endowed with higher vascularity. and a more rapid power of growth, than is possessed by any modification of ordinary tissue; but it is very easily destroyed, by injury or by increased inflam- mation. The formation and the effect of the granulation structure prove, that parts, previously healthy, are disposed to heal, in spite of many impediments thrown in their way. Here, however, there is no vis medicairix naturce, in the sense of an independent power, THE REPARATIVE PROCESS. 43 interposing, just at this juncture, for the individual's good. An invariable law controls the process, though the nature of that law is not yet fully understood. My own conviction is, that, when granulations are formed, the capillary vessels in connexion with the part affected are always abnormally enlarged, either by irri- tating causes from without, or by the latter stage of inflammation within. The chemical influence of the atmosphere tends to weaken innervatiori, and thereby to relax and over-distend the coats of the capillaries. In the passive stage of inflammation, the ves- sels are yet over-distended, though the counteracting effect of the active period of the disease has essentially subsided. In this case, there is a secretion of liquor sanguinis, but it is modified by the existence of the white globules, or by a chemically changed con- dition of the blood. Either these globules actually pass through the walls of the over-distended capillaries to form crude cells with- out; or what is more probable, the primary granules, perhaps, in a modified condition, pass through the vessels, with liquor san- guinis of a modified character ; so that the hyaline fluid without differs from what is normal, and from it a different structure is consequently elaborated. In the case of granulations from exter- nal irritation, the modification of the hyaline fluid is evidently the result of a change produced either directly on the surface, or at the secreting points of the capillaries. This irritation does not, like inflammation, produce coagulation in the capillaries. Still, it may extend its effect somewhat beneath the surface, so as to form in the vessels, a proteirie compound, like that of inflammation. In the hyaline fluid, as granulations are forming, there are seen extremely minute molecules, composed probably of fatty matter, and granules measuring from one twelve thousandth to one eight thousandth of an inch in diameter, consisting essentially of the deutoxide of proteine with a central molecule of fat ; also, still larger bodies, exudation corpuscles, compound granules, or cells, measuring from one six thousandth to one seven hundreth of an inch in diameter. Basides these bodies, there are extremely fine, interlaced, and decussating fibrils much like those seen in the buffy coat of the blood. . The kind of action, then, in the formation of granulations is essentially the same, as that in union by the first intention, or in 44 THORACIC DISEASES. the modeling process. Liquor sanguinis, modified, is secreted ; and, the serum or its watery portion being disposed of, the blaste- ma remains pregnant with cells, which arrange themselves one upon another, presenting the appearance which has been undesira- bly called that of exudation corpuscles. Over all, an imperfect epi- thelium is formed, probably by means of transition cells. In this process, as in the more perfect one already described, a portion of the blastema is assimilated and more fully organized. New lay- ers are developed, and the void is, at length, filled. The effect of any external irritating influences and of any re- maining inflammation having passed, the usual reparative process goes forward. In the ordinary nutrition of the system, effete mat- ter is thrown off, as new matter is deposited : and so, in this case, the granulation deposit is separated and absorbed, as the new and more permanent tissue is formed. One peculiarity of appearance, however, remains, after a wound has been permanently healed. The granulation structure, which is removed by interstitial absorp- tion, being less dense than the more permanent tissue, the portions removed, in a given time, occupy more space than those which are deposited. The consequence is, that, after the work is com- pleted, the paTts are left contracted and a cicatrix shows itself. Those fungous growths which are commonly called proud flesh, are the result of an excessive granulating process. That they oc- cur in accordance with fixed law, and under modified nervous ac- tion, cannot be questioned, though we cannot trace all the work- ings of vitality in such exuberant formations. In every case of lesion, in whatever way created, the healthy condition of the part must be restored by the reparative process, in some one of the modes now considered. If the lesion has been produced by inflammation, and that under ordinary circum- stances, as in the muscular and areolar tissues lying near the sur- face, and if, at the same time, there is no appreciable destruction of the tissues, the reparative process has comparatively little more to do than it has in serving the ordinary 'purposes of nutrition. When, however, the inflammation is upon a serous tissue, there is frequently a too luxuriant growth, ordinarily termed false or exuda- tion membrane. In this case, the hyaline fluid is copiously depos- ited in much the same manner as in superficial fungous growths. THE RED CORPUSCLES. 45 When fungous growths and exudation membranes give place to a normal condition of the parts, the process is evidently that of ab- sorption, just as ordinary granulations are absorbed, when the more permanent structure is formed. It is proper here to remark, that the plastic power of the blood, that is, its capability of being transformed into organized tissue, is in proportion to the quantity of fibrine which it contains. Though the chyle exhibits faint traces of fibririization, immediately on passing the lacteals, and though the current of chyle and lymph united partakes more and more of this character, till it reaches the thoracic duct ; yet, in the blood, the proportion of fibrine is greater than in any part of the lymphatic current, and that notwithstand- ing the constant withdrawal of it from the blood for the purposes of nutrition. From this fact it is sufficiently evident, that fibrine is elaborated, partly, by some agency in the blood vessels. As to Avhat that agency is I have already given my opinion. When blood is drawn from the body, and its fibrine is coagula- ted in a vessel, that coagulated fibrine has something like a rudi- mentary appearance of organization. It contains what appear much like organic germs. This particular resemblance to the change effected by the conversion of the hyaline fluid into solid tissues, has probably been principally concerned in giving rise to confused notions and uses of terms, in speaking of the reparative process. These organic germs, or corpuscles, as they have been called, which appear in a clot of fibrine, seem to be formed by means of an electric influence derived from the atmosphere. But electricity is not nervo-vital fluid, and, therefore, cannot do the full work of that fluid. It, to some extent, imitates, but it cannot become vital action. CHAPTER VI. THE RED CORPUSCLES. ' The human blood corpuscles or red globules" says Dr. Mor- ton, "are flattened circular discs, with a central concavity or de- pression on each surface, which, in some respects, gives them an 46 THORACIC DISEASES. annular appearance. They vary between the 300th and the 400th of a line in diameter, and their thickness is about one fourth of that measure. Each corpuscle is a cell, of which the envelope is elastic, homogeneous, pellucid, and colorless; and the contents are of a more or less deeply red color. They are, however, destitute of distinct nuclei, the dark spot which is seen in their centre being merely an effect of refraction, in consequence of the double con- cave form of the disc. But, since the corpuscles of the lower an- imals are distinctly nucleated, some physiologists insist, that the nucleus exists also in the blood of mammiferse, although it has hitherto eluded positive demonstration." "The vesicular envelopes of the blood discs have been sup- posed to be analogous in character to fibrine, being extremely del- icate, transparent, and highly elastic membranes." " The contents of the capsule consist of two different substan- ces, called heematine" or hcematocine. "and globuline." " HcBinatine or hcemalodne is the compound that fills and forms," with globuline, "the substance of the corpuscle, and gives it its characteristic color. When the coloring matter is separated from the other constituents, it appears as a dark brown substance, inso- luble in water, ether, acids, or alkalies, or in alcohol alone, but dissolves in alcohol with the addition of sulphuric acid or ammo- nia. This solution has also a dark color, and possesses all the properties of the coloring matter of venous blood. It contains a considerable proportion of peroxide of iron ; but Scherer has proved, contrary to the received opinion, that the coloring matter is not derived altogether from the iron, because, when the latter is wholly separated from the hasmatirie, a deep-red coloring mat- ter still remains." Kirkes and Paget, however, say of it, that, as ordinarily ob- tained, " it is soluble in water, by which it may, with the globu- line, be washed out of the blood corpuscles; and from this solu- tion it is precipitated, by most metallic salts and by concentrated acids. In the living or recent state of the blood corpuscles, the heematine is confined within their cell-walls, and appears to be in- soluble in the serum ; but, when the blood begins to decompose, and the cell-walls, losing their texture, permit the outward pas- sage of their contents, both the hsematine and the globuline are dis- THE RED CORPUSCLES. 47 solved in the serum which thus becomes blood-colored, and may impart its tinge to the surrounding parts. In the purest state in which it can be obtained, it is so far changed as to be insoluble in water, of a deep blackish-brown color, and not liable to change of color on exposure to gases. Boiling alcohol will dissolve small quantities of it, and it is freely soluble in alcohol acidula- ted with sulphuric, hydrochloric, or nitric acid, and in weak so- lutions of potash, soda, or ammonia." "The presence of so large a proportion of iron, constitutes a peculiar feature in hasmatine. The mode in which the metal ex- ists in it has been much discussed. By some it is supposed to be in the form of an acid, or a salt, or in the form of peroxide in arterial blood, and carbonate of the protoxide of iron in venous blood. The greater probability is, that the iron is combined, as an element, with the four essential elements, in the same manner as, it is held, sulphur is combined with them in albumen, fibrine, cystic oxide, &c." " It is very doubtful, whether the rapid change of color, which is effected in respiration and on the contact of various gases, can be referred to any chemical changes whatever, in the hosmatine. Much more probably it is due to changes in the form of the blood corpuscles and their consequently different modes of reflecting and transmitting light. Saline solutions, if denser than the liquor sanguinis, contract and shrivel up the corpuscles, making them deeply bi-concave ; and distilled water has the contrary effect, swelling out the corpuscles, and making them thickly bi-convex or spherical. Changes corresponding with these are produced, by the contact of oxygen and of carbonic acid with the corpuscles ; the former contracting them, and making their cell-membranes thick and granular, the latter dilating them, and thinning and finally dissolving their cell-walls. Herein, then, is a sufficient ex- planation of the changes that the corpuscles undergo, without sup- posing any immediate chemical alteration in the hasmatine." " Globuline" says Dr. Morton, " is obtained from the capsule of the red corpuscles and is their component element. It is regarded, by the chemists as a proteine compound, closely allied to albumen, from which it differs, however, in being soluble in serum and in coagulating in a granular form, unlike the residue from albu- 48 THORACIC DISEASES. men. Henle suggests, that globuline is albumen, modified by combination with the substance of the disc-envelopes. The glob- uline and hsematine combined constitute the admitted contents of the globules, and are called the en/or." Kirkes and Paget say, that " globuline appears to be a proteine compound. According to Simon, it bears some resemblance to caseine, on which account he named it caseine of blood : but Liebig and others regard it as more similar to albumen. It is so- luble in water, and its solution, when heated, forms a granular coagulum." What I have now quoted refers to the chemical character of the corpuscles. In regard to their origin, Dr. Morton says, "The human blood corpuscles are, by many physiologists, even by those who deny their nucleated character, regarded as cells, capable of reproduction in the manner of the cells of other tissues." In thus speaking of "other tissues," the doctor seems to regard the blood itself as a tissue. He continues, " This process, accord- ing to the latest microscopists, is shown in the following manner. First, radiating lines are seen to pass from the centre to the periphery, dividing the disc into several segments, usually six in number: and these parts become gradually isolated from the par- ent corpuscle, and constitute as many new and independent cells. It is. in this manner, that the red corpuscles are rapidly generated by a power of self-production within themselves, which is in- creased or retarded, however, by various circumstances." Thus much, in regard to the nature of the red corpuscles, being understood, the grand but hitherto unsettled question arises, What is their function? Different conjectures have been formed. One is, that they convert the albumen of the blood into fibrine. But, to this view, there are serious objections. Fibrine is exten- sively found in the lymphatic vessels, and yet these vessels con- tain no red corpuscles. Again, invertebrate animals have no red globules in their blood; but albumen, with them, is changed into fibrine as readily as with animals having red blood. Another conjecture is, that the red corpuscles are " carriers of oxygen to the various tissues, and of carbonic acid from these tis- sues to the lungs." To an extent this is, doubtless, the correct theory. Experiments, it is true., have shown very clearly, that a THE RED CORPUSCLES. 49 portion of the oxygen taken into the lungs, in respiration, is, in those organs, united with carbon which is in the blood, there to form carbonic acid. So far, then, as the oxygen is there used, it cannot be carried through the circulation by the corpuscles ; and, so far as carbonic acid is formed in the lungs, it cannot be brought to the lungs, by the corpuscles. Still, it is certain, that oxidation takes place in the capillaries, throughout the system ; and the oxygen employed must be trans- mitted through the arteries by the red corpuscles, while the car- bonic acid created at the capillaries must be returned through the veins, by the same vehicles. The most directly vital office of the red corpuscles, however, is the reception and transmission of electricity. Whether this is attracted from the inspired air, by the power of the iron contained in them, or is generated in connexion with the oxidizing process, is yet a matter of doubt. Be that as it may, electricity being found in connexion with the corpuscles, they then, through afferent nerves connected with the serous coat of the blood-vessels, con- vey that electricity to the nervous centres or ganglia of the sever- al nervous systems. At these ganglia, the electric fluid is con- verted into nervo-vital fluid, and is then sent, by efferent nerves, to every part of the body. Of course, a portion of this nervo- vital fluid, sent from the ganglia of the nutritive system, passes to the lymphatic glands, where the elementary granules of the cells have their origin, there to form these granules, as well as to the lymphatic ducts generally, to elaborate fibrine from the albumen of the lymph and chyle. The shut sacs of the body, generally, are lined with serous tissue and become the repositories of nervo-vital fluid. Hence, when any portion of that tissue is inflamed," the excited nervous action, circulating an increased quantity of nervo-vital fluid, gives a full and hard pulse ; whereas excited nervous action on mucous tissues, passing off this same fluid too rapidly to the atmosphere around, creates a rapid and feeble pulse. In regard to the white globules or lymph corpuscles, which are found m the blood, they are evidently allied in character to the primary cells, which repair the system as already explained. Experiments have conclusively shown, that repeated venesec- 7 50 THORACIC DISEASES. tions reduce the quantity of red corpuscles and of albumen in the blood, but do not readily affect appreciably the amount of fibrine. The explanation of this truth is as follows. As the veins are being partially emptied of their contents, they collapse upon the remaining current, for the time being ; but they are soon filled again by the absorption of a watery liquid from the system. The blood abstracted diminishes proportionally the corpuscles, the al- bumen, and the fibrine ; but the last being elaborated, to a con- siderable extent, in the lymphatic vessels, those vessels, almost immediately, supply a quantity nearly equivalent to what has been removed. The red corpuscles elaborated in the blood-ves- sels, and the albumen of the serum which escapes the fibrinizing power, are not subjected to influences to give them so rapid an accumulation. CHAPTER VII. THE FORMATION OF PUS. That pus is very commonly formed, in connexion with the pro- duction of granulations is admitted by all; but whether it is al- ways so formed, what its precise nature is, and by what means it is created, are questions which, till of late, have been quite un- settled. Pus appears under various modifications, and circumstances will rapidly change its qualities. Well-formed pus is an opaque, smooth, yellowish fluid, without scent, arid having nearly the consistence of cream. By the old writers, it was spoken of as laudable pus ; and it is still quite frequently called healthy pus. The latter epithets, laudable and healthy, are unfortunate ones. They were selected when the most incorrect and absurd notions prevailed in regard to the reparative process. A degree of inflam- mation was considered benign in its influence, and as constituting, in itself, the process of healing. Well-formed pus always indica- ted, that, to some extent, reparation was going on. So, as it would seem, it was taken as evidence of a very laudable trait in the gov- ernment of that superintending power, the vis medicatrix natures ; THE FORMATION OF PUS. 5.1 or as evidence, that healthy inflammation was restoring the part diseased. Well-formed pus consists of yellowish glohules, diffused through a thin fluid, which somewhat resembles the serum of the blood. "If six or eight ounces of good pus be suffered to stand in a phial, it will separate into two portions. A yellowish matter will sink to the bottom, and there will be a slightly yellow, clear, su- pernatant fluid, like oil in appearance, but not greasy to the touch." The sediment consists of the globules ; and, by some, they have been regarded as the blood corpuscles, deprived of their coloring matter, and modified in form. To this view, however, there are, at least, two objections. The most prevalent opinion of physiol- ogists, at present, is that the red corpuscles take no part in the for- mative process; and, to my own mind, it is pretty clear, that an entirely different office is assigned them, in the discharge of which they do not leave the vascular system, and cannot, therefore, ap- pear, with the granulations, upon any surface. The other objec- tion, alluded to, has respect to the rapidity and the kind of change which the pus globules are apt to undergo, on exposure to the air. The blood corpuscles, by a like exposure, coagulate and form a clot ; whereas the change wrought on the pus globules, is clearly one of degeneracy or decay. But pus is not always icell-formed. Sometimes, the globules do not bear a due proportion to the watery part ; and then the pus is called ichorous. When some of the coloring matter of the blood happens to be effused or extravasated and combined with it, it is spoken of as sanious. Mucus may be mixed with it, ren- dering it viscid and slimy. In scrofulous persons, diseased lymph may blend with it, and give it flaky and curdled appearance. Oc- casionally, morbific or effete matter, in the system, may find an outlet, in connexion with pus, giving it a fetid odor. When, by a breaking down of tissues, to some extent, a cavity forms abnor- mally in the system for the reception of pus, that cavity is termed an abscess ; and pus from abscesses which form in or near the al- imentary canal, is peculiarly liable to be offensive in character. This fact is probably owing to the tendency of the system to depuration through mucous surfaces, and to the existence, near those surfaces, of matter which needs to be eliminated. 52 THORACIC DISEASES. According to Lebert, a French writer, as translated by Dr. John A. Svvett of New York, pus globules "are alwiys found floating free in serum. Their mean diameter is from .01 to .0125 of a millimetre. Their shape is spherical. Their surface is slightly rough, and is sometimes covered by molecular granules. Their investing membrane is more or less transparent. Their contents are liquid; and you can notice in them, when they have attained their full size, one, two, three, rarely four or five true nuclei, whose diameters are from .0033 to .005 of a millimetre, and in the interior of which a nucleolus can often be detected. " With a high magnifying power, it is easy to discover these nuclei without the aid of any chemical reagent. The acetic acid, however, renders them more distinct." Bearing in mind that the pathological and surgical writers, gen- erally, have not distinguished the reparative process from inflam- mation, we shall see, by their writings, that they considered sup- puration to be a process necessarily succeeding the formation of new tissue. Dr. John Hunter says, " The new-formed matter peculiar to suppuration is a remove farther from the nature of the blood than the matter formed by adhesive inflammation." Dr. Thomas Watson says, " Pus appears to be poured forth or secre- ted by coagulable lymph, after it has become organized. Its for- mation seems to characterize a more advanced stage of inflamma- tion to denote that the inflammation has been pressed a little be- yond the adhesive stage." Dr. S. G. Morton, speaking of exu- dation corpuscles arid false membranes, says, "By tracing the metamorphosis a single step further, we come to the pus-globule." Dr. Watson does, indeed, say, that, " in the natural cavities of the body, pus seems, sometimes, to mingle gradually with the se- rous effusion, which grows turbid and whitish, and at length dis- tinctly assumes a punform character." But, whether he intended this remark to involve an exception to the usual manner in which pus is formed, or not, it is clear to my own mind, that, in fact, he only describes a case in which the reparative process goes on slowly, and is, at the same time, attended with but a slight elab- oration of pus. Just that condition of things must be induced, when the vital or recuperative power is not strong, and yet, as in THE FORMATION OF PUS. 53 a shut sac, there is not great irritating or destructive influence at work to counteract the granulating process. Let us suppose, then, that suppuration is, ordinarily, an inter- ruption of action in the formation of granulations, and that it is never a direct secretion from the blood, irrespective of tissue form- ing or formed. Still, another question arises whether false mem- branes and other granulation structures, which gradually disap- pear during the existence of suppuration, are not converted into pus; and whether even old tissues, which are broken down in the case of ulceration, do not undergo the same connection. On this question, I remark, we know, that often granulations are removed by interstitial absorption, when there is no suppuration ; and we know, that, in ulceration, matter often loses its vitality and breaks away from the living tissue, just as in a simple case of mortifica- tion. Antecedently, therefore, to a consideration of the true na- ture of suppuration, the probabilities are, that existing tissues, whether temporary or permanent, are always removed by other means. But what is the true nature of pus ? or what is the kind of ac- tion which elaborates it? I regard suppuration as simply a degen- eration and disintegration of the organized hyaline fluid, or exu- dation corpuscles just as they are being deposited, in the granula- ting process. The change always supposes a reduced state of vi- tality in these corpuscles, by which they, in a measure, lose their power of organization, and become a kind of loose aplastic ma- terial. With the loss of vitality, there is, also, in the material involved a chemical change, which consists, mainly, in an increased oxid- ation of that material. Well-formed, pus "is composed chem- ically of water, deutoxide of proteine forming the cell-walls, tri- toxide of proteine and albumen in solution, fat, osmazome, and other extractive matters, and the same salts as those in the blood." In a more general description of these, however, it is sufficient to say, that the more solid parts are deutoxide of proteine, and the more dissolved or liquid parts, the tritoxide. " Microscopically, pus consists of a limpid serum, and very nu- merous globules of pretty regular size and form," or of such glob- 54 THORACIC DISEASES. ules containing such serum. "These globules have much resem- blance to granular cells or exudation corpuscles ; but they are larger, and are more distinctly and constantly provided with a cell-wall and nucleus, in addition to granules and molecules." In form, they are generally "spherical," though "sometimes irregu- larly rounded or oval. Their cell-wall is commonly opaque and somewhat uneven, from being studded with minute granules." "Pus globules are," in general, "larger than exudation corpuscles, even exceeding in size the blood-discs. According to Mr. Addi- son, they measure from 1-2000 to 1-1500 of an inch." They are evidently a modification of exudation corpuscles. Physically, pus globules are without great power of cohesion. In this respect, they are in contrast, with the primordial cells and the red corpuscles. This physical effect, however, is, doubtless, the result of a chemical change. The circumstances which give rise to suppuration are mainly three; an increase of inflammation, an irritating influence of air, and a certain depraved condition of the blood. It is easy to il- lustrate, at least in part, the manner in which these circumstances produce their effect, and increase the oxidation of the material concerned. It is, however, only necessary for me here to say, that it belongs to the nature of inflammation to expose the affected part to the reception of more oxygen ; the pressure of the air does the same directly, and likewise increases the inflammation ; and a certain depraved condition of the blood irritates and tends to the same result. All these influences, where the vital powers are at work, feebly and under embarrassments, are sufficient to give chemical laws the ascendency over vital, and thus to produce the effect, of degener- ating and destroying the imperfectly organized material which is about to form a temporary tissue. But, when once that tissue is formed, especially, when the more perfect organization of per- manent tissue is produced, it is not to be expected, that the kind of chemical influence referred to can be made to overcome vital in- fluences. In this view of the subject, we perceive, that to speak of pus as a secretion, is not philosophically correct. Liquor san- guinis is secreted, and subsequently undergoes vital changes, upon the surface. Indeed, if a surface which is suppurating be fre- ULCERATION. 55 qnently sponged, a thin fluid only will, from time to time, be dis- covered, and no pus, as such, will be seen. The simple reason is, it has not time to form. What has thus been said of the nature of suppuration throws important light on the question how the absorption of pus pro- duces hectic fever. In the first place, the loss of vitality in what is absorbed renders it foreign matter; and that, when absorbed, always produces more or less constitutional disturbance. In the next place, the increased size of the pus globules must render them exceedingly irritating in their forced passage through the capillaries. And, finally, the soluble tritoxide of proteine, which is a prominent part of pus, acts, chemically, as an irritant. It will even dissolve dead animal matter ; and it, doubtless, has an inju- rious effect, wherever it travels in the human system. CHAPTER VIII. ULCERATION. In ulceration there is a breaking-down and removal of tissue, essentially in the same manner as in mortification. The loss of vitality, in the part, however, is gradual ; and, at the same time, there is, in immediate proximity to the decaying part, a struggling and partially successful effort of vitality. By this effort, granula- tions are being formed, though they are also being disintegrated, in part, and converted into pus. In the case of an abscess, the hyaline fluid forms an organized or exudation membrane, around a limited part, and thereby de- fends the exterior structure from the noxious influence of the gathering pus. This membrane has been called pyogenic, on ac- count of its supposed office of secreting pus. We have seen, how- ever, that pus is not a secretion. Still, the name, for distinction's sake, may well enough be retained. This pyogenic membrane varies somewhat, in its strength and influence, according to cir- cumstances. Very commonly, it affords the least resistance in the direction of some cutaneous or mucous surface, and the abscess is said to point in that direction. The parts there are put more upon 56 THORACIC DISEASES. the stretch, the vessels are more obstructed, the vitality is dimin- ished, and the liquor sanguinis is less secreted. Fibrous and other hard textures generally resist pretty fully the progress of ab- scesses and the escape of pus. " Serous membranes, by their ready plastic process, first adhere together, and then often give passage to the contents cf an abscess through them," thereby for- bidding the escape of any pus into the sacs which they form. After an abscess has opened and discharged its contents, the gran- ulation process, to an extent, gets the ascendancy of the morbid chemical influences ; and, though the superficial layer of exuda- tion corpuscles degenerates, more or less, into pus, the healing process is, in time, effected, and the cavity is obliterated. Sometimes ulcers form superficially. Inflammation gives ori- gin to the destruction of the tegumentary, and portions of deeper- seated tissues. They lose their vitality, and are either absorbed or carried away with the pus discharged. The excavation being greater, in some portions than in others, often gives a ragged form to the ulcer. Sometimes, especially when the impurity of the blood enfeebles the vital power, the reparative process will go on but imperfectly, and the pus discharged, or a portion of it, will not be well-formed. It may be ichorous or sanious, or may, by other characteristics, show the weakness of the vital action ; but, as soon as the vital energies, working by fixed laws, begin to get the ascendancy, well-formed pus takes the place of that of other traits, and granulations, to a greater or less extent, restore the part. In general, ulceration has its origin in a suspension of the nor- mal nutrition of the part, by means of inflammation. Frequently, however, it is immediately preceded by an induration which is produced by some abnormal deposit, either from the blood vessels, or from the lymphatic system, or from both. In this case, " the ulceration commences in the centre of the induration, because the nutrient influence of the vessels is most reduced, by the pressure at that spot." Sometimes, it would seem, that the impoverished and impure condition of the blood gives rise to ulceration, with- out its being preceded by induration or inflammation. This es- pecially happens in parts, the blood vessels of which become con- gested by posture; and in the non-vascular textures, which are not nourished the most directly by .the blood. MORTIFICATION 57 CHAPTER IX. MORTIFICATION. Mortification consists in the decay of animal tissue, in conse- quence of a suspension of circulation in the part, or of the blood's having, in a great degree, lost its vital properties. The part dies; and, if the vital energies in the parts immediately around are suf- ficiently energetic, the reparative process is immediately set up, and, by means of it, the dead portion is separated or sloughed from the living. If, however, the vital power in the surrounding parts is but feeble, and the separating process takes place but slowly, decomposition will, to an extent, ensue, while the dead portion remains attached to the living. For convenience's sake, degrees of mortification have been ex- pressed by different terms. When the death of the part seems en- tire, when the color is a dark bronze or almost black, and when sensible decay is going forward, the mortification is called sphace- lus. On the other hand, when vitality seems gradually to depart, when the color is only livid or a greenish yellow, and when decay is not yet sensible, the mortification is called gangrene. These terms, however, are not always used with precision. When the vital energies have been sufficient to cause a slough- ing of the mortified part, immediately the granulating process will appear, attended with suppuration. Sometimes, when a part is gangrenous, and even when its mortification seems almost entire, it will be, in a measure, supplied with warmth and moisture from the healthy adjoining tissue, it will exhale an offensive odor, and, if it be upon the surface of the body, the cuticle will run in blis- ters. At other times, the mortified portion becomes dark-colored, dry, arid horny, but does not rapidly putrify. It is then called dry mortification or dry gangrene. When the mortification is internal, as the matter becomes putrid, it is liable, by being pent up, to affect the living body and produce constitutional symptoms. If, however, the constitution be vigor- ous, and the reparative process be well established, the living parts will be more or less protected from the infectious influence of the 8 58 THORACIC DISEASES. dead matter; but, in persons of feeble constitution, whose blood is deficient in plastic power, the infection will be felt, and typhoid or putrid symptoms will appear. And, in general, it may be said, that no living parts, however great their activity, can long resist the pernicious influence of dead matter in connexion with them, without experiencing a poisoning or injurious effect. CHAPTER X. LYMPHATIC SWELLINGS. Besides the enlargements produced by inflammation and serous effusion, there are forms of swelling which arise from an accumu- lation of lymph in the part. The lymph is detained in the lym- phatic vessels, and over-distends them. Of course, the part is enlarged. Such an enlargement, when it exists simply, may be called lymphatic congestion. In some cases of ague, nervous swelling, &c., the enlargement is little more than congestion of the lym- phatic vessels. When, for instance, the face suddenly swells, in consequence of diseased teeth and a disordered condition of the nerves connected with those teeth, the effect is evidently lym- phatic congestion. So, too, when the abdomen suddenly puffs up, by means of disordered uterine action, the puffiness is imme- diately caused by lymph detained in the lymphatic vessels. The nerves connected with this set of vessels, become weakened in their power, and the lymph does not pass with its normal rapidity ; it accumulates in the part affected. Such, at least, is my view of this matter. There are, however, modifications of this condition. Not un- frequently, lymph is detained in the glands, until it becomes hard- ened and assumes a pasty appearance. Inflammation is set up in and around the glands, and so the enlargement is compound in its character. It arises partly from lymphatic congestion, and partly from inflammation. Scrofulous enlargements of glands about the neck, in the axilla, in the groin, and in other localities, are instances of this compound character of disease. So, also, TUBERCLES. 59 are those scrofulous swellings which, at length, take on the char- acter of abscesses. Here, too, I confidently rank the case of phlegmasia dolens. The swelling is mainly owing to the lym- phatic congestion, while phlebitis and perhaps inflammation of different tissues, to some extent, attend the lymphatic disturbance. CHAPTER XL TUBERCLES. According to Dr. Wm. B. Carpenter, tubercle is a degenerated form of the exudation corpuscle. It is unpossessed of organiza- tion, and exists, like a foreign body, in the tissues in which it is deposited. It consists of albumen, with a greater or less admix- ture of fibrine. It generally exhibits no other trace of structure, than a congeries of minute albuminous granules, mingled with shapeless flakes or filaments ; but cy toblasts and cells may be oc- casionally detected in it, especially when it is recently formed. Dr. Carpenter, also, supposes, that tuberculous matter is deposi- ted in persons of a scrofulous habit, in the same manner as what he calls organizable lymph is deposited in persons of sounder con- stitutions ; or, as I should say, in the same manner as granula- tions or exudation membranes are formed. He, also, further says, that " the difference between a deposit of tubercle and the effusion (I should say secretion] of plastic lymph consists in this, that the former is composed of the albuminous constituent of the blood, a mere chemical compound, which is riot prepared to un- dergo organization until it has passed through the condition of fibrine, whilst the latter is a portion of the vitalized fibrine, which possesses within itself the tendency to organization and only re- quires the contact of a living membrane to enable it to pass into a regular structure." He, however, admits "that tubercular mat- ter may be deposited by a perversion of the ordinary process of nutrition, without anything like an inflammatory state." "Unor- ganizable albumen " takes the place " of organized fibrine." That these views of Dr. Carpenter are not very remote from the truth, is sufficiently clear, in the present light of pathological 60 THORACIC DISEASES. science ; and yet, to my own mind, it is equally clear, that a crude and peculiar organization characterizes tubercle. It is something more than a mere chemical compound. It is a somewhat vital- ized, though a cacoplastic deposit. It is " the result," says Dr. C. J. B. WilliaTis, "of modified textual nutrition. The cell-germs, by which the material of textures is renewed, are imperfect at par- ticular points; a granular or amorphous matter is deposited from the plasma, and concretes without fibres or regular cells' being de- veloped. At this point a granulation appears, and gradually hard- ens. When a granule has once been formed, it becomes a nucleus for the concretion of more ; a new habit or mode of nourishment is established at the spot; or, to speak less figuratively, cacoplas- tic matter (if present in the blood plasma) concretes around it by a process similar to that by which fat attracts fat, or bone osseous matter. Perhaps the process is not wholly unlike that of crystal- ization. But, however it happens, the result is, that the granular tubercle grows, and may attain the size of a millet-seed, hemp seed, or even a small cherry stone; or, being subjected to press- ure, may slightly spread or flatten into various shapes. "The microscopic character of these miliary or granular tuber- cles is the complete predominence of minute and often irregular granules, and the comparative absence of fibres and cells, of which mere traces are seen, at least in the older specimens. The gran- ules are aggregated together by an amorphous material, the solidi- ty of which gives hardness and some transparency to the mass. The chemical nature of granular tubercle is albuminous, with some gelatine, and a little fat, the latter in very minute proportion, and occupying the centre of some granules, and the gelatine being, probably, the amorphous cement just noticed. In all these characters, we find a close analogy to the granular degeneration of textures, of which, doubtless, these deposits are a kind of exaggeration. " Tubercles rarely grow much or last long, without exhibiting another change in their appearance. They lose their semi-trans- parency, and become of an opaque or dead pale yellow hue, like the color of raw potato or parsnip. This is the transformation to crude yellow tubercle, first described by Laennec. This change is the result of a further degradation or degeneration of the de- TUBERCLES. 61 posit. The few fibres and cells which are to be detected in gray tubercle become indistinct, the interstitial hyaline or amorphous solid diminishes, and oil globules appear in its stead, and the mass becomes less coherent and more granular, . and therefore quite aplastic. Generally, the change begins in the centre of the mass ; apparently because, being devoid of vessels, the centre is further removed from the vivifying influence of the blood. "But tubercle is frequently deposited at first in this yellow opaque state, this circumstance being a mark of the still more degraded condition of the nutritive function; and the more ex- tensive forms of tuberculous disease commonly abound in this aplastic matter. Thus, in rapid phthisis, yellow tubercle com- monly forms a large portion of the deposit. Yellow tubercle is rarely so hard or so tough as the gray or semi-transparent kind and, in the cases of rapid deposit, just mentioned, it is often much softer and more friable. Now, this is the commencement of a change to which the lowest forms of tubercle tend, that of ma- O * turation and softening into a cheesy substance." In the softening of tubercle, "the deposit becomes less dense, and loses the little trace of structure which it possessed. It degenerates into an amorphous granular mass; and, being lifeless, it is no longer nour- ished. Its granules lose their cohesion and become disintegrated by the chemical action of the adjoining fluids. Mr. Gulliver and others have observed a remarkable increase of fat globules in soft- ened tubercle. In fact, from the time that tubercle assumes the opaque form, these oil globules appear to increase, until it either is softened and eliminated, or undergoes a kind of " petrifactive change," a chemical and mineral transformation. But the microscopic character of tuberculous deposits is that by which they are specially discriminated. This character is admira- bly described by Lebert who, at present, "is the highest authority in France on this subject, and is, perhaps unsurpassed, by any microscopist now in existence, in microscopic pathology." I add a portion of what he says on this subject, in the translation of Dr. John A. Swett of New York. " The constant elements of tubercle are : " 1st. A great number of molecular granules, perfectly round, of a grayish-white color, or with a slight yellow tint, sometimes 62 THORACIC DISEASES. compact, sometimes transparent in their centres, with a diameter of -0012 to -0025 of a millimetre. These granules completely sur- round the tubercle globule, so that it is often difficult to recognize it in the crude yellow tubercle. They are seen in much greater numbers, and quite disaggregated, in the softened tubercle. "2d. These granules, as also the tubercle globule, are united with each other by an intergranular, interglobular, hyaline sub- stance, of considerable consistence, which serves as a cement to the elements of tubercle, and which becomes liquefied by soft- ening. " 3d. If the two elements which I have just described possess no peculiarities which belong to tubercle, and which do not dis- tinguish it from other morbid products, there is a third element which is much more important, which, in fact, is entirely charac- teristic of, and peculiar to tubercle the tubercle globule, or cell. " The form of the tubercle globules is seldom perfectly round, although it is probable, that, at the time of their excretion by the capillaries, they do assume a form more or less spherical, and that they afterwards assume a less regular shape, often becoming an- gular, on account of their close juxtaposition. Thus, as they commonly appear under the microscope, especially in the crude tubercle, their outline is irregular, approaching sometimes to the sphere, sometimes to an oval ; but generally they are irregularly angular and many-sided, with the angles and the edges rounded, as is very evident when they are suspended in water or in serum. Their color is a clear yellow, assuming a blackish tint when a high magnifying power is employed. Their interior is irregular and of unequal consistence, which gives them a spotted appear- ance, independently of the granules which they may contain. But I have never been able to detect a true nucleus in these glob- ules, although they sometimes present in their interior the appear- ance of an irregular vacuum, which resembles a nucleus. I have always examined this point with great attention, using the highest and the best denning magnifying powers, as well as different chemi- cal re-agents. We cannot consider the granules, which are irregu- larly distributed in the substance of the tubercle globule, as nuclei. These are only molecular granules, whose diameters seldom reach, and never exceed, -0025 of a millimetre ; often, indeed, they are TUBERCLES. 63 not more than -0012 to -0015 of a millimetre. These granules, variable in number from 3, 5, to 10, or more, are not regularly distributed, and are not all visible in the same focus. The inter- granular substance of the globules surrounds them, so that they are not ordinarily encompassed by a transparent areola. The in- terior of these granules appears opaque. " The diameter of the tubercle globule varies. In the rounded globules, it ranges between '005 and -0075 of a millimetre, rare- ly extending to -01 of a millimetre. The oval globules, as a mean, are -0075 of a millimetre in length, and -005 to -006 of a millimetre in breadth. The diameter of the tubercle globule in- creases at the commencement of the period of softening. " The diameter of the tubercle globule varies within certain limits ; but this variation is independent of age and of the tissue or organ in which the deposit has formed. It is more easily rec- ognized in the yellow crude tubercle, than in the gray miliary granulation. In the recent tubercle, the tubercle globule is de- tected with difficulty, because it is concealed by the interglobular hyaline membrane which unites the globules, and by a large number of molecular granules which surround them. "It is important, therefore, in commencing the study of the tubercle globule, to select for examination a yellow cheesy tuber- cle, not too hard nor too soft, to disaggregate it with needles, in a drop of water, which can, however, never be done completely; and this difficulty is one of the most striking characteristics of the tuberculous deposit. It is well, after this has been done, to let the preparation dry a little between the plates of glass, in order that as many globules as possible may be seen at the same focus. The distinctness of the view may be increased by a fine dia- phragm and by a good light. A lamp is, however, not as favora- ble for the examination of tubercle as the daylight ; and, if the lamp is employed, care must be taken that the light is not too strong. We having thus become familiar with all the details of the tubercle globule, it will be easily recognized whenever it is pres- ent. By this method, then, the tuberculous deposit can be readi- ly distinguished from all other morbid products, a result \vhich, in doubtful cases, no other mode of examination is capable of producing. 64 THORACIC DISEASES, Water does not change the tubercle globule. Acetic acid ren- ders it more transparent without changing it much, and establishes the absence of nuclei in its interior. It is a very valuable mode of distinguishing the tubercle globule from other globules resem- bling it, except that they contain one or more nuclei. Acetic acid is especially useful in distinguishing the tubercle globule from the pus globule. Ether and alcohol react very slightly upon the tu- bercle globule. Strong ammonia renders it, at first, more trans- parent; it then dissolves the intergranular substance, and allows the molecular granules contained in it to become separated. A concentrated solution of caustic potassa completely dissolves the tubercle globule. The concentrated acids, especially the hydro- chloric and the sulphuric acids, also dissolve it, but more slowly. "What is the position which the tubercle globule is entitled to occupy among the pathological cells? If it be true, that a perfect cell is composed of an investing membrane, and of one or two nuclei, and of nucleoli in the interior of these nuclei ; yet I am convinced, from many observations of pathological cells, as well as of those found in healthy organs, that this mode of cell-forma- tion is by no means universal, and only peculiar to a certain num- ber of elementary globules. The tubercle globule appears to me to be one of the most simple forms of pathological cells, being composed of an enveloping membrane, containing a semi-liquid substance and a certain number of molecular granules irregularly scattered through it, as in the pyoid globule. This pyoid globule, however (, which is a variety of the development of the pus glob- ule), differs from the tubercle globule in being more regularly spherical, more pale, more transparent, and by containing granules which are transparent in their centres, and seated in the periphery of the pyoid globule. 'I will now pass to the study of the softened tubercle, limiting myself, for the present, to indicating the physical changes in the softened tubercle as revealed by the microscope, and reserving the physiological explanation for another place. In order to appreci- ate properly the changes which take place during the softening of -the tuberculous matter, the use of the microscope is indispen- sable, for the reason, that the parts surrounding the tubercles often inflame and secrete pus, and then the elements of suppuration are TUBERCLES. 65 mixed with those of tubercle. As the naked eye cannot discover all these details, much confusion would exist without the aid of the microscope. "I may say, in general terms, that the principal change that occurs in the tubercle, while softening, consists in the liquefaction of the interglobular hyaline substance, which is sufficiently solid and consistent in the crude tubercle to hold the tubercle globules in close union. But, in the softened tubercle, they become disag- gregated, separated, although clustered groups may still be discov- ered. As the globules become free, they become more rounded, almost spherical; they become, at the same time, more transpa- rent and more thin, and the blastema which surrounds them be- comes more granular. " Both by the naked eye and by the microscope, pus is fre- quently found united with softened tubercle. It would appear that the presence of pus hastens the decomposition of the tuber- cle globule, and this is one reason why the matter contained in tuberculous ulcers is so often without tubercle globules. "Finally, it may be stated, that the tubercle globule disappears in a nearly perfect dissolution, after having been disaggregated into granules. These globules, then, undergo three phases of development. They are at first closely packed together, and compact in their interior. Then they separate from each other and increase in size, which, instead of being owing to a more perfect development, is, in fact, the commencement of decompo- sition, and is owing to an endosmosis of the surrounding blastema, which becomes more and more liquid. At last, these little glob- ules, whose internal and molecular cohesion has already been dis- turbed, finally, by running together, form a yellow and a more or less liquid mass. "There is some analogy in the mode in which the pus globule and the tubercle globule disappear. The former is disintegrated into granules before it can be absorbed. " If the crude tubercle and the softened tubercle constitute the first two stages of this deposit, and the diffluence of the elements of tubercle the third stage of its evolution, there is still a fourth stage, its passage into a cretaceous state. I can confirm the opinion that this cretaceous transformation of tubercle is one of 9 66 THORACIC DISEASES. the most powerful means which nature employs to cure the tu- berculous disease. Its microscopic composition is altogether in favor of this view of the question. At the commencement of this change, we can still recognize a considerable number of tu- bercle globules, arid with them a kind of mineral dust formed of very fine granules, whose diameters are from -001 to -0015 of a millimetre, transparent in the centre, looking black under a high magnifying power, but under low power, as well as by the naked eye, having a yellowish-white tint, and being more resis- tant to compression than the soft elements of ordinary tubercle. These latter elements diminish in proportion as the granular, amorphous, mineral elements increase. They become more solid and dry, as the portions capable of dissolution are absorbed. The cretaceous tubercle often contains much black pigment, and many times I have met with a considerable number of crystals of chol- esterine. "Having described the elements which are essential to tubercle, I will next examine other elements which are not essential, but yet are of frequent occurrence. " The pigment infiltration, or melanosis, which is also met with in many other morbid products, appears in three different forms. 1st. As a granular infiltration. 2d. As the contents of certain globules, having a diameter from -016 to -024 of a millimetre, and sometimes reaching -033 of a millimetre. 3d. As fine granules contained in certain normal, or pathological cells. Thus it is fre- quently contained in epithelial cells, and expectorated in abundance. ' This pigment is also found surrounding pulmonary tubercles, as the gray granulation, the cretaceous tubercle, and tuberculous excavations. It is also often found in abundance in the bronchial glands. It is sometimes noticed in the mucous membrane of the intestine, and especially around tubercles of the peritoneum. It is a carbonaceous substance. ' Fat, in the form of fat vesicles, is frequently found in tubercles. 11 It is not uncommon to find fibres in tubercle, but they very rarely belong to the tuberculous secretion. Generally, they are fibres of the tissue of the organ in which tubercle is secreted. Thus, the gray, semi-transparent tubercle in the lungs, often con- tains the elastic fibres of the cellular tissue of the lungs. TUBKRCLF.S. 6? ' In certain rare cases, crystals exist in tubercle. Once I met with three-sided prisms in tuberculous matter from the lungs; another time, in the bronchial glands; and, in a third case, rhoni- boidal plates of cholesterine in softened tubercle in the neck, which was not cretaceous. " Another element not unfrequently met with, and which might easily lead to mistakes, are young epithelial cells, derived from the capillary bronchi, when the lung is cut, having a diameter of 0125 to -015 of a millimetre. These are of an irregularly round- ed shape, containing a nucleus with a diameter of -005 of a millimetre, which sometimes contains a nucleolus, or a finely granulated matter. These cells are found in considerable number around agglomerated masses of tubercle globules, but never in the midst of them, so long as they are united by the intercellular hy- aline substance. By the side of these round or oval young epith- elial cells, are found the cylindric epithelial scales, with or with- out vibratile cilia, which could not easily be mistaken for tu- bercle globules. " In conclusion, we find, as the constant and essential elements of tubercle, granules, and an interglobular hyaline substance, and globules peculiar to tubercle. After its excretion, the tubercle first assumes a compact form, then it softens, and at a still later period it dissolves; or it withers and becomes cretaceous. The elements which are not constant, but which are found more or less frequently in tubercle, are melanosis or black pigment, which is the most common, fat, fibres, globules of a decided color, and finally crystals, commonly those of cholesterine. "As elements accidentally mixed with tubercles, we often find under the microscope different products of inflammation, of exu- dation, of suppuration, and of the epithelial secretion, globules of different kinds, which come from the tissues surrounding the tu- bercle, but which are never met with in the midst of its elements. <: In the gray semi-transparent granulation of the lungs, we al- ways find a mixture of areolar fibres with a grayish hyaline sub- stance and with tubercle globules. The fibres are composed of the elastic fibres of the pulmonary cellular tissue. The gray tint of the granulation is sometimes heightened by the admixture of the black pigment. 68 THORACIC DISEASES. " The yellow opaque tubercle is identically the same as the gray semi-transparent tubercle, only, in the latter, the tubercle globules are smaller, and more closely packed in the substance xvhich surrounds them. The yellowish aspect is produced by the confluence and increased size and abundance of the tubercle globules after the destruction of the surrounding fibres which tended to separate them, and at the same time the hyaline mem- brane becomes more opaque and granular. " The gray, semi-transparent granulation is not the constant or the necessary commencement of the tuberculous deposit. It may occur originally as the yellow opaque granulation. Very small yellowish points make their appearance, in which the microscope discovers a few fibres, much less numerous than in the gray gran- ulation. Their principal element is the tubercle globule, and the interglobular hyaline membrane is granular, and with very little transparency. " The liquid which covers the internal aspect of tuberculous excavations contains, sometimes, tubercle globules in their perfect form ; but generally they are more or less distended by the soften- ing that has taken place, and most of them are in a state of dif- fluence. It also contains pus globules, the large granular globules of inflammation, a viscid mucous fluid, blood globules, pulmonary fibres, black pigment, epithelial scales, three-sided prisms, and fat vesicles. " Under this liquid layer, composed of so many elements, are false membranes, composed of a fibrous stratified substance, and containing numerous pus globules. " Beneath this layer of fibrine is the true lining membrane of the excavation it is organized and vascular. Its structure is ir- regularly fibrous, and among the fibres are numerous small globules. Sometimes it contains but very few blood-vessels, and then the fibrous tissue is dense, white, and very abundant, appearing like cartilage. But I have never found in it the slightest traces of the elements of cartilage. " The microscopic examination of the expectoration in tuber- culous phthisis discloses the following facts : The matter contains, in the first place, substances which are not at all specific, as sali- va mixed with mucus and epithelial scales from the mouth, which CARCINOMA. 69 latter are sometimes quite abundant; epithelial scales from the bronchi, mucus, vibriones, blood globules, crystals, black pigment, globules of fat, granular globules, and pus globules. " Besides these, are noticed small masses or little pellicles, which at first sight might be mistaken for tuberculous matter. The mi- croscope, however, only discloses globules of pus and a granular coagulation. These are probably false membranes coming from tuberculous cavities. Again, we notice masses like the preceding in appearance, in which the microscope only discloses numerous molecular granules, which are probably produced by diffluent tu- berculous matter. Again, there are noticed amorphous mineral granules, which, perhaps, come from cretaceous tubercles. And, finally, we may meet with the true tubercle globule. But this is very rare. I am not sure, that I have ever met with it so dis- tinctly that its existence was not doubtful. Sometimes pulmonary fibres are found in the expectoration. There is, then, nothing spe- cific in the tuberculous expectoration." CHAPTER XII. CARCINOMA. Carcinoma, from the Greek xapxivo?, a crab, and synonymous with cancer, indicates a disease which has generally been consid- ered to exist in three distinct forms. These forms are originally such, and not merely different stages of the disease; and they arise mainly from the different proportions and arrangements of the elements entering into the composition of the deposit. " These elements," Dr. Svvett has well remarked, "area fibrous tissue, and a viscid fluid, contained in cells and called the cancerous juice. " If the fibrous tissue predominates, you will find the mass hard and creaking, when divided by the knife. You will notice that its cut surface is intersected by white lines, or by larger mas- ses of a dense white structure. In the midst of these lines you will discover a finely granulated substance, contained in cells, which is the cancerous juice, and which may be pressed out by the finger or scraped off 'by the scalpel, when it often very much THORACIC DISEASES. resembles apple-juice, in appearance. This form of cancer is known as scirrhns. '' When the fibrous element is less distinct, and the cancerous juice more abundant, the cancerous mass is much softer in texture. It is often more distinctly granular; and, from its resemblance, in many cases, to the substance of the brain, it has been called en- cep haloid. " Finally, the fibrous tissue may be still more deficient, or even entirely absent, and a jelly-like mass, sometimes semi-fluid or even fluid, and collected in cells, often of considerable size and united with cancer cells, may exist, constituting what has been called the colloid or gelatinous cancer." But, in addition to this three-fold division of cancerous depos- its, there are minor differences, which arise from accidental causes. One of these respects the color. Commonly, the cancerous juice is semi-transparent and of a yellowish- white color. Its ap- pearance has well been compared to that of apple-juice. Some- times, however, the mixture of fatty matter gives it a greater yel- lowness; and then a mass, of the proper consistence, bears the re- semblance of a tuberculous deposit ; or, if it be more fluid in form, it very much resembles pus. Sometimes, too, the juice is of a milky-white color, and gives to the fibrous deposit an aspect al- most white. Often the fibrous deposit is of a rosy-red appearance ; or portions of it may take on a dark, and almost black or melan- otic appearance. The cancerous mass, also, varies much in form and general character. Sometimes, it is exceedingly vascular, and the vessels are easily ruptured. Often, it is loose and spongy in texture like the lungs. Again, its fibrous structure is close and unyielding. Sometimes, there is a large undivided mass; sometimes, minute particles are deposited in clusters; and, sometimes, there is an un- defined infiltration into the tissues involved. Generally, the deposit is at first of pretty firm consistence. In process of time, it softens and discharges a fluid. It is then called a cancerous ulcer. The terms fungus hasmatodes, rose cancer, &c., are very commonly employed to designate some of the ap- pearances now described. Chemically considered, the most abundant element in the com- CARCINOMA. 71 position of cancer is albumen. "It, also, contains," says Dr. Svvett, "some fatty matter, and some fibrine, with inorganic salts, as the sub-phosphate of lime, the carbonates of lime, soda, and magnesia, the hydrochlorates of soda and of potassa, the tartrate of soda, and the oxide of iron."' It is only microscopically, however, that cancer, as such, can be recognized with certainty. The elementary cancer cells or glob- ules differ from all other cells, whether concerned with healthy or with diseased structures. The cancer cells are not, indeed, found alone, but they are mixed with other forms of matter; and these accidental ingredients assist in varying the visual appearance of the mass, as a whole. It is now admitted, that inflammatory indurations, non-malignant fibrous tumors, &c., when the eye is the only test employed, are liable to be mistaken for true carcino- ma. Hence the importance of a means of diagnosis on which re- liance may be unerringly placed. This means is found in micro- scopy. In illustration of the microscopical character of cancer, I quote from Lebert's work on Pathological Anatomy, as translated by Dr. S \vett. "Authors of much merit have denied that the microscopic ele- ments of cancer were characteristic. I have arrived at an oppo- site conclusion, and I maintain that the cancer globule has strik- ing characteristics which distinguish it from every other form of morbid product. It must not be forgotten, that there are certain general forms of cells and of nuclei, the types of which are met with in very different products. Cut this I maintain, that the different pathological products which are composed of elementary globules, individually present certain characteristics by which they can be distinguished by those somewhat accustomed to the use of the microscope. I will go even further, and state that the cancer globule is one of the cells which possess the most striking char- acteristic features to distinguish it from every other kind of cell. It is important, however, to add, that the cancer globule is sub- ject to very many variations; but I hope, by pointing out these varieties carefully, and at the same time by explaining the sources of mistake, and the difficulties in the diagnosis, to place before the reader their peculiar characteristics. 72 THORACIC DISEASES. "Not only the globules of cancer, but even their nuclei, are larger than the entire tubercle globule. The globules of scirrhus have a diameter of -0175 to -02 of a millimetre, and sometimes of '025 of a millimetre. Their outline is regular, their appear- ance pale, and their surface is finely dotted with minute granules, which are situated between the investing membrane and the nu- cleus. This nucleus is commonly single, but sometimes double, and with a strongly marked outline, round or oval, and with a diameter of from -0125 to -015 of a millimetre. These nuclei are often found freed from their investing membrane. When this is the case, and a large number of these free nuclei are clustered together, they resemble somewhat tubercle globules ; but the dif- ferences in the diameters, in the outline, in the central substance, and in the existence of a certain number of perfect cancerous globules, will remove any doubt that may exist. " The globules of encephaloid, which are very much like those of scirrhus ; or rather the nucleus of the true encephaloid glob- ule for authors have generally mistaken the nucleus for the per- fect globule has a diameter from -01 to -015 of a millimetre. Its shape is a very regular sphere, or oval, with a marked outline finely shaded all around its internal circumference, containing, be- sides a fine granular matter, one, two, rarely three round nucleoli, with diameters of from -0025 to -0033 of a millimetre, and trans- parent at the centre. A fact which establishes the diagnosis still more clearly is. that, when the globules are perfectly formed, they are surrounded by an investing membrane, which is often irregu- lar in shape. The whole globule thus represented has a diameter of -015 to -02 of a millimetre, and sometimes even of -035 of a millimetre, and possesses characteristics peculiar to itself. "The cancer globule is composed of an enveloping membrane, and a nucleus which contains nucleoli. The diameter of the external cell varies in different cases. Its mean diameter is -02 of a millimetre. Sometimes it is only -015 of a millimetre. Yery often it is much greater, extending to -03 of a millimetre, or even beyond that point. Its shape is round or ovoid round more frequently in the globule of encephaloid, a little elongat- ed in the globule of scirrhus. In many cases it is easy to trace the progress of one of these forms, as it passes into the other CARCINOMA. 73 form. Very frequently this external enveloping membrane as- sumes many different forms. It is generally more flattened than the nucleus. Sometimes it is pale, and perfectly transparent. At other times it is covered by fine dots; and quite frequently it is so filled with granules that it exactly resembles the large granular globules of inflammation. It is also not uncommon to meet with both regular arid irregular globules, which contain a certain number of nuclei ; and we may discover large parent cells, with a diameter reaching even to -05 of a millimetre, of a rounded or oval shape, which contain four, five, six, or even a greater num- ber of nuclei. At other times we meet with large membranous expansions, in which we can distinguish a considerable number of nuclei, surrounded by a granular and dotted mass. " The nuclei vary in their diameters from -0075 to -02 of a mil- limetre. The smaller are found chiefly in the perfect globules of scirrhus. The large round or elliptical nuclei, with diameters ex- tending from -015 to -02 of a millimetre, are principally found in the encephaloid cancer. In some forms of cancer these nuclei constitute so decidedly the predominating element under the mi- croscope, that we might be tempted to assume that they were the type of the cancer globule, did we not observe these same glob- ules in their more perfect form, that is, with their enveloping mem- brane, in other cases of cancer. These nuclei are sometimes very pale. At other times, and this is especially the case in scirrhus, their outline is very distinct. In many cases of encephaloid they present a characteristic shading at their whole circumference. In a certain number of cases the enveloping membrane of the cancer globule is elongated, pointed at each end, and even at several points of its circumference. It then bears some resemblance to the fusiform fibro-plastic bodies. It can always, however, be readily distinguished from these bodies by its much greater size, by being much less elongated, and by its characteristic nuclei and rmcleoli. "If the nuclei and nucleoli of the cancer globule always pos- sessed the distinct form which I have just described, nothing could be more easy than to detect them by a microscopic examination. Bat, as it generally happens that cancer is mixed with much fatty matter, the nuclei are found to undergo different changes on this 10 74 THOHACIC DISEASES. account. Thus we often find them filled with granules and small grumous masses. Sometimes, indeed, they are infiltrated with a homogeneous and confluent fatty matter. " The nucleoli have a diameter which varies from -0025 to '0033 of a millimetre, and even to -01 of a millimetre. Their number is from one to five. But, as the nuclei which contain them are somewhat thick and spherical, we cannot recognize them all under the microscope at the same focal distance. These nu- cleoli have a peculiar character. Their outline is distinct, but their interior is seldom transparent ordinarily it is dull and hom- ogeneous. I was for a long time in doubt what these nucleoli were; but I have recently discovered that they are imperfectly developed nuclei. In examining some large nucleoli under a mag- nifying power of 1000 diameters, I saw that they contained two or three secondary nucleoli. "It is not uncommon to meet, in cancer, with large concentric cells with a diameter from -04 to -05 of a millimetre, and with thick walls inclosing many concentric globules. " The cancer globule appears to me to be formed in this way : The capillaries excrete the cancerous matter in a liquid state. In this liquid, nuclei form, and soon after nucleoli. Possibly the nu- cleoli may form first. Around the nucleus, molecules of the liquid blastema first excreted arrange themselves, so as to form irregular enveloping shreds, or regular rounded or oval globules. It may possibly be the case that these concentric globules are only ordina- ry cancer globules, all the portions of which are remarkably devel- oped. I have also seen the cancer globules assume the appearance of clustering when they were filled with granules of fat, and when the nuclei also were deformed by the infiltration of fatty matter. ''It is not reasonable to suppose that the cancer globules, which are first secreted, continue to exist for a long time. After a time they become deformed, they lose their distinct outline, and are fi- nally dissolved into granules. At the same time, the excreted blastema which is constantly being poured out by the vessels, forms new cells. Thus, a certain number of the cancer globules appear incompletely developed, others are well developed, and a certain number are undergoing decomposition. " The cancer globule of scirrhus is ordinarily furnished with an CARCINOMA. 75 enveloping membrane, which is round, ovoid, or irregular in shape. Its mean diameter varies from -015 to -02 of a millimetre. It is finely dotted all around the nucleus. This nucleus is small, its diameter varying from -0075 to -01 of a millimetre. Its outline is very sharp, and it exhibits, in its interior, granules and little masses (grumeaux), and sometimes nucleoli. " The cancer globule of encephaloid is surrounded by an en- velope, regular or irregular in shape, having a diameter between 02 and -03 of a millimetre. The nucleus is spherical, or very often elliptical, pale, shaded at its circumference, and containing from one to three very distinct nucleoli. Generally, as already stated, the nuclei are seen under the microscope in greater num- ber than the perfect cells. Frequently every form intermediate to these two types of the cancer globule will be noticed. "Next to the cancer globule, which is the characteristic element, is the fibrous element, which is sometimes the predominating ele- ment. It presents very different appearances in different cases. In scirrhus, it is formed by a network of fibres arranged in bun- dles, which cross each other in every direction, and communicate with each other by fibres, which pass from one bundle to another. The primitive fibres, in this case, are well defined. They are del- icate, and do not exceed in breadth the -0025 of a millimetre. They are generally less tortuous than the fibres of ordinary cellu- lar tissue. In some cases these fibres interlace with each other without being arranged in bundles. In certain organs, especially in cancer of the mamma, there are numerous elastic fibres. In some exceptional cases, I have met with a fibroid network, in- closing in its meshes cancer globules and resembling exactly co- agulated fibrine. In the soft encephaloid cancer, the fibres are pale and delicate, and much less numerous than in scirrhus. Nev- ertheless, I have met with cases of medullary cancer, in which the encephaloid matter was inclosed in a dense and fasciculated fibrous stroma. " Fusiform bodies, such as are met with in other morbid prod- ucts, are very frequently seen in cancer. They are distinguished from the fusiform cancer globule by the difference in their nuclei, that of the cancer globules being much larger. " These fibres, these fusiform fibre-plastic globules are formed 76 THORACIC DISEASES. from the exuded blastema, as is also fat, pigment, and other sub- stances. " After the cancer globules, the fibres, and the fusiform bodies, the substance which is met with most frequently and abundantly in cancer, is fat. It is seldom absent, and it is sometimes so abun- dant and so mixed with the cancer globules, that they can hardly be distinguished. The fatty element occurs under the forms of granules, of free fat vesicles, fatty spots, and cholesterine. The granules are commonly found in abundance outside the cancer globules ; but very often, also, they exist in their interior, and then we can distinctly trace the change from a simple cancer globule to that which resembles exactly the large granular globules of inflam- mation. Frequently, these granules are deposited in the nuclei of encephaloid globules. But that which renders these globules not easily recognizable, is the fact that fat is frequently depos- ited in them which is confluent and homogeneous in its character. Their outline is thus altered, and it requires great attention to distinguish them. It is these globules which constitute the fatty matter which looks like tubercle, an appearance noticed especially in sarcocele. " Large granular globules analogous to those noticed as the prod- uct of inflammation, with a diameter of from -02 to -03 of a mil- limetre, are commonly noticed in cancer. I have already stated that the cancer globule when infiltrated with fat, may assume the appearance of these inflammatory globules. But I think that the true inflammatory globule is also often found in cancer. When it is examined by a low power and by direct light, it appears in groups of a dull white or yellowish aspect. With a high power, and by reflected light, it appears of a blackish-brown color. It is usually so spherical, that it can be burst by compression, and made to discharge numerous granules. These globules are found in all kinds of cancer. I have sometimes seen them existing as a general infiltration into the cancerous mass, and sometimes form- ing a network of a dull-white color, constituting the reticulated figures so well described by Muller. They can sometimes be enucleated and studied separately. " The black pigment or melanosis, both in the form of granules and of globules, is found in both scirrhus and encephaloid cancers. MELANOSIS. 77 " I have also noticed a peculiar coloring matter, of a yellowish tint, which I have named Xantliosis. It varies from a saffron to an orange tint. It appears to be a kind of fatty matter. " Crystals of cholesterine are one of the most common elements of cancer. I have also seen prismatic needles in cancerous depos- its; also, mineral concretions, amorphous or bone-like, yet with- out the structure of bone. "All the forms of cancer present the evidences of vascularity. "The colloid or jelly-like cancer is as well recognized a form of the disease as scirrhus or encephaloid. The cancerous tissue, especially the encephaloid, sometimes constitutes the base of the tumor, and then the cancer globules are only found in the deeper portions. In this case the gelatinous matter does not contain the true elements of cancer. We find a network of fibres forming large areolae, and filled by a transparent matter, containing pale granular globules. This colloid matter does not appear to be dif- ferent from that noticed as the product of inflammation, or as the contents of various kinds of benignant tumors. It only differs from it by being combined with encephaloid. But, in other cases, these areolse are filled by large cells or semi-transparent lobules, which contain numerous cancer globules and nuclei. CHAPTER XIII. MELANOSIS. The term melanosis, is derived from the Greek word fxsXa?, sig- nifying black. It is a disease in which there is the deposit of a dark unorganized substance in some portion or portions of the sys- tem. As exhibited in the solid tissues, the deposit commonly has a viscous appearance, strikingly resembling the vitreous humor of the eye, and is, in color, very much like the pigmentum nigrum. It has no smell nor taste. It is soluble in water; and, when dis- solved, will stain like Indian ink. There are, however, different shades of color, it sometimes exhibiting a brown and sometimes even a yellowish hue. Hard melanotic deposits, unlike tubercle and scirrhus, do not 78 THORACIC DISEASES. soften down at any stage of their existence. Sometimes, from the part where the deposit exists, a dark-colored fungus will arise, resembling fungus haematodes, and probably being of essentially the same nature. On the other hand, where carcinoma previously exists, especially the encephaloid variety, a melanotic deposit not unfrequently takes place. Sometimes absorbent glands, en- larged as in scrofulous disease, become blackened by a deposition of melanotic matter. In such cases, of course, the substance of the tumor is mainly organized structure, the melanosis doing lit- tle more than give the coloring. Sometimes, as is the case with scirrhus, we have melanotic tu- bera. occurring as a secondary form of the disease, and appearing simultaneously in various parts of the system. Indeed, scarcely any organ or tissue is exempt from liability to be affected by it. The lungs, the pleura, the heart, the pericardium, the liver, the spleen, the uterus, the ovaria, the bladder, the peritoneum, the ali- mentary canal, the areolar and mucous tissues generally, the muscles, the skin, and even the bones are subject to the affection. So, also, are false membranes, or the depositions of organized lymph, which take place upon previously inflamed serous membranes. Occasionally, melanotic matter appears in a fluid form. In this case, a cyst is filled with a dark liquid, which, in its general fea- tures, precisely resembles the solid deposits. It seems, however, to be originally fluid, and not the result of a converted solid. That, in this disease, the blood itself is impregnated with par- ticles of melanotic matter, which really give rise to the formations in the solid tissues, is evident ; and, not unfrequently, it is easy to detect these particles, by a chemical analysis. The discovery of melanosis, as a disease, is claimed by Dupuy- tren. It was, however, first described by Laennec. He repre- sented it as existing under the following four forms. 1st, Masses enclosed in cysts. 2d, Masses without cysts. 3d, Infiltration of the tissue of organs. 4th, Deposition on the surface of organs. This division, it is clear, presents the leading distinctive features of the disease. Dr. Carswell, however, has suggested another ar- rangement more comprehensive and various, as follows. MELANOSIS. 79 Origin, A modification of secretion. Locality. 1st, Tissues, systems, arid organs ; a, In the substance and on the surface of organs, b, In the cavities of hollow organs.. 2d, New formations. Form, 1st, Punctiform, 2d, Tuberiform, 3d, Stratiform, 4th, Liquiform. Seat, 1st, Molecular structure of organs, 2d, The blood. As there are other morbid states of the system and products presenting distinctive characters, similar to those of melanosis, Dr. Carswell has also given us a tabular view of what he calls spuri- ous melanosis, in distinction from the true. The following is his arrangement. Origin, A, Introduction of carbonaceous matter, B, Action of chemical agents, C, Stagnation of the blood. Locality, Of the first kind, the lungs. Of the second kind, the digestive organs, the surface of serous and mucous membranes, the cavities of hollow organs, new formations. Form, Of the first kind, uniform. Of the second kind, 1st, punctiform, 2d, ramiform, 3d, stratiform, 4th, liquiform. Of the third kind, 1st, punctiform, 2d, ramiform. Seat, 1st, The blood, contained in its proper vessels, or effused, 2d, Pulmonary tissue, cellular, and membranous.* Persons, suffering this affection, sometimes discharge a dark and almost black secretion from the intestines,- the stomach, and even the cystis. Under these circumstances, the old authors termed the disease melocna the black disease. The morbid secretions, in all these cases, are evidently melanotic; and, aside from the natural secretions with which they are mixed, are scentless and tasteless. See Cyclopedia of Practical Medicine, Volume 2d, Page 86th. 80 THORACIC DISEASES. The pathology of this disease is not yet, it is true, fully under- stood. The melanotic discharge, however, so far as it has been analyzed, is found to contain the important elements of the blood, fibrine, albumen, &c.; but, in addition, nearly one third of the quantity is a highly carbonized and abnormal substance. That the disease is one producing general and decided debility will readily be inferred from the few hints given above, respect- ing its pathology. The depraved condition of the blood, of course, renders it, at best, an inadequate stimulant to the nervous system; but, especially, when the alvine and other discharges are melanotic, the nutrient and stimulating portions of the blood are abnormally removed, in such quantities, as greatly to exhaust the vital powers. In conclusion, I will only add, that various new formations, such as tubercle, carcinoma, and melanosis, may exist simultane- ously in the body and in the same organ ; yet each is as distinct in its nature, as are the influences by which one organ is atrophied another hypertrophied, one indurated another softened, at the same time. CHAPTER XIV. NON-MALIGNANT TUMORS. Tumors in general differ from hypertrophy and euplastic de- posits in the peculiarity of their structure, or their kind of vitali- ty. They differ from cacoplastic and aplastic deposits in their possessing a higher degree of organization, that is, their degree of vitality. They are new structures; though some of them, in general characters, and most of them, in elementary composition, have a resemblance to healthy textures. Tumors may be divided into malignant and non-malignant. The various forms of carcinoma, already generally considered, constitute essentially the class of malignant tumors. The non- malignant may be sub-divided into different classes, though it is difficult or impossible to draw a clear line of demarcation between some of these classes. NON-MALIGNANT TUMORS. 8i NON-MALIGNANT TUMORS are, in general, those growths which occur in any part of the body without tending to infect other parts, which, though arising among, yet do not invade the healthy structures, and which prove injurious only by their bulk, their position, or their obstruction of the nourishment of the body. The principal portion of them may be included in one or the other of two classes. The first of these classes is that of common encysted tumors. These tumors consist of a shut sac, containing either a liquid or a solid substance. The sac is formed so as to appear like areolar tissue condensed, or like serous or fibrous tissue. The liquid contents may be serum, blood, or pus, or a mixture of different ingredients. The solid contents may be either adipose, or fibrous, or sarcomatous, or cartilaginous matter; or they, too, may be o.f a mixed character, and may possess various kinds of structure. The solid contents, and the sacs of the tumors in the cases of both the solid and the liquid contents, are formed by altered vital properties in the cells, or primary granules, or some of the mole- cules of the textures, in some state of their progression. These molecules grow in modes more or less peculiar, and under influ- ences more or less independent of the adjoining healthy parts. The second of the two classes of non-malignant tumors referred to is that of hydatids. These, in character, approximate malig- nant tumors, in some respects. They are quite detached from healthy tissues, and are, perhaps, more peculiar, in structure and contents, than any other morbid growths. They seem to possess a vitality, in themselves and independent of the parts with which they are physically connected. That vitality, it is true, is of a low grade, but is real. They have a power of self-nutrition, manifest in the growth and structure of their walls ; a power of secretion, shown by the j^eculiarity of their limpid and colorless contents ; and a power of reproduction by gemmation, the young being developed between the layers of the parent cyst, and thrown off, either internally or externally, according to the species. Ac- cording to Professor Owen, the hydatid is "an organized being, consisting of a globular bag, which is composed of condensed albuminous matter, of a laminated texture, and containing a lim- pid colorless fluid, with a little albuminous, and a greater propor- 11 82 THORACIC DISEASES. tion of gelatinous substance." Whether, however, it is an ani- mal or a vegetable, the Professor is slow to decide. But, surely, it can scarcely be considered an animal, as it neither feels nor moves. It has no contractile power, arid is impassive under the application of stimuli. It evidently has nothing but organic or vegetable life ; and it grows in the system, as the plant grows in the earth. It is, however, a nucleated cell, from the interior of which are developed nuclei and nucleoli, the germs of young cells ; and. whether animal or vegetable, it would seem, that it must be, in its origin, an offset from healthy structure. Certain molecules, in a way not understood, must, at first, assume this abnormal form and detached life. Hydatids are found in the lungs, liver, spleen, kidneys, uterus, and even in the mammse. Their serous or protective cysts are formed much like those of common encysted tumors. Their existence supposes a state of cachexia or mal-nutrition in the sys- tem. They injure the system and destroy the health, by their bulk and position, by their compressing, displacing, and irritating some of the organs, and by the atrophy and inflammation of tex- tures which they cause. Their cysts contain laminated matter more or less opaque, which is evidently the debris of collapsed hydatids; and, with this, sometimes a quantity of yellowish, opaque, pultaceous matter, consisting of granules, imperfect cells, fat, and other substances, deposited from the surface of the sac and degenerated so as to be aplastic. Among non-malignant tumors have, also, been reckoned those which are vascular or erectile. These consist of a congeries of blood-vessels of considerable size, apparently enlarged capillaries, with more or less connecting filamentous tissue. Their structure, however, or their kind of vitality does not seem to be materially different from that of euplastic deposits. When they are supplied by large arteries, they are florid in color and pulsate, and, if them- selves large, give a bellows or rasping sound with the pulsation, like what is heard in bronchocele or goitre. When the arterial communication is not free, they exhibit the darker hue of venous blood. There are various other modifications of non-malignant tumors, the consideration of which is not necessary to my present purpose, DIAGNOSIS. SYMPTOMS. 83 DIVISION II. DIAGNOSIS. Diagnosis is originally a Greek term, Siayvugis, signifying the art of distinguishing or discerning. Medically applied, however, it imports either a discriminating acquaintance with disease, or the science which gives that acquaintance. As a science, diagnosis teaches the various methods of detect- ing existing pathological conditions. In other words, it illustrates the phenomena attendant on the different forms of disease. These phenomena may be general in their character, or special; they may be constitutional or local ; they may disclose themselves only to the patient, or they may be manifest to the senses of another. In what follows, I shall attempt an explanation of such topics as are important in understanding the nature of diseases, and yet are liable to fail of being accurately comprehended. My remarks will apply mainly to diseases of the thorax, though I shall devel- op the principles of physical diagnosis, in their application gener- ally. CHAPTER I. SYMPTOMS. The symptoms by which the knowledge of disease is gained, may be divided into rational and physical symptoms. According to this division, the rational symptoms embrace those which we learn through the medium of the patient's mind. Thus, pain or any peculiar sensation, and its locality, are made known to us by the intellectual and communicating faculties of the patient. The physical symptoms, on the contrary, reveal themselves to us, through our own physical senses. By the eye, for instance, we perceive the form and the countenance of dis- 84 THORACIC DISEASES. ease. By the ear, we take cognizance of a diseased action of the heart and lungs, as, also, of many changed conditions of the structure of those organs. By the touch, we learn the character of the pulse, the consistency of the tissues, and the position and relation of various organs. The sense of smell alone will often decide the character of a disease, as in the case of cancerous and febrile affections. Even the taste has sometimes been employed upon the excretions, to detect the existing malady. This division, though simple, is of but little practical utility ; and, hence, different classifications have been suggested. In reference to pulmonary diseases, Dr. John A. Swett of New York, adopts the following division of symptoms. "The constitutional symptoms, which are the changes pro- duced by these diseases, in the general system and in remote organs : " The rational symptoms., which are the changes produced, by a perversion of the healthy functions, or of the physiological ac- tion of the lungs : ;t And, finally, the physical signs, which are produced by phy- sical changes in the structure and condition of these organs." According to this division, the furred tongue, the excited pulse, and the hot skin produced by pneumonitis, for instance, are consti- tutional symptoms. The cough, the expectoration, and the dys- pnoea are rational symptoms ; while the dulness on percussion, the shrill bronchial sound in respiration, and the like evidences of the disease are physical signs. This distinction, we may, if we choose, apply to the indications of other diseases, as well as those of the lungs. Sometimes, symptoms have been divided into general and physical. When this division is employed, the phrase general symptoms is intended to embrace what Dr. Swett would include under the two heads of constitutional and rational. A better division is into general symptoms and special. The former class embraces phenomena which respect the constitution generally, or parts remote from the immediate seat of the disease. The latter includes the indications which arise more directly from the part affected, or what Dr. Swett would place in the two class- es of rational symptoms and physical. TOPOGRAPHICAL TERMS. 85 Sometimes, and with much propriety, a technical distinction is made between symptoms and signs. According to this distinc- tion, symptoms are the existing phenomena, as they appear to all, without revealing any condition of things as their cause. These same phenomena become signs, when they are understood to in- dicate some particular state of the system. Thus a certain crack- ling sound, proceeding from the thorax, gives, to the uninstructed man, no important information whatever. He knows not of what disease it is indicative, or whether, even, it may not accom- pany a state of health. It is, to him, a mere symptom. To the intelligent physician, however, it is something more. It speaks the existence of incipient pneumonitis, and is, therefore, called a sign of that disease. Several symptoms, existing together, may render certain the existence of a particular disease, though any one of them, by itself considered, gives but a doubtful indication. Such a collec- tion of symptoms is called a diagnostic sign. By comparing present symptoms with those which have preceded, at different times, we judge of the prospect for the future, and, thereby, make the succession a prognostic sign. A pathognomonic sign is one which attends but a single condition of things, and, there- fore, makes that condition absolutely certain. In general, however, without an accurate regard to such dis- tinctions as the above, we apply the terms, physical symptoms and physical signs, rather indiscriminately, to those indications of disease which are embraced in auscultation, percussion, and their kindred means of diagnosis. CHAPTER II. TOPOGRAPHICAL TERMS. To assist in describing the physical examination of a patient, it is convenient to have certain topographical terms, marking dif- ferent superficial portions of the thorax. For this purpose, we may divide the anterior portion into three parts, on each side of the sternum. The superior, extending 86 THORACIC DISEASES. from the summit of the lungs to the top of the third rib, is the right and the left superior third. This region, on each side, which may be called the supra-mammary, is important; and. for further convenience, may be sub-divided into the post-clavicular space, or that partially behind and partially above the clavicle ; the clavicular, corresponding to the clavicle : and the sub-clavi- cular, beneath the clavicle. The middle third, on each side, which may be called the mammary region, may be made to extend from the top of the third rib to the top of the sixth. The inferior third, on each side, will, of course, extend from the top of the sixth rib to the inferior margin of the thorax. This may be called the infra-mammary region. Sometimes, too, we give, to certain localities of the anterior portion of the thorax, other names according to anatomical relations, as the prcecordial region, the sternal region, &c. The posterior portion of the thorax may be divided into thirds, the superior extending from the top of the shoulders to a line drawn horizontally over the spine of the scapulas. This may be called the superior dorsal region. The second third may be called the middle dorsal region. It extends, from the lower mar- gin of the superior third, to another horizontal line drawn so as to touch the inferior angles of the scapulas. This may be called the inferior dorsal region. Each of these three regions may be sub-divided, by the spine of the back, into the right and the left parts of the regions severally. Here, likewise, we sometimes derive, from anatomical parts, other terms to designate particular localities ; and we speak of the scapular regions, the intra-scapu- lar, the dorsal, &c. The spaces in the axillae and above the fourth rib on each side may be called the axillary regions. The lateral spaces beneath these, extending downward to the seventh ribs, may be called the lateral regions. And, sometimes, the narrow spaces at the very tops of the shoulders, extending from the acromion processes to the neck are called the humeral regions. In like manner, for examining the abdomen (including the pelvis), we have a topography sufficiently accurate, in the follow- ing delineation. Suppose a line, drawn horizontally around the body, so as to touch the extremity of the ensiform cartilage. This THE POSITION OF THE PATIENT. 87 will define, near enough for practical purposes, the superior boun- dary of the abdomen. Suppose a second line, drawn parallel to the first and touching the lowest portion of the last false ribs. Between these two lines, we have a zone or belt across the abdo- men. Suppose, now, a third line, drawn parallel to the former two and touching the crest of each ilium. Between this and the second, we have a second zone ; and, below this, we have a third zone. Suppose, now, we raise a line, vertically, on each side of the abdomen, from the anterior spinous process of the ilium, so as to cut the horizontal lines at right angles. This will divide each zone into three regions. The middle region of the superior zone may be called the epigastric ; and those on each side the right and the left hypochondriac. The middle region of the middle zone may be called the umbilical; and those on each side the right and the left iliac. The middle region of the lowest zone may be called the hypogastric ; and those on each side the inguinal. Sometimes, terms designating particular parts of the superficies of this cavity are suggested by other anatomical con- siderations, or by the position of certain viscera within. Hence, we speak of the pubic region, the hepatic, the gastric, &c. CHAPTER III. THE POSITION OF THE PATIENT. For interpreting the constitutional and rational symptoms gen- erally no specific rules need be given ; but, to be taught correctly by physical signs, various directions must be carefully observed. Such of these as relate to the position of the patient I will now briefly point out. For succussion, the upright posture is mostly, though not al- ways, required. For palpation, both the upright and the recum- bent posture are necessary in different cases, and, sometimes, in the same case. Abdominal and pelvic examinations mainly de- mand the recumbent posture, and generally a dorsal decubitus, sometimes, however, one partly lateral. Inspection and mensura- tion usually require, each, the upright posture ; though, from the re- 88 THORACIC DISEASES. cumbent, with dorsal decubitus, some information may be gained. For percussion, the proper position of the patient varies accord- ing to the relation and circumstances of the part to be examined. In abdominal examinations, the recumbent posture is generally needed, and almost always dorsal decubitus. In thoracic exami- nations, however, the case is different. Ordinarily, the upright posture, but sometimes the recumbent, and sometimes both in connexion are required. When the upright posture is to be as- sumed, if the patient is well able to leave his bed, I choose to have him seated in a convenient chair. Let the muscles of his chest be put somewhat upon the stretch, and the skin be rather closely drawn, so as to render the parietes as tense and elastic as convenient. When the percussion is anterior, the shoulders should be thrown slightly backwards, so as to give a little tension to the pectoral muscles ; and the arms should hang easily by the sides, or the hands be laid forward upon the thighs. In posterior percussion, on the contrary, the patient should lean forward, and firmly clasp his arms in front. The dorsal and cervical vertebras thus forming a curve, the scapulas will be drawn away from the spine ? and the muscles of the back will be rendered suitably tense. To percuss either axilla, let the arms be raised, and the palms of the hands rest lightly on the top of the head. If, however, the feebleness of the patient forbids his being seated in a chair, he may sit upright in his bed ; or, if too feeble for that, he may be percussed with accuracy, while recumbent. For anterior percussion, let him lie evenly upon his back, with his head and shoulders but slightly raised, and with no such eleva- tion or depression of any portion of the body as shall vary the symmetry of his form. For posterior percussion, he may be turned upon his face and abdomen. For axillary percussion, he may lie partially on the opposite side. For auscultation, essentially the same rules are to be observed, in regard to the position of the patient, as have been given for observance in percussion. Less attention, however, needs be paid to the tension of the muscles and the skin ; as, in the suita- ble application of the ear to hear, this object will be sufficiently accomplished. When the strength of the patient does not allow SUCCUSSION. PALPATION. 89 of his assuming the erect posture, he may be ausculted, with sufficient accuracy, in bed. Let his position, when necessary, be varied from dorsal decubitus to lateral, and even abdominal and facial. When his prostration by disease is considerable, the symptoms recognized from the anterior part of the thorax will usually be found decisive; and, consequently, the dorsal decubi- tus only will be necessary. CHAPTER IV. SUCCUSSION. Of all the means of physical diagnosis, this is of the least im- portance. The term signifies a shaking; and the act consists in suddenly agitating a patient with the view of detecting the exis- tence of a fluid in some one of the cavities of the body, partic- ularly, one of the pleural sacs. Seizing, by the shoulders, an individual, as he is ordinarily seated, strongly jolt or shock his whole frame. In this way, the sound of a contained fluid may sometimes be heard, like that of a liquid in a cask or bottle that is forcibly agitated. This has been called the metalic splash. Sometimes, the patient m bed is able so to shake himself as to give the splashing sound of the water, in the thorax. Even water in the pericardium has occasionally been, by succussion, detected. The art was known to Hippocrates, and has, hence, sometimes been termed Hippocratic succussion. There is, however, but little occasion to employ this method of detecting the existence of water in a cavity, as ordinarily it is made perfectly evident by other means of diagnosis. CHAPTER V. PALPATION. The matter of palpation is of a little more practical utility than succussion. The term signifies feeling or handling ; and the act consists in the application of the hand or fingers to the part to be examined. Thus, if, while a person is speaking, the hand be ap- 12 90 THORACIC DISEASES. plied to the parieties of the thorax, a tremor will ordinarily be felt; and the character of this will vary according to the condi- tion of the viscera immediately within. If no tremor appears, that negative circumstance has a language of its own. The en- largement of an internal organ, as the liver, the existence of a tumor or of an aneurism, an abnormal action of the heart, and the fluctuation of the liquid in some forms of dropsy may sometimes be detected by the hand. Palpation, however, like succussion, is, at present, but little used ; as, in most cases, we have surer and better means of diagnosis. CHAPTER VI. INSPECTION. Rising a little higher in the scale of importance, we come to the subject of inspection. This consists in an ocular survey of the patient, for the purpose of judging, by some recognized want of symmetry, or other abnormal condition if it exists, in what manner and to what extent, there is a departure from health. To apply, with effect, to the chest, this means of diagnosis, the clothing of that portion of the body, must be entirely remov- ed, and the attitude of the patient must be such as not unnatural- ly to vary the relation of those parts which, in health, should be found symmetrical. In this condition, any considerable lack of symmetry is easily detected by the eye. So, also, are many such prominences and depressions as are created by disease, whether they destroy the relation which one part of the body bears to the other, or not. Of this nature, are the fulness of the precordial region, the enlargement or contraction of one of the sides, the elevation or depression of one of the shoulders, the contraction about the clavicles increasing their apparent prominence, and like variations from the standard of health. The phenomena, thus in- spected, become signs of the disease existing within. So, al- so, do certain abnormal motions of the chest, neck, or abdomen, occurring in respiration or with the impulses of the heart. Even the absence of the proper movement may indicate disease; and this absence may be made known by inspection. MENSURATION. PERCUSSION. 91 CHAPTER VII. MENSURATION. As an aid to inspection, and as a matter not far from tantamount in importance, is mensuration. This consists in the admeasure- ment of certain parts whose form is altered by disease, and in the comparison of that admeasurement with the standard of health. Passing a tape or measuring line around the thorax, we may, by means of it, learn very accurately the comparative fulness of the two sides. We 'may, also, by comparing the circumference at the superior with that at the inferior portion of the thorax, decide whether the relation of those portions is consistent with the con- dition of health. By mensuration, too, we may determine the po- sition of the nipples with reference to the sternum, to the clavicles, and to the spinous processes of the ilia; and, by so doing, may gain diagnostic signs of certain diseases. CHAPTER VIII. PERCUSSION. None of the previously considered means of diagnosis compare, at all favorably in importance, with percussion. By this is meant the method of detecting the condition of internal organs, from the character of the sound produced, when the surface of the body directly over those organs receives the force of a light blow. It was invented by Avenbrugger. The sounds produced by percussion are divided, generally, into two, the resonant and the dull. The resonant sound is heard on percussion over a space filled with air or gas, usually termed an empty space. The dull sound is heard on percussion over a solid or a liquid substance. The former of these sounds is illustrated in the case of striking upon an empty barrel or cask; the latter, by the same act, when the barrel or cask is filled with liquid. Or we have a modified il- THORACIC DISEASES. lustration in the case of a barrel partially filled with liquid. Strike upon that barrel above the surface of the liquid, and you hear a hollow or resonant sound. Strike below the surface, and you hear a dull or a flat sound. In percussing over any of the cavities of the human body, if no internal viscus lies near the paries or wall, we have a very res- onant sound. If the cavity is filled partly with air or gas, and partly with solid viscera intermixed, or if there be within a viscus of a spongy character, we have a less resonant sound. If a solid of medium density lies within, we have a slightly dull sound. If a very dense solid or a liquid within receives the force of the percussion, we have a very dull, often called a flat sound. Hence we speak of very resonant, resonant, dull, and very dull or flat sounds. We even use other qualifying terms to mark nicer differ- ences, according to circumstances, as the ear is able to distin- guish those differences. There is, however, one peculiarity of sound, or one adventitious sound of percussion, which deserves a moment's special consider- ation. It is usually called the cracked-pot sound, in French, bruit de pot fele. The name sufficiently explains itself. It is a kind of cracking or chinking sound. It may be imperfectly imi- tated, by clasping the hands together, in such a manner, that the palmar surfaces shall constitute the walls of a small cavity, and then striking the dorsal portion of one of the hands on the knee or some solid substance. The sound is heard when percussing over a cavity, with thin walls; as, for example, over a tuberculous cavity near the surface of the lung, when the pulmonary and costal portions of the pleu- ra are united at the part concerned. It may be heard, when a disease of the lung draws a portion of it away from the thoracic wall, so as to leave a hollow space. Percussion is either immediate or mediate. Immediate percus- sion supposes the blow to be made immediately upon-the body of the patient, no substance intervening. Mediate percussion, on the contrary, supposes some substance interposed or placed on the part to be percussed, primarily to receive the impulse and to com- municate it to the body beneath. Immediate percussion was the form in which the art was first PERCUSSION. 93 practiced. By it, Averibrugger threw much new light on the na- ture of many diseases; and, shortly after, Corvisart, adopting and advocating it, contributed much to establish its reputation. As thus practiced, however, the art was imperfect. At length, M. Piorry, physician to the Hotel Dieu of Paris, in- vented mediate percussion, and applied it, with greater success, to the investigation of the nature of diseases; and now the increased advantages and accuracy of the latter mode have caused it entire- ly to supercede the former. In mediate percussion, as at first em- ployed, a dense body, of a small superficial extent, was placed in contact with that portion of the patient to be percussed ; and was made to receive an impulse from the fingers or some artificial per- cussor, used after the manner of a small mallet. This body took the name pleximeter, or, as it has been sometimes written, ples- simeter, signifying a measure or measurer of percussion. The object of the pleximeter is to gather the sound from some little extent of surface, and thereby produce a stronger impression upon the ear. Besides, if the patient be thin in flesh and very sensitive, immediate percussion will give him uneasiness, and will be too impatiently borne for its practical advantages ; or, on the other hand, if there be a rather abundant amount of adipose tis- sue, or if the areolar tissue be somewhat infiltrated with serum, the condition of the internal organs will not be truly represented. The pleximeters in earliest use were made of metal and ivory. Afterwards, leather and other substances were tried ; and, of late years, a square piece of caoutchouc, about one fourth or one third of an inch in thickness, and about two inches in diameter, has been recommended. This, which was first proposed by Dr. J. B. S. Jackson of Boston, Mass., has an advantage over the mate- rials which are more solid and scarcely elastic, in its power of ac- commodation to any unevenness of surface, and the transmission thereby of a greater volume of sound. By being, too, of a den- sity nearly similar to that of the tissues over which it is placed, it represents more truly the quality of sound created by the con- dition of the organs and space within. A hard unyielding sub- stance necessarily gives some degree of sharpness even to sounds which would otherwise be measurably resonant ; and, besides, if the instrument shall happen not to be applied with sufficient firmness 94 THORACIC DISEASE&. and care, the true sound is liable to be masked by a clack of the air beneath. To do justice to the quality of sound, the plexime- ter should gently compress and measurably displace any tissues adapted to prevent the natural vibrations of the part percussed. In accomplishing this end, nothing is found to answer so well as one of the fingers. For convenience, we take either the index or the middle finger of the left hand. This is easily adapted to any irregularities of the surface to which it is applied, and is, in every respect, decidedly superior to any artificial instrument that human ingenuity can invent. Ordinarily, the palmar surface of the finger should be presented to the body of the patient, and the percussion should be made on the dorsal surface. The reason of this direction is, the softer por- tion of the finger best adapts itself and covers the part from which we wish to gather the sound; while the harder portion, by means of its density, best conveys and represents the sound to the ear. In some conditions, however, it is convenient and desirable to re- verse the finger. By its natural curve, for instance, it better fits certain depressions, as those above or behind the clavicle, some places between the ribs, and other parts; and the advantage gained in the matter of adaptation may more than counterbalance any consequent defect in the communication of the sound. In percussing certain symmetrical portions of the body of the chest particularly ,when we wish to compare one sound with the other, a caution or two must be observed ; Do not make one of the above-named applications of the finger to one part, and the other to the other part. It may prevent a discriminating compari- son of the sounds. Be careful, also, to press the finger equally firm, and to apply it in analogous directions, in both instances, as well as on analogous portions. In comparing the two sides of the chest, for instance, we must percuss at equal distances from the sternum, and in corresponding intercostal spaces or over corres- ponding ribs. For the purpose of giving the blow in percussion, an instrument has been contrived by Dr. Jacob Bigelow of Boston, Mass. It consists of a handle, about six inches in length, made of whale- bone or tough but slightly elastic wood, to one extremity of which is attached a ball, about an inch in diameter. This ball is made in- PERCUSSION. 95 ternally of some solid substance, and covered pretty thickly with velvet or buckskin, so as to be externally quite elastic. Besides, however, the trouble of preparing it and keeping it by one for use, it muffles the sound, and forbids an accurate discrimination. Incomparably the best percussor every one has received as the boon of nature. It is found in the right hand simply. Of this, we may use directly one or both of the index and middle fingers ; or with these two we may unite, also, the ring finger, taking care to place them so that their extremities shall form a line, and all be equally impressed on the finger of the left hand used as a plex- imeter. The phalanges should be so arranged that the third set shall form nearly a right angle with the first, and constitute the head, so to say, of a light mallet or hammer. In that position they must be firmly retained. Of course, the blow brings only the extremities of the fingers in contact with the pleximeter. The act of percussion should be performed, as far as possible, without any motion of the arm, or even of the forearm. The wrist becomes the moveable point or hinge, and the metacarpus the handle of the percussor. By using any portion of the arm, we almost necessarily strike a blow too firm for the convenience of the patient or for delicacy of sound. We almost necessarily, too, allow the contact to exist for a moment instead of instantly withdrawing the fingers. The consequence is, we prevent the proper vibration of the parts concerned, and thereby obscure the sound. When motion is made from the wrist only, it is much more easy to give suddenness to the impulsion, and thus to favor the reaction of elasticity. When percussing over thick adipose tissue or tissue infiltrated with serum, we must necessarily use more force than is desirable where the parietes are thin and the internal organs delicately sen- sitive. In such a case, we should not fail to employ together, the three fingers before named ; but we must be particularly careful to have them suddenly rebound after the blow. It is the quick- ness, rather than the force of the impulsion, which gives the prop- er clearness and sharpness to the sound. On the contrary, when we are concerned with tissues unusually thin, when, for instance, we are percussing the chests of children, or of persons greatly 96 THORACIC DISEASES. emaciated, the degree of elacticity is such as to render preferable the use of but a single finger. Percussion is extensively applicable in detecting the condition of organs both in the thorax and in the abdomen. Its importance, however, is much greater, in the former case than in the latter. The degree of resonance or dulness is different in different por- tions of the body, while in health. In the abdomen, the alimen- tary canal is ordinarily distended partly with gaseous substances ; and, hence, percussion directly over this canal gives considerable resonance. On the other hand, over the solid viscera, over the liver, for instance, we get a degree of dulness. In the thorax, the resonance, cceteris paribus, is greatest over those portions of the lungs, in which the vesicles and smallest bronchial tubes are most numerous, because the thin parietes of those cells and tubes favor the vibration of air within them ; while, on the other hand, the thick and rigid walls of the large bronchi- al tubes allow of comparatively little vibration, and render, in per- cussion, a degree of dulness. The sound, however, is very much modified by the character of the parietes of that part of the tho- rax on which we percuss. Thickness of muscular, adipose, or osseous substance creates dulness. The heart is a substance much more solid than the lungs. Hence percussion on the prascordia gives a duller sound than over any portion of the lungs. In general, the resonance, the thoracic viscera being normal, is greatest in the axillas, on the sides, along the lower part of the an- terior margin of the chest, and below the scapulas, posteriorly; while, at the summit and at the root of the lungs, the sound is comparatively dull. Where a portion of the left lung overlaps the heart, the sound, of course, is intermediate between the natural dulness at the centre of the prascordia, arid the resonance where the vesicles are most abundant. In judging whether there is disease of any viscus, we compare, in our minds, the sounds heard with such as we believe health ought to render. Where, too, there are analogous parts, we direct- ly compare the sound of one part with that of the other. AUSCULTATION. 97 CHAPTER IX. AUSCULTATION. The most important of all the means of physical diagnosis is auscultation. By this is meant the art of detecting the condition of internal organs by means of the sounds produced by vital in- ternal movements. It was invented by Laennec. Any organ, which, in either of the grand cavities of the body, yields a sound, when the purposes of the vital economy are being fulfilled, may be examined by auscultation ; and, by the existence and the qual- ity of the sound, knowledge is often gained respecting the healthy or the diseased condition of that organ. In regard to the abdomen, however, this art is of less practical value than percussion. The sound of the foetal heart in an ad- vanced state of pregnancy may be recognized by auscultation. So, too, may a peculiar thrill of the larger arteries ; and certain intestinal movements in the abdomen give evidence of peculiar internal conditions. But it is to the viscera of the thorax that it principally applies. By it various conditions of the lungs and of the heart are determined with much accuracy. These, in subse- quent pages, are to be made the subject of careful and extended remarks. SECTION I. THE MODE OF APPLYING AUSCULTATION. Auscultation is either mediate or immediate. Mediate auscul- tation supposes, for the purpose of conveying the sound, the in- tervention of a tube between the part of the patient to be auscul- ted and the ear of the auscultator. Immediate auscultation, on the contrary, supposes the ear to be applied directly to the part to be examined. Laennec employed mediate auscultation. Having, accidentally, in a sense, rolled a piece of paper into the form of a cylinder and applied it to the chest of a person whose heart was diseased, he 13 98 THORACIC DISEASES. was struck with the distinctness of the cardiac sound ; and this gave origin to the systematic use of an acoustic instrument, which took the name stethoscope, from its being primarily and princi- pally applied to examinations of thoracic viscera. Since the first adoption of mediate percussion, stethoscopes of various materials and various forms have been employed. The kind of instrument originally used by Laennec was crude and un- wieldly, and, with great propriety, has been laid entirely aside. The sounds to be communicated to the ear are variously crea- ted, and require a somewhat peculiar instrument of conduction. Those originating in solids are best transmitted by a solid ; and those originating in air are best transmitted by air. Indeed, the more nearly the conducting substance agrees, in density and struc- ture, with that giving origin to the sound, the better is the sound conducted. For a stethoscope, then, we want a substance which will convey sounds such as are generated by the solids within the cavities of the human body, particularly those within the tho- rax. This purpose may be tolerably well secured by any one of several different kinds of material but by no one better, perhaps, than by some wood, of a light kind but having firm longitudinal fibres. Cedar, hard pine, mahogany, &c., answer very well; but none is better than the first-named. But several of the most important sounds to be regarded in aus- cultation, are made in air, and therefore require an aerial conduc- tor ; that is, they must be conveyed through a column of air. To secure this object, a cylinder is perforated from one extremity to the other so as to give a calibre of about one fourth of an inch in diameter. The column of air rising in this will conduct aerial sounds, such as those created in the thorax, by the respiration, the voice, and the cough. One extremity, however, of a calibre of the above-named size can come in contact, at any one time, with only a very small spot of surface, and, consequently, can successfully transmit those sounds only which are produced at or near that point of contact. This limitation, on condition that the sound is distinctly audible, secures an advantage in not allowing different sounds from an extended space to reach the ear simultaneously. For ordinary AUSCULTATION. 99 purposes, however, such a cylinder would be very imperfectly adapted. Beside increasing the labor of examining a surface of any extent, there cannot be received into such a calibre a suffi- ciency of vibrations to render the sound sufficiently audible. To remedy this inconvenience, the calibre of the instrument is increased at its basal extremity, so as to take a conical or funnel- shaped form, the opening or mouth being one inch or more in diameter. By this arrangement, all the vibrations beneath the whole surface covered by the base of the cone are concentrated, and thereby so conducted as far more forcibly to impress the ear. The sounds, too, are further increased in power by their reflection from the walls of the instrument, whose conical relations, give to the vibrations an onward direction, or one forming a less angle with the central axis. Now, though metals, glass, porcelain, &c. will reflect aerial sounds even better than any forms of wood, yet such materials are too dense to receive those vibrations which orig- inate in the solids under examination, and are, for that reason, un- desirable. There is even another advantage derivable from the use of light but rigid wood in forming the stethoscope. As, on the one hand, by its comparative rigidity, it will receive the finest vibrations from denser substances, and yet, by its comparative lightness, will give extent to these vibrations and cause them to impress a greater amount of air; so, on the other, it will receive the rarer vibrations from air, condense them, and transmit them to a more solid substance, or to the ear. Hence, it will tolerably well transmit any strong vibrations which fall upon the walls, too perpendicularly to be reflected much onward ; and thus sounds are so transmitted, by the walls of the tube and by the contained col- umn of air, that a tinkling echo, which would otherwise mask the original character, is avoided. To complete the acoustic instrument, it should be furnished, at the extremity which is at or above the apex of the cone, with an ear-piece essentially flat and of such size as to adapt itself well to the auscultator's ear, varying somewhat, of course, according to the shape and size of that ear. Or he may have the extremity form a nipple-shaped projection; and, by inserting that directly into the organ of hearing, thus secure the whole sound. A prop- er length for the cylinder is about six inches. Tt should not be 100 THORACIC DISEASES. so short as to endanger a reception of sound passing to the ear without the instrument, nor yet so long as very much to dimmish the intensity of the sound which it transmits. A stethoscope, consisting of a flexible tube about two feet in length, and having a calibre of the ordinary size, has sometimes been employed. This, like the one in more common use, is fur- nished, at one extremity, with a funnel-shaped opening, and, at the other, with an ear-piece. It was first introduced, by Dr. Pen- nock of Philadelphia, for the purpose, more particularly, of ex- amining the sounds of the heart ; because it would convey the vibrations to the ear, without giving an impression of the impul- sion against the walls of the thorax. I have frequently employed it, with good effect, in ausculting, not only the heart, but the lungs. Tt affords one advantage in the examination of a person who is too feeble to be raised into the upright posture. You may sit or stand by his bed, and the length of the instrument will en- able you to make any wished-for application. One other kind of stethoscope remains to be considered. It has been introduced by doctors Camman and Clark of New York, specially for auscultatory percussion. This instrument consists of a cylinder, not perforated, made of cedar or some similar kind of wood, about six inches in length, and three fourths of an inch in diameter, and furnished, as usual, with an ear-piece. It is appli- cable to any case in which we would detect the dimensions of a solid viscus or tumor in either of the large cavities of the body. Its principal use, however, is in ascertaining the dimensions of the heart, including its investing membrane, the pericardium. Sometimes a parabolic or wedge-shaped form is given to the ex- tremity to be applied to the patient, in order to adapt it to the in- tercostal depressions of the prsecordia. In auscultatory percussion, we place the solid stethoscope somewhat centrally over the organ to be examined, and apply the ear, as in other cases, supporting the instrument by the ear. We then percuss, as usual, over the organ and near its border; and, gradually moving the pleximeter, we continue the percussion, un- til the line of the margin is indicated by a change of sound. While percussing over any organ, as the heart, for instance, and near the stethoscope, we hoar "a clear, sudden, intense sound of AUSCULTATION. 101 a high tone ;" and this is accompanied with a short abrupt impulse apparently produced directly under or within the instrument. If we strike a little remote, where the lungs overlay the heart, we have a mixed sound or one somewhat modified, but retaining in part its cardiac type. But, moving the pleximeter, by degrees, still farther, as soon as we pass entirely from over the heart, the sound suddenly changes, "losing its intensity and high tone, and being no longer impulsive, but grave and distant." In the same manner we may explore the boundaries of the liver. The stethoscope being centrally placed, the sound pro- duced near it will be somewhat clear and intense, and seem to be directly under the instrument, though more prolonged and rever- berant than in the case of the heart. As we pass from the instru- ment, the sound diminishes, and is lost as soon as we get beyond the hepatic margin. Auscultatory percussion may be applied to the spleen, the kid- neys, aneurisms, and internal tumors. It is supposed, also, that, by it, fractures of bones may be detected, and that true anchylo- sis may be discriminated from false. Where the parts are contin- uous and united, "the sound and impulse are transmitted;" but, where the parts are separated, the sound and impulse scarcely appear. That this mode of detecting disease may be made of some further utility is probable enough. Still, with the benefit of the more common means of physical diagnosis, it is hardly to be ex- pected, that the province of auscultatory percussion will be very much extended. Mediate auscultation and immediate have each its advantages. The advantages of the former are principally the following. By the stethoscope, especially by one whose funnel-shaped portion is contracted, we can, with precision, determine the point from which an internal sound originates. We can accurately mark, for in- stance, the position of a pulmonary cavity, and can discriminate from which of the cardiac orifices a morbid sound of the heart proceeds; whereas, by the ear directly applied to the thorax, we gather the sound from so large a space, that as nice discrimination is impossible. We may hear several modifications of sound, arising from points a little remote from each other, but confusedly 102 THORACIC DISEASES. mingled. There is even a liability of our mistaking tracheal res- piration, conveyed to the ear by the surface of the head, for cav- ernous respiration in the superior lobe of the lung, over which the ear is placed. Another advantage is in the better application of the stethoscope than of the ear, to some portions of the body, as the axillae, the spaces between the scapulae, and the post-clavicu- lar regions, in cases, especially, of emaciation and depression. Again, in the case of the female, modesty sometimes requires the application of the stethoscope, in ausculting the mammary region. And, still further, the immediate application of the ear to any portion of the body, when the patient is filthy, especially if freely perspiring, is not pleasant ; and, if he happens to be afflicted with an infectious disorder or with certain nameless specimens of ani- mal life, it is neither pleasant nor safe. On the other hand, immediate auscultation is more simple, more easily adopted, and more readily learnt. If the stethoscope is employed, it must be so adjusted as to have a perfect contact with the surface to which it is applied ; and the ear must be carefully adapted to the ear-piece. In immediate auscultation there is noth- ing of this sort to require attention. The sounds, too, appear louder, and better characterized than when the stethoscope is em- ployed. The reason is, vibrations, in greater amount, enter the ear, being conducted to it, by the solids of the patient's body and the auscultator 7 s head. This, in ausculting the chest of a person whose respiration is feeble, or, in any case in which the sounds lack distinctness, is of no small advantage. When the stethoscope is used, there is more danger of mistaking a rustling of the pa- tient's clothes or other external noise, for a sound rendered through the instrument. More care, too, needs be taken in assuming an unconstrained position, and in having the part to be examined nearly or altogether divested of covering. In immediate auscul- tation, unless the case be one demanding niceness of discrimina- tion, these particulars need not be as closely regarded. Again, in a large majority of cases, the direct application of the ear is decidedly to be preferred, on account of the greater rapidity of its application. Not only is there no delay by reason of the absence of the stethoscope, but the ear can be passed much more rapidly, and yet ordinarily as successfully, over the part to AUSCULTATION. 103 be ausculted. As we gather the sound from a considerable sur- face at once, we can make each successive application at a point more remote from the preceding, in passing over those parts where there is nothing abnormal or what requires special attention. SECTION II. THE HEALTHY SOUNDS OF RESPIRATION. Healthy respiration has two elements of sound. 1st, The tubal or bronchial sound. 2d, The vesicular sound, sometimes called the vesicular mur- mur, or vesicular respiration. In health, these sounds, in inspiration, are always combined, but in different proportions. In some diseases, however, the for- mer may be heard without the latter; but the latter must always be more or less modified by the former. In expiration the sound, in health, is in a good degree bronchial, being modified compara- tively little by vesicular influence. The better to illustrate the character of these sounds or ele- ments of sound, I present, in few words, some matters connected with the anatomy of the parts concerned in their formation. The great mass of each lobe of the lungs is filled with air-cells or vesicles ; but these are divided into clusters, and each cluster, with the tissues involved, is called a lobule. Each lobule is com- pletely separated, from those by which it is surrounded, by areolar tissue. The large bronchi or bronchial tubes, forming the bifurcation of the trachea, almost immediately enter the lungs, divide and subdivide, but without anastomosis, until they have sent branches, that is, smaller bronchi or bronchia (the latter term being some- times employed to designate the branches of the largest tubes) to every part of the organs. There is, however, a difference in the manner in which these tubes enter the lungs. The one lead- ing to the right lung is shorter and larger than the one leading to the left, the latter passing behind the aorta, and necessarily tak- ing a more tortuous course than the former. "All the larger branches " of these tubes, in the language of 104 THORACIC DISEASES. Kirkes and Paget, "have walls formed of tough membrane, with organic-muscular circular fibres, giving them some power of spon- taneous contraction, portions of cartilaginous rings, by which they are held open, and longitudinal bundles of elastic tissue, for greater power of recoil after expansion. They are lined with mucous membrane, the surface of which is covered with vibratile ciliary epithelium. But, when the bronchi, by successive branch- ings, are reduced to about 1-100 of an inch in diameter, they lose these structures, and their walls are formed of only a tough, elas- tic membrane, with traces of fibrous, perhaps muscular structure, over 'which the capillaries are spread in a very dense network, and on various parts of which air-cells irregularly open. Tubes of this kind are named, by Mr. Rainey intercellular passages. The air-cells, opening into them, may be placed singly on their walls, like recesses from them ; but more often are arranged in rows, like minute saculated tubes ; so that a succession or series of cells, all opening into one another, open by a common orifice into the tube." Each lobule has one small bronchus or bronchium of its own. This terminal bronchus passes directly to the centre of the lobule, and there terminates in a slight enlargement so as to be fitly compared, on a reduced scale, to a pipe-stem with a sponge attached to it. On their way towards their termini, the bronchi, in connexioa with blood-vessels, pass, in the areolar tis- sue, between the lobules. " The cells are of various forms, according to the mutual pres- sure to which they are subject. Their walls are nearly in contact, and they vary from 1-120 to 1-1200 of an inch in diameter. Their walls are formed of fine membrane, similar to that of the intercellular passages, and continuous with it, which is folded on itself, so as to form a sharp-edged border at each circular orifice of communication between contiguous air-cells 3 or between the cells and the bronchial passages. The cells have no epithelial lining ', but, on the exterior of the membrane of which they are construc- ted, a network of pulmonary capillaries is spread out so densely that the interspaces or meshes are even narrower than the vessels, which are, on an average, 1-3000 of an inch in diameter." Each terminal bronchus is surrounded by the air-cells of that lobule. Those cells in immediate contact with the bronchus open directly AUSCULTATION. 105 into it. Those more remote open only indirectly, that is, through those that are nearer. " The multitude of these cells," says Dr. Morton, "and the great space they must afford, by their collective internal surface, may be, in some measure, conceived of from the calculation of Rochoux, that the number of air-cells grouped around each terminal bronchus is little less than 18,000, and that the total number in the lungs amounts to six hundred millions." From this construction of each lobule it is seen, that the passage of air through any terminal bronchus must distend the air-cells connected with that bronchus, not simultaneously, but in quick succession. The first element of healthy respiration, then, called the tubal or bronchial sound, is made by the passage of air through the bronchial tubes. It is a clear blowing sound, somewhat resem- bling what may be made in the mouth and fauces, by quickly in- haling the air, with the mouth a little open. It is most distinctly heard directly over the large bronchi, at the root of the lungs; but is appreciable, also, to a considerable distance from those parts. Indeed, passing from the root of the lungs, there is a diminution of the bronchial sound, until it is fully masked by the vesicular. This diminution is measurably uniform, but not entirely. At the summit of the lungs, or in the subclavicular regions, the bron- chial character of the sound is quite as evident, as it is a little lower, and nearer the pulmonary roots; owing, probably, to the comparative thinness of the muscular tissue, upon the superior portions of the thorax. It should, also, be here remarked, that, owing to a.n anatomical fact already alluded to, the bronchial sound, both anteriorly and posteriorly, is sometimes appreciably louder, on the right, than on the left side. This sound, though purer, or less modified by the second, in expiration than in inspiration, is yet feebler in the former case than in the latter. Indeed, the act of expiration is usually, in health, considerably shorter than that of inspiration; the former being variously estimated as one fifth, one third, and one half of the latter, the last estimate, however, being evidently the near- est to the truth. And, while the act itself is shorter, the sound generally ceases to be audible before the expiration is closed. 14 106 THORACIC DISEASES. Some have considered, that the original seat of the bronchial sound is in the fauces and nasal cavities, and that it is little more than conveyed by the bronchial tubes to the part over which it is heard. This, however, is clearly an error. We know, from the nature of wind instruments, and from the effect of blowing strong- ly into any tube, that sound is produced in every part of the cal- ibre ; and so it must be with the air passages. The quality of the sound, however, is given by the size of the calibre and other conditions. Hence, the same current of air which, at length, enters the bronchial tubes, to produce a sound there, produces, while passing through the trachea, a fuller and coarser sound, to which we give the name tracheal respiration ; but tracheal respir- ation is not bronchial, nor bronchial tracheal. The second element of healthy respiration, called the vesicular sound, is made in the air-cells or vesicles, partly, perhaps, by the vibration of the air in those cells, but, more especially, by their simultaneous and successive expansion. It is a gentle breezy sound, very much resembling the strong whisper or breathing out of the word awe; and, on account of its character, is often des- cribed as a murmur, or called the vesicular murmur. It is best heard, or is least masked by the bronchial sound, over those por- tions of the lungs containing the greatest number of vesicles and only the smallest bronchial tubes ; that is, in general, the portions most remote from the root of the lungs, particularly the base an- teriorly, and the axillary and sub-axillary portions laterally. This sound, from the manner in which it is made, is confined chiefly to acts of inspiration. In expiration, the vesicles empty themselves gradually; and, hence, scarcely give rise to the vesic- ular murmur. There is very little opportunity for a rustling of the air against the sides of the cells, and almost none for a crack- ling to be produced by the movement of the walls. In the dilatation of the vesicles, they are forced open by the entering current of air, and somehow the vesicular murmur is produced. This is proved by creating an artificial respiration with an animal suddenly killed. As the air enters the vesicles, the murmur may be distinctly heard ; but expel the air from the vesicles, and they empty themselves almost noiselessly. In in- spiration, the vesicles become the terminating and impinging AUSCULTATION. 107 points of the air. In expiration, there is no terminus, but the current passes freely to the external world. In the dilatation of the vesicles, in inspiration, the pulmonary tissues are moved by the mechanical pressure of the air within, the parts being dis- placed, not simultaneously, but as one tissue crowds upon another. In the contraction of the vesicles, in expiration, probably their walls collapse first, and the outer tissues follow, without pressure one upon another. The vesicular sound differs in intensity in different individuals in health. As heard with some, it is always feeble ; with others, it is comparatively loud. With persons of a nervous tempera- ment and consequent rapid respiration, it is louder than with those of a different temperament, though more robust and athletic. In general, it is louder in women than in men, and in children than in adults. It is mainly, indeed, the increased strength of the vesicular sound, which makes a peculiarity of respiration in children, and has given rise to the phrase puerile respiration, and, in disease, to signify supplementary or increased healthy respira- tion in one lung, in consequence of impaired action on the part of the other. Puerile respiration, however, supposes, to an ex- tent, an increase of the bronchial, as well as of the vesicular sound. In ordinary respiration, the vesicular sound is never complete, though in some persons it is nearer so than in others. Fully to dilate the vesicles always requires a forced respiration ; but the inferior portions of the lungs call for a greater respiratory effort, than do the superior ; inasmuch as the bronchial tubes, in the former case, have to pursue a longer course, and become more reduced in size. The two sounds now described, the tubal or bronchial and the vesicular, enter in a degree, into every healthy respiration ; but the vesicular is scarcely observable in the expiratory act. In in- spiration, the bronchial sound is least modified by the vesicular directly anterior or posterior to the large bronchi. The vesicu- lar, on the contrary, is least modified by the bronchial, as heard from those parts of the thorax most remote from the large bron- chi, particularly at the base of the lungs, anteriorly and posterior- ly, and at the lateral portions of the thorax. Over the medium-siz- 108 THORACIC DISEASES. ed bronchial tubes, equally removed from the largest and from the vesicles at the extremities of the smallest, the two sounds are mingled the most equally ; but, in health, perhaps neither of the two, in inspiration, is heard from any part of the lungs, without being mingled, more or less, with the other. In expiration, how- ever, the bronchial sound is but slightly modified by the vesicular. It is true, that it differs, very appreciably, from the most marked form of bronchial respiration in disease ; but this, probably, is to be mainly ascribed to the elasticity of the tubes and the softness of the surrounding pulmonary tissue, circumstances very differ- ent from those which give the morbid character to the sound. The bronchial sound of health, as least mingled with the vesi- cular, is very commonly called the blowing sound. I usually describe it, as the blowing or healthy bronchial sound. The res- piration, as heard over the greater portion of the lungs and hav- ing the vesicular element very distinct, is often called the respi- ratory murmur ; but, as this sound is limited to inspiration, it is, with equal propriety, called the inspiratory murmur. There are some varieties of healthy respiration, which require to be carefully noticed. I have already spoken of the respiration of children, as being characterized by an increase of both the healthy sounds, but, especially, the vesicular. This peculiarity seems to be owing essentially to the facts, that the parietes of the thorax with children, are comparatively thin, and, especially, that there is, in early life, a greater activity of the respiratory organs, by which the air is driven into the lungs more forcibly. I now remark, that, in advanced life, the respiration becomes more feeble than it is in middle age, from the diminished activity of the vital functions. The muscles of respiration have less energy, and, probably, the pulmonary tissues themselves are less susceptible of vigorous action. This diminution of force characterizes both sounds ; but is quite as perceptible in the bronchial as in the vesicular. There are other varieties dependent on the peculiarities of physical developement. In corpulent persons, the temperament and other conditions being equal, the respiration, as heard, is more feeble, the adipose matter of the chest being a bad con- ductor of sound. The serous infiltration of the areolar tissue, AUSCULTATION. 109 produced by disease, may have the same effect. The lungs may act normally but the sound is obstructed in passing to the ear. In females, the mammary glands repress the sounds in por- tions of the chest. There are, also, varieties dependent on accidental causes, as the influence of digestion, muscular exercise, nervous excite- ment, and -the like : but these do not require a delineation. The discriminating judgment and practical tact of the experienced auscultator will be his best guide. The elements of healthy respiration, as now described, should be thoroughly studied by every one who desires a correct knowl- edge of auscultation, or who designs ever to practice it. I would recommend, to every learner, to take frequent opportunities to lis- ten to the bronchial sound at the root of the lungs, and to the vesicular, at the inferior and lateral portion particularly. I would also advise him to make his examinations, with individuals of dif- ferent ages, temperament, and conformations, and of both sexes. In this way, he will, by habit, the better discriminate the radical features of the two sounds, and will learn to trace these, amidst numerous shades of difference arising from incidental causes. Having formed, for himself, an idea of each sound as distinct as possible, he will be able to detect each element of respiration, even where the sounds are most equally mingled and thoroughly blended. It is well, too, to be familiar with the differences resulting from voluntarily modifying the act of breathing. A protracted and forced inspiration, by more thoroughly dilating the air-passages, particularly the vesicles, will considerably vary the character of the sound. A strong but short and hurried breathing will also give a peculiarity. And, finally, one must accustom himself to the influence pro- duced, upon portions of the lungs, by the solid viscera in imme- diate proximity. The heart affects the sound of a certain portion of the left lung, and the liver that of a different portion of the right. Having formed a distinct conception of the sounds which char- acterize healthy respiration, one is prepared to understand the va- rious departures from that respiration ; in other words, the abnor- mal or morbid respiratory sounds. 110 THORACIC DISEASES. SECTION III. THE DISEASED SOUNDS OF RESPIRATION. The diseased sounds of respiration are made while the air is passing through portions of the lungs, and their character depends especially on the size and form of the air-passages, the man- ner in which the air impinges against the sides and angles of those passages, and on the circumstances under which the sounds are conveyed to the ear. These sounds are variously modified. Those modifications, however, which are the most marked and which first demand our attention, are the three following, the shrill bronchial respi- ration, the cavernous, and the amphoric. In general, the shrill bronchial respiration differs from the blow- ing bronchial, or the bronchial respiration of health, in three par- ticulars, it is less modified by the vesicular murmur, it is louder, and it is heard at parts of the thorax at which, in health, the res- piration is mainly vesicular. It is produced by those diseases which harden the parenchyma of the lungs and block up or com- press the vesicles. Of course, it differs much less from the sound heard in healthy expiration, than from that heard in healthy in- spiration, as it is in inspiration only that the vesicular murmur is distinctly heard. When shrill bronchial respiration is perfect, it is entirely devoid of the vesicular sound ; that is, it is perfectly tubal. When the vesicles are in a condition partially to receive the air, the shrill or diseased bronchial respiration is imperfect, and is sometimes called rude respiration. The increased loudness of the shrill bronchial sound is merely the result of a more perfect conveyance to the ear, by means of hardened tissue. If the induration immediately around the larger bronchi be considerable, the shrill tubal sound will be louder, than when those portions of the lungs in which exist only the vesicles and smaller tubes, are the seat of the disease. The reason is obvious. The larger bronchi are mainly concerned in giving origin to the bronchial sound. Of course, the conducting medium being the same, a greater sound will reach the ear, im- mediately over those tubes, than at a distance. AUSCULTATION. Ill But the shrill bronchial sound is very commonly heard, in cer- tain diseases where in health the vesicular murmur is most mark- ed. This is because the induration, obliterating the vesicles, pre- vents the vesicular murmur, while it, at the same time, conducts the tubal sound more perfectly than does the spongy tissue of health. Perhaps one other circumstance contributes to this result. The smaller tubes, as well as the vesicles, may become obliterat- ed by the hardening of the pulmonary tissue. In that case, the air is suddenly arrested in its passage, and impinges against the walls of the tubes more forcibly, so as to create a greater tubal sound. In a case like this, bronchial respiration may be even louder in remote parts of the lungs, than is the healthy bronchial sound immediately over the largest bronchi. The disease most fully developing the shrill bronchial respiration is pneumonatis in the stage of hepatization. Tubercles, however, in the second stage, often produce, under a limited surface, a marked instance of this form of respiration. Pleuritis, in the stage of effusion, may so compress the lung as to render the bron- chial sound considerably shrill. Scirrhus, too, or other abnormal deposits, may have to some extent, the same effect. The cavernous respiration, as the term implies, is the sound produced by the passage of air into a cavity. This sound, in quality, very much resembles trachea respiration. Until it has been heard, the best idea of it can be gained, by listening, though the medium of the stethoscope, to the sound in the trachea. The principal difference, between tracheal and cavernous respiration, consists in the different lengths of the sounds. In a cavity, the current of air, admitted in inspiration, is suddenly arrested, whirl- ed around for a moment, and then forcibly expelled. This gives a degree of abruptness to the sound. In the trachea, the inhal- ing effort forces the air along, in one direction and in a steady current, till the close of the act. This renders the sound rather more prolonged than that which is heard in a cavity. Should an unpracticed ear, however, be unable to discriminate, with sufficient accuracy, between the character of the cavernous and that of the shrill bronchial sound, he will be aided in arriving at a correct > O conclusion, by considering that cavernous respiration is limited to a very circumscribed portion .of the lung, while the shrill bron- THORACIC DISEASES. chial, if marked, is always more extensive, being limited only by the extent of the indurated portion of the pulmonary tissue. The line of demarcation, too, between the hardened and the healthy portions is not so distinctly drawn as are the walls of a cavity. Hence, in an examination of different points, with a stethoscope especially, we find the shrill bronchial sound losing its distinctive character less abruptly, than the cavernous. Not all cavities produce a distinct cavernous respiration. One about the size of a walnut, communicating freely with some of the larger bronchial tubes, and having firmer walls of indurated parenchyma, gives the sound in its most perfect character. If the cavity is larger, the air reverberates less fully ; and, if the surrounding tissue is measurably permeable to the air, it con- ducts the sound less perfectly. When a tuberculous cavity has been of long standing and is much enlarged, it will often render but a very indistinct cavernous sound. In such a case, the most hardened portion of the walls is doubtless ulcerated away ; and it may sometimes happen, that the tubes opening into the cavity become contracted or otherwise obstructed. By far the most frequent cause of the existence of pulmonary cavities is tuberculous disease. They sometimes, however, result from the ulceration of pneumonitis in its last stage, and from the sloughing of mortification. There may, also, be a dilatation of the bronchial tubes of such extent as to give, to the respiration, a cavernous character ; but, in this case, the sound is more exactly like that of tracheal respiration, as the air pursues its onward course and is not reflected as in other cavities. Amphoric respiration is really but a modification of cavernous. The sound, however, is peculiar, and, therefore, demands consid- eration under a distinct name. It is derived from a word in the Latin language, or a similar one in the Greek, signifying a firkin or large measure. Hence the phrase, amphoric respiration, indi- cates a sound made in a cavity occupying considerable space ; but the conditions necessary to its full development arc, not only largeness of extent in the cavity, but the existence of firm, tense, and elastic walls. The proper amphoric respii^tion is a clear and ringing sound, and may be imitated by blowing into an empty flask, a large glass vial, or even a metallic vessel. The best imj- AUSCULTATION. 113 tation, however, is obtained, by pressing one extremity of a com- mon lamp chimney upon the palm of one hand, and then resting the back of that hand on the ear, while another person breathes forcibly into the other extremity of the chimuey. If the cavity giving rise to the amphoric sound has a free communication with the bronchial tubes, the peculiar ring will be heard in both inspi- ration and expiration ; but, if this communication is so interrupted that the air is discharged but slowly, the expiration will be at- tended with but little sound and that not distinctive. Amphoric respiration is most commonly produced in a tubercu- lous "cavity, under the conditions already named. A gangrenous cavity, however, may produce it, in a degree ; but the surround- ing tissue, in this case, is generally too soft to render the peculi- arity very marked. The amphoric sound is said to have been heard in cavities created by pneumonitis ; but the cases in which its character is very appreciable, must, I am sure, be exceedingly rare. The most marked degree of the peculiarity is in pneumo- thorax. In this case the pleural sac becomes the cavity, and there is a perforation or fistulous opening into it from the air-pas- sages. The cavity is, of course, large, and its walls are suffi- ciently firm, tense, and elastic. There are some other varieties of respiration which deserve a passing notice. Among these, the most important is the rude bronchial respiration. I use this term, not to denote merely an imperfect form of the shrill bronchial sound, or to imply, simply that the vesicular murmur is somewhat, though feebly, heard, modifying the bronchial sound. I use it rather to denote a rough or husky sound. It is not distinctly tubal, like the shrill bron- chial, nor having the breezy smoothness of the vesicular. It is probably made by the action of small fibrilla in the air-tubes, while, it may be, that the calibre of the tubes themselves is somewhat reduced, either by the existence of incipient tubercles pressing on the tubes, or by the thickness of their coats in in- flammation. I am not, however, indeed, fully satisfied as to the pathological condition which gives rise to this sound. I have heard it in the % most marked form, in connexion with a degree of chronic hoarse- ness, and a chronic cough, which by some would be termed ner- 15 114 THORACIC DISEASES. vous. In this case, there was, at the same time, considerable evidence, that incipient tubercles pervaded the lungs. On the whole, my impression is, that the condition of the tubes approxi- mates that which produces the sonorous rale, yet to be consider- ed and heard particularly in acute bronchitis. The peculiarity of the patient's constitution, in connexion with the diseased condition of the pulmonary parenchyma and of the membranes of the tubes, may cause a viscid and delicate secretion, which, by its dryness, takes on a fibrillous or ciliated form. If so, the pe- culiarity of the sound would, in strictness, rank it with the rales ; but it is so slight a modification of the respiration as scarcely to merit a consideration with that important class of sounds. At any rate, the sound is worthy of the further consideration of pathologists. Another variety of respiration is the interrupted or jerking. In this, the air seems to be measurably arrested in the tubes, for an instant, before it passes on to the vesicles. The quantity of the sound is essentially normal ; and the respiration takes its name solely from the broken manner in which the air passes. It arises from different causes. In a nervous sensitive patient, jt is often produced by spasm, under the influence of excitement. In bronchitis, a thickening of the walls of the smaller tubes, by inflammation, may produce it. So, too, may simple congestion. But the most serious condition which ever gives rise to it, is a de- posit of incipient tubercles. This, of course, limits the sound to that small portion of the lung in which the tuberculous disease is commencing. It is a symptom of but little importance, except as, in this last instance, it becomes a sign of phthisis. Dr. Bowditch speaks of what he call mucous respiration, and says that, in it, " the respiratory murmur seems more moist than natural, almost enough so to produce a crackling rale/' He says, "it may be heard, throughout both lungs, but is most distinct at the lower and posterior portions.'' According to him, the sound is indicative of chronic bronchitis ; and a fit of coughing will sometimes so augment the secretioii ( as to produce the mucous rale. Though he speaks of the existence of this sound as a dis- covery of his own, and says he is not aware, that " others have noticed it," yet, to my mind, it is perfectly clear, that he attempts AUSCULTATION. 115 to describe what Dr. C. J. B. Williams calls the sub-mucous rhonchus. Dr. W., having spoken of the mucous and gurgling rhonchi, says, "when there is a little liquid in the smaller bronchi, the bubbling or crackling is more regular, although the sound is weaker, and is sometimes only a roughness added to the ordinary respiratory murmur. This is the sub-mucous ?-fwnchus. It may result from slight degrees of bronchitis, and owes its importance only to its being permanently present, when such slight inflamma- tion is constantly kept up by the irritation of adjacent tubercles in an incipient state." I am not aware of having myself noticed a peculiarity of this kind worthy of any separate description. It is perfectly conceivable, however, that the bronchial tubes may be a little moistened with a thin or mucous secretion, and yet the quantity of this secretion may not be sufficient fully to develope either the mucous or the subcrepitant rale. That the sound, when in exists, should in strictness, be classed with the rales, rather than as a simple sound of respiration, is, to my mind, clear. The peculiarity is evidently produced by a. slight liquid obstruc- tion, and not by the mere force of the air striking against the walls of the air-passages. Still, such nicities of classification are practically of but little importance ; and thn sound is so slight a change from the normal respiration, as hardly to entitle it, in de- scription, to the dignity of a rale. Beside these modifications of the respiration, still others may be named. Both the normal sounds may be increased, or they may be diminished, without any other change of character. A portion of the lungs may become so compressed or so diseased, as to be impervious to air, and incapable of performing the proper ollice. In that case, another portion will act with increased ener- gy, and give a louder sound of respiration. Instances of this are observed in pleuritic effusions, and in pneumonitis. Even in bronchitis, there may be so much lesion of the bronchial tubes as to obstruct the passage of air into one part, and thereby give an increase of sound in another part. Again, the sound of respiration as it reaches the ear, may be less than is normal, in consequence of disease in the structure of the lungs or in parts adjacent. In emphysema, for instance, both the bronchial and the vesicular sounds are enfeebled. In bronchi- 116 THORACIC DISEASES. tis, too, this sometimes occurs. In phthisis, it is frequently ob- served in a portion of one lung ; but, in this disease, there are usually, perhaps uniformly, other alterations of the respiratory sounds. In the second stage of pleuritis, in hydro-thorax, in em- pyema, or whenever the pleura contains a liquid of any kind, the respiration, as heard, is more or less feeble, partly by reason of the compression of the bronchi and vesicles, and partly because the interposed liquid interrupts the conduction of the sound to the ear. SECTION IV. RALES. Rales are an important class of sounds, made, indeed, by the passing of air through air-passages, but yet in a manner some- what different from that in which the simple diseased sounds of respiration are produced. The rales always suppose impediments or partial obstructions to the passage of the air ; and it is the re- sistence met with which mainly, gives the modification of sound. The term rale has been transferred from the French to express an idea for which we have had no authorized English word Even this, in the original, is far from giving the exact meaning. It merely signifies a wheezing, or a rattling in the throat. Some pathologists prefer the Latin term rkojichus, which signifies a snoring or snorting. The idea being a new one, of course, to ex- press it, a new term must be adopted, or there must be an accom- modation of an old one. Either expedient is well enough ; and the term rale, or rhonchus, or even the simple English word rattle, will convey the idea, when once its application is defined and un- derstood. I prefer the term which I have adopted, simply be- cause it is a monosyllable and easily pronounced, while, ortho- graphically, it forms its plural after the usual English manner. The rales are properly divided into the dry, and the moist or humid. This distinction is founded on the nature of the impedi- ments which produce the sounds. These impediments are either solid or liquid. The dry rales are three, the sibilant the sono- rous, and the crackling. AUSCULTATION. 117 The sibilant rale is a musical or gently whistling sound. It may be sufficiently well imitated by whistling between the teeth, with the lips partly closed or slightly apart. It is produced by the passage of air through a small and rather circular aperture. This aperture is generally formed by a slight obstruction in one of the smaller tubes, though it may be made by a greater ob- struction in a tube of larger size. The sound is extremely moveable, and equally irregular in the time of its reappearance. Heard, at one point, in one respiration, in the next, or not until some subsequent one, it may be heard at some point remote from the first. It exists, both in respiration and expiration ; and from the situation of the smaller tubes from which it mostly arises, it is mostly heard over those portions of the thorax, es- pecially the anterior, which are a little remote from the pulmo- nary roots. Under different circumstances, however, it is heard over almost every portion of the chest, anterior, posterior and lateral. It is produced in asthma, in which the tubes are congested, and are constricted by the spasmodic contraction of their circular fibres. In this disease, particularly if severe, it is a protracted sound, heard in both inspiration and expiration. In bronchitis, the tubes may be so narrowed, by the swelling of their mucous and submucous coats, as to produce it. In the third stage of phthisis, it is quite frequently heard, in connexion with other dis- eased sounds, the tubes being constricted by the muco-purulent matter which passes into them. In the latter case, the sound is short, and is generally heard from different tubes during the same or successive respirations. It may be caused, in different diseases, by such an adherence of viscid mucous to the walls of the tubes as diminishes their calibre. The sonorous rale might, with more special propriety, be called a rhonchus. It is more of a snoring sound, or like deep guttural breathing, than any of the other rales. Various similitudes have been adopted to describe it. It has been compared to the sound of a bassoon, and to that of a bass-viol ; to the cooing of a pigeon, to the hum of insects, to the sounds produced by a piece of paper fluttering in the wind, and to the grating of a cart-wheel upon snow in weather severely cold. But, whatever idea may 118 THORACIC DISEASES. be formed of it, from these and like comparisons, it is sufficient to say, that it is a deep cavernous sound, so unlike any other pro- duced in the thorax, that when once distinctly heard, in its mark- ed form, it may ever afterwards be recognized. It, however, varies considerably in tone, according to the circumstances under which it is created. It is produced by such an obstruction as leaves a flattened aperture. It is a vibrating sound ; and either the walls of the tubes generally, or the lips of the aperture, where the obstruction exists, must be the seat of the vibration. The latter is probably the true explanation. A partial " swelling of the sides of a tube, particularly at its bifurcation, a pellet of tough mucous in it, or external pressure on it," may give the prop- er aperture to produce the sound ; but then there must be, in ad- dition to the form, a vibrating surface. I am of the opinion, that a viscid secretion assuming a fibrillate or stringy character, is real- ly the vibrating substance, though it may be that the substance of the tubes, when hardened by inflammation, is capable of vibrat- ing. It is mainly produced in the larger bronchial tubes, though sometimes in those of medium size. In the latter case, the sound usually has a higher note than in the former ; though it would seem that the size of the aperture, at the point of partial obstruc- tion, is principally concerned in giving key to the sound. It is most heard both anteriorly and posteriorly, when the ear is placed in most immediate proximity to the larger bronchi. It is well spoken of as a fugitive sound, since it will frequently cease and return, so far as one tube or point is concerned, with almost every act of respiration. It is not, however, always so move- ble ; and when it is, it still may often be heard with every respi- ration, though, successively, from different points. It exists with both inspiration and expiration ; but is quite as marked with the latter as with the former. The sound is pathognomanic of bronchitis. In the acute form of the primary disease, it almost uniformly attends the progres- sive stage. In the chronic form it is not heard. In many cases of secondary bronchitis which attends other diseases, it is heard. If not connected, however, with any of the humid rales, it is in- dicative of but a mild affection. I have only to add, that the sibilant and sonorous rales now AUSCULTATION. 1 19 described are sometimes commingled ; or there is a condition of the tubes which creates a sound partaking partly of each charac- ter. A sufficient explanation of this will readily be suggested, on recalling to mind the description of the physical cause of each sound. One other dry rale remains to be considered. It is the crack- ling. So far as I know, this has never, by pathologists, been par- ticularly described ; and yet it seems to me to be a peculiarity worthy of a definite description. The sound has generally been classed as a subcrepitant rale ; though by Dr. Gerhard, in the third edition of his work on Diseases of the Chest, it is clearly referred to, under the designation of a variety of the 'mucous. The French, indeed, in their hospitals, speak of it as un craquc- ment, the crackling, but do not assign it a separate rank among the rales. In its marked character, it is pathognomanic of phthi- sis ; and Dr. G. says of it, " It is produced by the softening of the thick pasty matter of tubercle, which gives a peculiarly dry and sharp sound." Though it merits a distinctive name as one of the rales, yet I have with some hesitation, decided to rank it with the dry, rath- er than with the humid. The sibilant and the sonorous are caused by a thickening, or a spasmodic contraction of the walls of the bronchial tubes, or by something internal, partially block- ing up the air-passages. Of course, the parts are, essentially, in a dry condition. The crackling rale of phthisis, however, indicates the third stage of the disease, when purulent matter is being dis- charged from softened tubercles. Still my impression is, that the sound is not produced exactly as Dr. Gerhard supposes, for I can- not understand the rationale of such a process. I think, that as the matter of tubercles is softening, some pasty portions block up the entrances just firmly enough to be removed with the full in- gress of the air, and that the movement of the partially dry and flaky deposits causes the crackling sound. Or it may be. that the change which inspiration effects in the relation of parts of indurated pulmonary substance, is concerned in the matter. As the air passes into the opening tubercles and disturbs their walls, the rubbing of one part upon another may produce a portion of the effect. Of course, so far as this is the case, the sound should 120 THORACIC DISEASES. not be regarded as a crackling rale, but should be classed with the adventitious sounds yet to be considered. When pus, in sufficient quantity, is poured into the larger bron- chial tubes, it gives the mucous rale, which is very commonly heard, in connexion with the crackling, though the latter may precede it, by a period of several days, and afterwards cease, leaving the mucous increasingly developed. Besides the sound now described, there is a comparatively un- important one, which I know not how better to class than as a crackling rale. Dr. Gerhard, if I understand him, speaks of this as the dry or rustling crepitant. He, however, scarcely describes it, and says that it " is of very little value, and hardly differs from the rustling sound of respiration." By this last phrase, he means what I have yet to describe as the emphysematous crack- ling. Dr. C. J. B. Williams, calls the sound the dry mucous rhonchus. He says, " It is produced by a pellet of tough mucous, obstructing a tube and yielding to the air only in successive jerks, which cause a ticking sound, like that of a click-wheel. When the air is driven very fast, these, as is the case of other click sounds, pass into a continuous note, and constitute the sonorous rhonchus. Sometimes, again, particularly in inspiration, the click sound sud- denly stops. the tough mucous being forced into a smaller tube, which it completely closes." The sound, which, however, but seldom occurs, supposes a condition of things somewhat similar to that which produces the sonorous rale. It is the result of chronic bronchitis, or a morbid power of mucous secretion ; and can hardly be confounded with the tuberculous crackling. The humid rales* are produced by the passage of air through a liquid of some kind, " forming bubbles of different sizes." These bubbles "vary according to the tenacity of the fluid, the size of the air passages, and the greater or less rapidity with which the air is forced through those passages." There are four of these rales, the crepitant, the subcrepitant, the mucous, and the gurgling. There is, however, no marked line of distinction between the crepitant and the subcrepitant, nor hardly between the subcrepitant and the mucous. The crepitant rale, in its most perfect form, is believed to be made in the vesicles the very extremities of the air-passages in AUSCULTATION. 121 the lungs ; or, in these, together with the very small terminating "tubes which ramify through the lobules." When the crepitus is not quite so delicate, the sound is probably produced in the small tubes, just before they enter the lobules. To describe this rale, various illustrations have been adopted. It has been compared to the sound produced by rubbing slowly and firmly, between the thumb and finger, a lock of hair near the ear; also, to the effervescing of bottled cider or champagne, to the crackling of salt, and to the successive explosions of a small train of wet powder. It seems to be formed by the rapid and equable succes- sion of extremely fine bubbles arising from the liquid which trav- erses the smallest bronchi. This liquid is necessarily thin ; as what is thick and viscid could hardly pass through the extremities of the tubes, and, especially, would not readily allow the passage of air in so delicate a series of bubbles. Some, however, have supposed, that the dilatation of the vesicles, thickened and stiff- ened by inflammation, assists in creating the sound.. So far as that may be true, it would not come within the definition of a rale. It would be an adventitious sound. I regard the former, however, as the true explanation. The sound is almost pathog- riomonic of pneumonitis in its first stage ; and, in that stage, the secretion into the air-passages is serous in character and thin in consistency. The other conditions which give rise to it are con- ditions of a thin liquid in the extremities of the tubes. It is con- fined to the inspiration, as, from the extremities of the tubes, the air is not pressed outward with a force sufficient to create the bubbles. From the nature of the morbid conditions which give rise to it, it must necessarily exist, mainly at the inferior and pos- terior portion of the lungs, though it may occur elsewhere. The sub-crepiiant rale is a coarser and less regular crepitation than the crepitant. The term is an awkward one to express the idea! It implies something less than the crepitant. It seems, however, to have been originally chosen, not to express that the former sound is less than the latter, but that the delicacy of crep- itation is less with the former than with the latter. I use the term, because it is established and for the want of a better. The second is intermediate between the crepitant and the mucous rales, and, by an insensible gradation, runs into the one or the 16 122 THORACIC DISEASES. other, according to circumstances. It is made, in the medium- sized tubes, by the bursting of bubbles through the contained liquid. The size of the tubes renders the sound coarser than is made in the extremities and the vesicles ; while the traversing liquid being commonly thicker and more viscid than is found in the smaller passages, causes the existence of less regularity in the succession of the bursting bubbles. This rale is heard chiefly in the inspiration, but very faintly in the expiration. Like the crep- itant rale, it exists, principally but not exclusively, at the inferior and posterior portions of the lungs. This results mainly from the nature of the diseases which produce it ; though the recum- bent, and the upright or partially upright position which the pa- tient generally preserves, favors the passage of the liquid contents of the tubes towards those portions. Ely far the most frequent causes of this rale are pneumonitis and bronchitis. It is heard in pulmonary oedema, and in hasmoptysis ; but serum and blood, being thin liquids, give a peculiar sharpness to the sounds produc- ed with them. The crackling rale of the third stage of phthisis, which is heard mainly at the superior portion of the lungs, has generally been ranked ag a form of the sub-crepitant. It is, how- ever, a dry sound, and is, withal, coarser than what ordinarily takes this name. For these reasons, I have given it a separate designation. The mucous rale is a louder and more irregular sound than the sub-crepitant. Indeed, the former is so fugitive, that it may pass away for the time, and not be restored, until a cough has trans- pired. The bubbling, also, of the former is more distinctly hur- ried than that of the latter. It is made only in some of the longer bronchi, where they are pretty well filled with a liquid. This liquid is generally pus, or mucus, or a mixture of both. Of course, it is generally thick, but not very tenacious. Serum and blood, however, will give rise to the sound ; but, when made by means of them, it will not have its usual softness of tone. When once heard in its marked form, it will ever afterwards be recog- nised. It very generally exists both in inspiration and in expira- tion. It is, however, comparatively a faint sound in the latter ; and, when the air returns from the lungs with but a feeble force, the liquid is not sufficiently agitated to excite it. The sound AUSCULTATION. 123 may be looked for, whenever the expectoration indicates that the larger bronchi are incumbered with a liquid which is not very te- nacious. It is produced in the developed stage of acute bron- chitis, and in the third stage of both pneumonitis and phthisis. Like the sub-crepitant rale, it may, also, be created by pulmonary cedema and haemoptysis. In some of these diseases, in phthisis especially, the rale is, in many instances, frequent and so loud as even to be audible, at a short distance from the thorax of the patient. One other rale remains to be considered. It is the gurgling. The sound of this does not differ very essentially from that of the mucous. It is, however, even louder, and is more hollow ; but it is, at the same time, more concentrated. It is produced in a cavity partially filled with a liquid of moderate tenacity, though of a size varying from that of a large pea to that of an orange, or even to the dimensions of the pleural cavity, in which this contained liquid is generally pus, or muco-purulent matter. The sound occurs in expiration, as well as in inspiration. The reason of this is, the returning current of air, as well as the entering, passes through the cavity and is reflected from its walls in such a manner as to disturb the liquid. Of course, the gurgling rale is almost continuous in its existence. It may cease, however, for a time, in consequence of the cavity's being emptied of its con- tents. In that case, the sound will be replaced by the cavernous or the amphoric respiration. This rale is, by no means, propor- tioned, in loudness, to the extent of the cavity. The quantity of liquid, the consistency of the surrounding pulmonary tissue, the amount of air admitted to pervade the cavity, and the position of its point of ingress in relation to the surface of the liquid, are all circumstances modifying the degree of sound. The diseases which give rise to this rale, are those in which pulmonary cavi- ties are formed and partially filled with liquid ; and, probably, forty-nine out of fifty of these will be found, on examination, to be tuberculous. Pneumonic and gangrenous cavities, however, occasionally yield the sound ; and so does the dilatation of one of the large bronchi. In this last oase, a sort of cavity is formed, through which the air freely passes, both in inspiration and in ex- piration. This cavity, if pus is not present, may yet contain 124 THORACIC DISEASES. mucus of such consistency as to give substantially the ordinary gurgling sound. SECTION V. ADVENTITIOUS SOUNDS. There are certain sounds, which have sometimes been classed with the rales or rhonchi, but which, from the circumstances of their formation, do not fall within the range of the definition usually given to that important class of sounds. I prefer, there- fore, to group them together, as a heterogeneous class, superadded to the rales properly so called. Hence the propriety of the des- , ignation, adventitious sounds. The first of these I term the emphysematous crackling. It is pathognomonic of the disease emphysema. In this disease, the dilated and stiffened parietes of the vesicles, rubbing against them- selves and perhaps against the pleura, in the motion produced by inspiration, cause a rubbing or crackling soi^nd. Dr. Gerhard calls this, in one place, the rustling sound of inspiration, and in another, the dry, sub-crepitant rhonchus. In strictness of defi- nition, however, it seems to me to belong to the adventitious sounds; for, though it results from the respiration, it is made me- diately, and not immediately, by the action of the air. The air distends the lungs, and the sound is the consequent rustling of the hardened and not very pliant membranes. Another of the adventitious sounds is the grating sound, sometimes called the creaking, the friction, the rubbing, and the new-leather sound. It is produced by the friction of the two surfaces of the pleura, when these surfaces are rough with the deposit of fibrin, constituting the condition which has, heretofore, been called that of false membrane. The real pathology of this condition will be elsewhere explained. Suffice it here to say, that, under the laws which govern the reparative process, the hyaline fluid or blastema deposited after the existence of inflam- mation of the pleura, renders that membrane uneven. When, therefore, an effusion of serous fluid does not keep the pulmonary and the costal portions of the pleura separate from each other, they rub together, in every act of respiration, and produce a sound AUSCULTATION. 125 very much like the crackling of pieces of parchment or new leather. This sound exists in both inspiration and expiration. When well developed, it is accompanied with a thrilling motion or quivering of the chest, which is very appreciable by the touch. When the deposit of fibrin is small, or when effused serum pre- vents the full contact of the roughened surfaces, the sound is im- perfect, and may very much resemble the crackling rale, or the sub-crepitant. They may generally, however, be distinguished without difficulty. The latter rales follow, more immediately and regularly, the act of inspiration, and they are less fugitive. The sub-crepitant, especially, is, likewise, more equal in its crepi- tation. Besides, the grating sound is mostly heard towards the lower part of the thorax, where the movement of the ribs is the greatest, and where the hyaline deposit is generally the most con- siderable. Other circumstances, too, will ordinarily assist in dis- criminating between the grating, and the resembling sounds. One of the latter may be simultaneously heard, in another part of the lung, and the history of the case may remove all doubts. The only other adventitious sound to be considered is the me- tallic tinkling. The name has its origin from the resemblance of the sound to the tinkle of a metallic vessel, when gently struck with some small but solid substance. A few years since, this sound was believed to arise from a drop of liquid falling from the top of a cavity upon the surface of the fluid occupying the lower portion of the cavity. More recently it has been suggested, that the tinkling is made by the bursting of a bubble of air, rising from beneath, upon the surface of the fluid. Possibly, each of these causes may, at different times, create the sound, though I believe the latter to be altogether the more common cause. Pos- sibly, too, the bursting of bubbles in the air tubes, constituting the mucous or the sub-crepitant rale, may sometimes be heard through a cavity, which is filled with air and the walls of which are elastic, giving to the sound, as it reaches the ear, the character of the metallic tinkling. To produce this sound, the cavity must be large. Generally, it is the pleural cavity, but sometimes a large tuberculous one. In the latter case, amphoric respiration is present, and determines the patient's pathological condition. Of course, the tinkling sound is not of much practical value. THORACIC DISEASES. SECTION VI. THE SOUNDS OF THE VOICE. In discriminating, between a healthy and a diseased condition of the lungs, and between different forms of disease, we are sometimes considerably aided by the peculiar sound of the voice, as heard from the thorax. Several circumstances, however, so modify the vocal vibrations, that we cannot rely on this means of diagnosis alone. The comparative thickness of the intercostal muscles and the amount of adipose tissue upon them, have an effect on the sound, a patient the walls of whose chest are ema- ciated yielding a fuller resonance in consequence ; while a large deposit of fat renders the sound feeble. The natural tone of voice, too, is concerned with its power of vibration. A bass voice is more resonant than a higher-toned one, and a naturally strong voice than a feeble one. Still, to some extent, the peculiarities of the voice correspond with the varieties of respiration. " In the ordinary act of speaking, the voice vibrates throughout the chest; and, if the hand be placed upon its parietes, a slight tremor is very perceptible. If we apply one ear to it, the other being closed, we shall hear a distant and confused sound." This sound is comparatively loud, if we listen immediately over the large bronchi ; and it becomes less, in proportion to the increase of the distance from those parts. The principal variation from exact proportion, has reference to the summit of the lungs, especially on the right side. The reasons already named, as varying the bronchial sound of respiration, have, also, an equal effect on the voice. Generally, where the vesicular structure abounds, and the bron- chial ramifications are small, we have, in health, but a faint vibra- tion of the voice. This may, therefore, be said to correspond with the vesicular murmur. Directly over the large bronchi, where the blowing bronchial sound of health is most marked, we have a strong vibration of the voice, which is usually called bronchophony, a sound from the bronchi. This may be de- scribed as a thrilling sound, in which no articulation is discovera- ble, and which seems to reach the ear as coming from the vocal AUSCULTATION. 127 cords or some point at a distance. It corresponds with the blow- ing bronchial respiration. Diseases of the chest often modify the vocal resonance. Some- times it is diminished. In emphysema, for instance, the increased quantity of air in the lung, renders it a bad conductor of sound ; and, hence the voice is heard more feebly. Liquid effusions into the pleural cavity, if considerable, compress the spongy texture of the lungs, flatten the bronchi, and partially or wholly destroy the vocal resonance. Most diseases of the chest, however, cause the voice to resound more strongly than it does in health. Bronchophony, as already defined, is generally produced, where it is not heard in health, by those diseases which cause bronchial respiration ; and it is pro- duced in the same portions of the lungs as the bronchial respira- tion. This sound, too, is usually more or less intense, according as the bronchial respiration is more or less shrill and tubal. The principal variation from the rale is in the case in which accumu- lated mucus obstructs the bronchi too fully to be removed by the act of speaking, but so that it is removed by a strong respiration. In this case, the vibrations of the voice are prevented, though the respiratory sound is not. In the most marked form of bron- ehophony, articulation seems almost to be heard, and the sound varies but little from pectoriloquy. The induration of a portion of the lung, in the second stage of phthisis, yields bronchopho- ny ; and pneumonitis, in the stage of hepatization, produces it in its most perfect form, Dilatation of the bronchi will increase the vocal resonance; but this is substantially of the nature of pecto- riloquy. In ail these cases, the principal evidence of the presence of disease, derivable from bronchophony, is its existence at points from which it is not heard in health. It is often, however, de- cidedly more distinct, than it ever is in health. Pectoriloquy, a speaking from the chest, is a resonance of the voice yielded by an ordinary cavity in the lung, or such a cavity as produces cavernous respiration. Of course, it corresponds essentially with cavernous respiration. In its most marked form, the vocal sound seems almost to be articulate, and to have its origin in the cavity from which it comes to the ear. In these two particulars, the resonance differs from that of bronchophony. 128 THORACIC DISEASES. When somewhat imperfect, however, the former can hardly be distinguished from the latter. A large bronchial tube surrounded by hardened pulmonary tissue may yield even a more thrilling sound than a cavity surrounded by spongy pulmonary structure and not so situated as freely to receive the external air. The most perfect pectoriloquy comes from a cavity of moderate size, entirely emptied, and having indurated walls. But pectoriloquy is seldom very perfect. A cavity is liable to be obstructed with muco-purulent matter, even if the other requisites to the creation of the sound are permanently present. Hence the sound is fugi- tive ; and cavernous respiration, together with the gurgling rale, is a more valuable guide in detecting the pathological condition, than pectoriloquy. Amphoric resonance of voice is a modification of pectoriloquy, heard from such a cavity as gives amphoric respiration. The difference between this sound, when marked, and pectoriloquy is, the former seems somewhat "more hollow, more distant, and more diffused," than the latter. If the cavity is one of consider- able size, the resonance is generally a clear ringing or quite metal- lic sound, somewhat like the noise produced by speaking into a glass tumbler or large open-mouthed vial, without entirely clos- ing the opening. This is especially the case, when the pleural sac becomes the cavity, in consequence of a communication made with the bronchi. In a tuberculous, pneumonic, or gangrenous cavity, the tone is not so short and the resonance is not so clear. It may even happen, that a cavity producing the' amphoric respir- ation, but, not being very large, shall be in such a condition, that the amphoric resonance will scarcely differ from pectoriloquy. If the parenchyma of the lungs around the cavity is soft and per- meable, the resonance is generally quite obscure. If the bronchi become obstructed, it will, of course, entirely cease. Egophony, sometimes written aegophony and hsegophony, is a peculiar quivering sound, and takes its name from two Greek words signifying the sound of a goat. It resembles the bleating of a goat or a sheep, and may be tolerably well imitated by speaking through a common speaking trumpet. The sound is really bronchophony, modified by the influence of a pleuritic effusion, or the existence of a thin liquid in the pleural cavity. RATIONAL SYMPTOMS* 129 In order to its production, however, it is necessary that the quan- tity of the liquid be limited. Generally, the lung must be mod- erately compressed, but not much flattened by the pressure. Hence the sound is heard, in the second stage of pleuritis or in hydrothorax, when the water is beginning to collect, and when it is nearly absorbed. Too small a quantity is riot sufficient to afford the vibrations. T^oo much so compresses the lung that the air is prevented from sufficiently filling the bronchial tubes. If, however, the substance of the lung happens to be somewhat rigid and solid, in consequence of previous inflammation, so as to produce strong bronchial respiration, the egophony will continue, as the water increases, much longer than it otherwise would do. It may last even during the whole existence of the disease. Still it is, ordinarily, quite transitory, passing away in a few days. Egophony, when existing, if the patient sustains the up- right posture, is most distinctly heard, posteriorly, near the lower margin of the scapulas ; but, with a change of position, there is a change in the audibleness of the sound, -it being best heard about the upper portion of the liquid, except so far as obstacles to the conduction of the sound modify the result. CHAPTER X. RATIONAL SYMPTOMS. SECTION I. D Y S P N CE A . As diseases of the thorax, to a greater or less extent, affect the respiration, a few general remarks on the subject of dyspnoea are not inappropriate in this place. There are four circum- stances, particularly, the existence of any one of which will disorder the respiration, unless its influence is by some means counterbalanced. These circumstances are certain disordered conditions of the blood, a deficiency in the quality or quantity of inspired air, a defect in the machinery designed to bring the blood and the air into contact, and a diseased state of the nerves, whose office is to invite to action the muscles of respiration. To some 17 130 THORACIC DISEASES. extent there may be a balance of influences. For instance, the distress which would otherwise arise from a deficiency in the quality of air allowed to enter the lungs, may be prevented by such a diminution of nervous sensibility as renders the patient insensible to the want experienced. Dr. C. J. B. Williams has given us the following table, showing what he calls " the proxi- mate causes of dyspnoea." The table is very accurate and appropriate ; though not being founded directly on the circumstances which I have named as remote causes, the classification is not what those circumstances would directly suggest. I would here remark that the original import of the term, dyspnoea, is difficult breathing, and Dr. Wil- liams has here used it in a sense so extensive as to embrace the slow labored respiration of coma, though it is ordinarily limited to what is hurried and distressing, and it is in this sense, mainly, that it is concerned with diseases of the thorax. 1. BY IMPEDING THE ACCESS OF PUKE AIK TO THB LCXGS. a. Mechanical. Rigidity of parts of the respiratory machine: e.g. Ossification of cartilages ; induration of the pleura ; rickety distortions/ Pressure on ditto : e.g. Tumors or dropsies of the abdomen. Obstructions of the air-tubes : e.g. Effusions in, swellings of, tumors pressing on, the air-tubes j Spasm of the glottis ; spasm of the bronchi. Compression of the lungs : e.g. Effusions or tumors in pleural sac ; Pleurisy, Hydrothorax, Pheumothorax, Aneurism, &c. Alterations in the tissue of the lungs : e.g. Engorgement, Effusions : (Edema, Hepatization, Tubercle, &c. Altered structure : Emphysema, Dilated bronchi, Vomicae, &c. b. Chemical. Deficiency of oxygen in the air : e.ff. Mephitic gaee? ; rarified air. RATIONAL SYMPTOMS. 131 c. Vital. Pain of parts moved in respiration : e.g. Pleurodynia; pleuritis; peritonitis, &c. Paralysis of muscles of respiration : e.g. Injuries of the spinal marrow on the neck, nitely, it signifies a soft tumor arising from air admitted into areolar tissue. In this sense surgeons still use it, to express that pufliness which arises from the admission of air into the areolar tissue, in connection with the occurrence of a compound fracture. In this case, however, the most common source from which the air is received, is the lungs. Suppose, for instance, a rib is frac- tured, and a bone has broken through the . pleura and wounded the lung. The air, passing directly into the areolar tissue, diffuses itself over the chest, neck, and other parts. It may even pass 200 THORACIC DISEASES. somewhat extensively over the body. The parts thus affected give a peculiar sense of crackling, when pressed by the fingers. The disease, however, of which I am now to speak is pul- monary emphysema, or air in the parenchyma of ^he lungs. For brevity's sake, this is commonly spoken of simply as emphysema, the epithet descriptive of locality being omitted. But emphy- sema, in this sense, is divided into two kinds, vesicular emphy- sema and interlobular emphysema. In the former kind, the air is pent up in the vesicles, dilated to a greater or less extent. In the latter, it is effused into the areolar tissue, or held in its meshes, between the lobules, and beneath the pleura. SECTION I. VESICULAR EMPHYSEMA. PATHOLOGY. The enlargement of the cells, in this case, is very analogous to that dilatation of the bronchial tubes already de- scribed. In fact, a slight modification of the causes which pro- duce the one will evidently produce the other. In the normal state, the vesicles are of such a size as barely to be discoverable by the eye ; but, when enlarged by emphysema, they very com- monly attain to the size of a millet-seed, and may become much larger. Sometimes sacs of the size of a pigeon's or even a hen's egg form ; but, in such cases, most unquestionably several vesi- cles rupture in such a manner as to form one cavity. In other words, they break into one. The sacs thus formed, by crowding against one another and against the more healthy pulmonary tissue, are made to assume various shapes, according to the accidental pressure. If the sur- face of a lung affected with vesicular emphysema be examined, the dilated vesicles can be seen through the pleura. Where they are equally enlarged, they appear like healthy vesicles viewed through a magnifying glass. But, sometimes the vesicles of one lobule are enlarged, while those of an adjoining one are of the natural size. In such a case, the emphysematous lobule be- comes conspicuous by its protrusion ; and the intermingling of those in an abnormal and those in a healthy condition, render the PULMONARY EMPHYSEMA. 20 1 surface quite irregular and uneven. Sometimes a large globular prominence is seen resembling a small bladder ; but this, when examined, will be seen to arise from a depression into the lung of essentially the same size as the elevation without. Of course, a bulla of this kind cannot be passed about, as can the sub-pleural collections of air in interlobular emphysema. Under the pressure of the finger, an emphysematous portion of lung crackles, like a piece of healthy lung, when dried. The walls of the vesicles, having lost their elasticity, have become rigid. The emphysematous portions, also, are pale, sometimes almost white. Occasionally, the parietes of the lung appear as if they had been bleached. This paleness is most seen towards the free edges of the lung. " Sometimes these edges are rounded and thick ; sometimes thinner and folded back ; while, some- times, the margin is blown out, as it were, into an irregular fringe ; some of the inflated portions remaining connected with the lung by slender pedicles, and these forming appendices to it, of a light yellow color," appearing like a fringe of fat. If this em- physematous border be held between the eye and the light, it will appear translucent. If it be punctured, the surrounding parts collapse, proving that the dilated vesicles communicate with each other. The size of an emphysematous portion of lung is increased, and the tissue becomes specifically lighter, so as to float light on water, like a bladder filled with air. The increased size causes a pressure against the ribs and the intercostal spaces, and distends the walls of the chest at the part corresponding with the dis- tended portion of the lung. There is, consequently, at this part, a protuberance, which sometimes becomes very marked. Some- times, however, so large a portion of the lung is affected, that one side of the thorax seems generally distended. The emphysematous portion of the lung, which is generally the anterior margin, becomes comparatively anasmic, while the posterior portion is not so affected, but sometimes even becomes congested in consequence of the attending dyspnoea. In vesicular emphysema, the morbid condition, once introduced, generally continues and gradually becomes worse. The interference with the nutrition of the lung renders it less able to resist the cause of 26 202 THORACIC DISEASES. the affection ; and, hence, the disease is almost necessarily progressive. Vesicular emphysema is very liable to be complicated with other diseases. In the first place, it is probable that bronchitis, either acute or chronic, is usually the leading cause of its exis- tence. The inflammation of the acute form, or the thickening of the membrane in the chronic, it is easy to conceive, may so affect the entrances into the vesicles that, while the air is readily forced in, in inspiration, it does not as readily return in expiration ; and, hence, the liability of the vesicles to become permanently enlarged. The air being incarcerated and accumulating in the vesicles, they yield to its distending force and lose their elasticity. If, at the same time, there exists a hard cough, the forcible efforts made will increase the difficulty. But, besides this connection of vesicular emphysema with bronchitis, the former disease is liable to induce the latter, and thus stand to it, in the relation of cause, as well as effect. The embarrassment of the respiration and the agitation produced ne- cessarily determine more blood to the neighboring tubes, produ- cing congestion and the liability to inflammation or bronchitis. The congested or posterior portions of the pulmonary tissue, too 3 readily pass into a state of inflammation, constituting pneumon- itis. Again, the obstruction of the blood in passing through the lungs prevents the right side of the heart from emptying itself freely. The consequence is palpitation, or increased muscular contractions of the right ventricle, followed by a " yielding of its walls to the augmenting [pressure of the contained blood." Of course, this embarrassment in the circulation is greatest when the dyspnoea is greatest ; but the right cavities of the heart become permanently dilated, and the dilatation leads to anasarca, particu- larly oedema of the feet arid ankles. Finally, the opinion has prevailed, that asthma is induced by this disease ; and it is easy to see how the nervous system may become so affected by it as to constrict the bronchial tubes. The manifestations of emphysema, however, so far resemble those of asthma, that the one disease has evidently been often mistaken for the other. Having referred to one perhaps the principal cause of em- physema, I now add further, that, besides bronchitis, any thing PULMONARY EMPHYSEMA. 203 else which impedes the free exit of air from the lungs may pro- duce it ; and, among the other causes, may be reckoned blowing on wind instruments, and pressure made on parts of the lung, as by a tumor in the thorax, an enlarged heart, an aneurism, tight lacing, or a deformed condition of the chest. DIAGNOSIS. Among the general signs of vesicular emphysema, an habitual shortness of breath, with occasional paroxysms of extreme dyspnosa, is prominent. In a case of moderate severity, the patient is conscious of a little shortness of breath, on walking up a hill or making some unusual exertion. In an extreme case, the act of ascending a few steps of a staircase will render him breathless. The paroxysms of dyspnoea will frequently occur without any assignable cause, and, when existing, will oblige the patient to sit erect or lean forwards. In such a case, the muscles of respiration are thrown into violent action ; the face becomes livid and swollen, and great constriction is experienced at the pracordia. There is, also, in this disease, a cough which is somewhat pe- culiar. At first, it is rather dry and wheezing ; or there is, to a small extent, an expectoration of thick pearly sputa, but, after paroxysms of dyspnoea are established, there is a more copious ejection of a thin, glairy, and transparent matter. Palpitation of the heart, and that secondary consequence, oedema of the ankles, are also among the general signs of this disease. The physical signs in a well developed case of vesicular em- physema are distinctly marked. They are principally these, the distention of a portion of the thorax, diminished movements of its walls, resonance on percussion, a peculiar feebleness of the healthy sounds of respiration, and the cmphysernatous crackling. The last, when heard, is pathognomonic of the one or the other form of emphysema. The distention of the thorax is necessarily the greatest in those portions in which the dilatation of the vesicles is the greatest, and those, I have already said, are at the anterior margin of the lungs. Hence the anterior thoracic plane becomes decidedly convex. The form of the distended portion is generally rather oval, hav- ing its long diameter parallel with the axis of the body. It is, 204 THORACIC DISEASES. however, irregularly prominent and unsymmetrical, bulging here and there in correspondence with the enlargement within. If the emphysema becomes extensive on one side, and especially if on both, it elevates the ribs and gives to the whole chest a form nearly cylindrical. But this happens only to those who have long been subject to the disease. The intercostal spaces, in this dis- ease, are elevated more than to retain their ordinary relation to the ribs. The intercostal tissues, being flexible, are pressed up to a level or more with the ribs. The appearance of the clavicle is almost effaced, the spaces above and below are so raised. It is proper here to remark, that the distention of the chest in emphy- sema is always comparatively moderate, and never attains to that degree which is common in pneumothorax. The movement of the thorax in vesicular emphysema, is decid- edly less than in health. The lung having lost its elasticity, and the vesicles during respiration, remaining distended with air, the thorax necessarily preserves nearly the position which it has im- mediately after inspiration. Its motion is very limited. This, however, gives rise, to some extent, to that peculiar motion of the abdominal viscera usually termed abdominal breathing. The resonance on percussion is greater, in vesicular emphyse- ma, than in health, from the fact, that the lung contains more air, and is permanently distended. With persons whose thoracic par- ietes are thin, the abnormal resonance is considerable ; but, with corpulent persons, and especially with those whose advanced age has appreciably diminished the elasticity of the chest, a moderate degree of emphysema will not give much unusual clearness. Over the most dilated portion of the lung, the clearness is always the greatest. Occasionally, where the lung is extensively dilated, the resonance approaches, in degree, that produced by pneumotho- rax ; but the sound, in the former case, is never so tympanitic as in the latter. In regard to the sounds of respiration, both the healthy bron- chial and the vesicular sound are diminished. Before the disease, however, has made much progress, and has not very much com- pressed the lung, the bronchial sound remains nearly normal ; but, in that portion to which the disease has extended, the vesicular sound is completely destroyed. The vesicles, when once filled, PULMONARY EMPHYSEMA. 205 remaining inflated, of course, can give none of the ordinary sounds. But the pathognomonic sign of emphysema, in one of its forms, when heard, is the emphysematous crackling sound. This is a rustling sound, which nothing but the condition of the lung ex- isting in this disease can produce. It is never heard till the dis- ease becomes severe. Indeed, it is probable, that vesicular emphy- sema, uncombined with interlobular, never gives rise to it, till nu- merous sacs are formed from the breaking of one cell into another. Be that as it may, the sound supposes a dry, hardened, and not very pliant condition of the membranes. It may even be, that it involves some inflammation of the parts affected. PROGNOSIS. The prognosis, in simple vesicular emphysema, is favorable, so far as prolonged life is concerned. Persons seldom or never die of this disease, alone. Recovery, however, is hardly to be expected ; and the danger lies in a complication with other and graver affections. Generally, the progress of the disease is slow and undisturbed. If, however, it happens to be suddenly devel- oped, by the influence of some preceding acute disorder, there may be a partial, though there is seldom or never, a full return towards health. TREATMENT. But little treatment of vesicular emphysema is of any service. Sinapisms, applied between the shoulders posteriorly, and over the dorsal vertebrae may, by their stimulating power, af- ford some relief in a paroxysm of dyspnoea. The anti-spasmodic effect of the lobelia inflata, too, is favorable. It may be given in common tincture, in doses of twenty or thirty drops. I prefer^ however, to combine it with cypripedium pubescens or scutellaria lateriflora. The compound wine tincture, according to the formu- la, may be given in dram doses, every two hours. To this prep- aration, twenty or thirty drops of chloric ether may be added, with a favorable anti-spasmodic effect. Opiates combined with nauseants, in sufficient doses to quiet the cough, have been rec- ommended ; but the effect of the simple nervines, in connection with the nauseants, is far preferable. The moderation of the paroxysms is essentially all that should 206 THORACIC DISEASES. be aimed at. We know of no means of eradicating the disease. Of course, if it is complicated with other difficulties which are remediable, those should be removed ; and circumstances tending to aggravate it may be guarded against. SECTION II. INTERLOBULAR EMPHYSEMA. PATHOLOGY. The areolar tissue which binds the lobules to one another, is, in its normal state, quite dense and close ; but, when inflated with air, it is capable of a good deal of expansion. It is, in this tissue, that the air is found in interlobular emphysema. When the disease is slight, such of the affected parts as are visi- ble on the surface of the lung, appear as little bubbles of air, ar- ranged like beads upon a thread. In extreme cases, however, the lobules are widely separated by the effused air, the partitions being sometimes, even one inch in breadth. These partitions are broadest towards the surface of the lung, and narrowest in the deepest-seated portions. Indeed, they show an arrangement some- what like the section of an orange in which the septa radiate and diverge from a centre. In this form of emphysema, it is common for bullas to form on the surface of the lung, by means of air in the subserous areolar tissue, that is, the tissue which connects the pleura with the pulmonary parenchyma. These bullee maybe distinguished from the bladder-like prominences which appear there in vesicular em- physema, and which are dilated vesicles. The former are moved hither and thither, underpressure ; the latter are stationary. This sub-pleural effusion of air is sometimes very great. The bulte are said, sometimes, to equal a hen's egg in size, or even to be larger. " Bouillaud," says Dr. Watson, " mentions a case in which the bladder or pouch was equal to the size of a stomach of ordin- ary dimensions." The contents of these sacs are supplied from the air passages, doubtless by the rupture of some of the superficial vesicles. Sup- pose then, such sub-pleural collections of air, and suppose that, under the pressure, the pleura gives way. The immediate conse- PULMONARY EMPHYSEMA. 207 quence is pneumo-thorax, complicating the emphysema ; and this condition of things sometimes, though not often, occurs. In severe cases of interlobular emphysema, the air readily passes to the areolar tissue of the mediastinum, and thence to the sub- cutaneous areolar tissue of the neck and chest. In such a case, we have not merely pulmonary emphysema, but emphysema, in a more enlarged sense. Between vesicular emphysema, and interlobular, there is an im- portant difference in the circumstances of their formation. The former is slowly and gradually established ; the latter, suddenly. The permanent dilatation of the vesicles requires time ; and they lose their elasticity and break into one another only by degrees. The interlobular effusion of air, on the contrary, may be effected in a few minutes, or even seconds. It is produced by some vio- lence. A woman may so exert herself in childbirth, or a man in lifting some heavy body, that, as a deep inspiration is taken and the glottis is voluntarily closed, some rupture takes place, opening a vesicle or vesicles into the areolar tissue. DIAGNOSIS. -The general and the physical signs of this form of emphysema are mostly the same as those of the vesicular. The emphysematous crackling, however, is much more extensive and perfect, in this form than in the other. The dyspnoea, too, the distention of a portion of the chest, and the resonance on the per- cussion of that portion may be greater. But the suddenness with which interlobular emphysema is developed, and the graver char- acter which it assumes, afford the principal means of discriminat- ing it. PROGNOSIS. The prognosis in this case is very different from that in the other. Under favorable circumstances, the newly de- veloped disease will sometimes cure itself. The rupture, proba- bly under the influence of inflammation and the subsequent gran- ulating process, closes over, and the effused air is absorbed. If, however, this does not soon take place, or if the opening is re- established and remains, the disease is generally, soon fatal. TREATMENT. But little can be done directly to aid the process 208 THORACIC DISEASES. of cure, if it takes place. Equalizing the circulation and quiet* ing the nervous system, so as to allow the reparative process to go on uninterrupted, will be of service. If the disease is termin- ating fatally, the means of palliating it, or relieving the urgent symptoms, are the same as recommended for vesicular emphy- sema. CHAPTER VII. PULMONARY CONGESTION. PATHOLOGY. This is an abnormal fullness of the blood-vessels % of the lungs, which are situated anatomically between the right and the left side of the heart. It is produced, sometimes by gen- eral and sometimes by local causes. When the right ventricle of the heart throws more blood into the lungs, than the left ventri- cle throws over the system, that is, away from the lungs, there must necessarily be an accumulation, and we speak of the lungs as congested. This difficulty arises from various causes. Cough- ing in pertussis or in severe bronchitis, may arrest, for a time, the circulation in the lungs. Running, straining, or any violent execution, by which the person is put out of breath may do the same. But disordered nervous action will frequently produce a less temporary congestion of the lungs. This remark is applicable to both sexes, though it is mainly illustrated in the case of nervous and hysterical females. Taking cold at the menstrual period, habitual amenorrhoea, or almost any disturbance of uterine action, with some constitutions, will be sufficient to develop pulmonary congestion. There are two very different conditions under which this con- gestion occurs. One is with females who are of sanguine tem- perament and plethoric habit, with whom the congestion is of the active kind. The other is with those whose tendency is towards anaemia or chlorosis. whose blood lacks corpuscles, or corpuscles and fibrine, and with whom the congestion, when it occurs, is of the passive kind. PULMONARY CONGESTION. 209 DIAGNOSIS. The indications of this disease are, principally, 'dyspnosa or hurried respiration, the lungs but imperfectly filling with air at each inspiration : some degree of dullness on percus- sion, in consequence of the fullness of the congested lungs ; and the existence of haemoptysis or pulmonary hemorrhage. This last symptom, when connected with active congestion, may be called tonic hemorrhage ; but, when with passive con- gestion, atonic hemorrhage. Hemorrhage not imfrequently occurs in connection with the existence of phthisis, either at an early period, or more often at an advanced. But, in all these cases, it is to be regarded as a symptom of disease, rather than as disease itself. In phthisis, blood-vessels are invaded by the tubercular disease, and even laid open. In congestion, the case is very dif- ferent. Sometimes, the smaller blood-vessels, it is true, are rup- tured. This is evidently done when the hemorrhage suddenly follows a straining or violent effort ; but, ordinarily, the discharge of blood is an effusion from the mucous membrane of the bron- chial tubes. Whether the leakage be from the capillaries, or, as is more probable, from the smallest veins, it is from vessels lying near the mucous surface of the tubes, they being there congested. In active congestion, the blood is too violently forced into those vessels. In passive congestion, the vitalizing power of the blood itself is feeble, the coats of the vessels most often, are morbidly relaxed, and the mechanical pressure of the current within produces an effusion, while there is not sufficient power to force the blood in its proper channels. The existence of the blood in the larger and the medium-sized bronchi, before it is ex- pectorated, causes the mucous and the sub-crepitant rales ; but thinness of the liquid through which the air passes, renders the sound sharper and more snapping than is that of those rales when made in mucus or pus. TREATMENT. If hemorrhage has occurred, the arrest of that is the first indication to be fulfilled. To effect that object, the in- ternal use of astringents, or astringents combined with vegetable stimulants, is valuable. As astringents, cutechu, kino, tannin, trillium pendulum, and lycopus virginicus are all valuable. The last, most of all, has a special reputation as an astringent and a 27 210 THORACIC DISEASES, styptic. Whatever article is relied on, liberal doses should be given and repeated every few minutes, till the hemorrhage ceases. The addition, in small quantity, of some simple vegetable stimu- lant, as capsicum baccatum, to the astringent, increases its effi- cacy. The best known styptic, however, to be employed, -whether in haemoptysis, or in other hemorrhages, is the chloride of sodium (common salt.) A saturated solution of this in water should be prepared ; and the patient may drink from a fluid dram to a fluid ounce of the liquid, frequently repeating the dose, till relief is gained. The modus operandi of this remedy is not very fully understood. I suppose, however, it acts by means of the stimu- lating or energizing properties introduced into the blood by venous absorption. In connection with these means, soaking the feet in warm water, swallowing small pieces of ice, and other means of equalizing the circulation are useful. The blood should, as much as possible, be invited and impelled away from the part affected. In regard to the removal of the congestion itself, and guarding against future hemorrhages, different means are required, accord- ing to the existing conditions and causes. If the hemorrhage is the result of violence, especially, if some of the vessels have been ruptured, rest or the most quiet condition possible should be peremptorily enjoined. The nervous system should be kept quite calm ; and, if possible, all severity of coughing should be avoided. Should pulmonary pneumonitis occur, it must be treated accord- ingly. After this has subsided, if a weakness at the spot remains, gentle local stimulants, as strengthening plasters, may be of some service. But regard to the general health, in the use of simple restoratives, should give the leading feature to the treatment. In the case of a sanguine and plethoric female, especially if there is menstrual suppression or a partial interruption of the menstrual function, the emmenagogue and depletive treatment is, to an ex- tent, indicated. Hence, agents to produce uterine action and a hydragogue cathartic effect, such as macrotine, podophilline, and the like, are beneficial. But, in the case of passive congestion, giving rise to atonic hemorrhage, a very different treatment must be adopted. The chlorotic or anaemic condition of the blood requires primary at- PULMONARY APOPLEXY. 211 tention. The deficient corpuscles and fibrine must be restored, and thus more vitality be added to the system. Direct and ef- fective emmenagogues used in this case, produce only evil. Agents adapted to produce a healthy uterine action, as the trillium pendulum, rnacrotine, and the like, will do no injury, but will be favoraqle ; but. all depleting measures must be avoided. Stimu- lating drafts applied to the feet, the tepid sitz bath occasionally, and friction to the surface, are beneficial. The vegetable stimu- lants and bitter tonics, to some extent, are indicated ; but the most effective means of removing the disease are the use of iron, in some form-, and such vegetable agents as directly improve the vital powers of the blood. Of the different preparations of iron, the iodide, the carbonate, and the sulphate are all valuable ; but I prefer the last. Of the vegetable remedies indicated, the com- pound sirup of aralia nudicaulis and guaiacum wood are among the most efficacious. CHAPTER VIII. PULMONARY APOPLEXY. I use this term for want of a better, though there is an etymo- logical objection to its use. Apoplexy, in Greek cwrwX"/^!^ is from the preposition a from and the verb tfX-^w to strike, to strike from, or strike down. The term is applied to a disease of the brain, under which a person falls suddenly down and lies in a comatose condition, the circulation and the respiration continuing, but the breathing being commonly stertorous. This disease, pathologically examined, was found to consist of a congestion of the blood vessels and an extravasation of blood upon the brain. When, therefore, it was found that a certain pathological condition of the lungs consists in the extravasation or the effusion of blood into the areolar tissue or the parenchyma, and that the blood remains fixed there, as does that thrown out upon the brain in the cranium, the term apoplexy was, by an analogy not very remote, applied to that pathological condition, and it was called pulmonary apoplexy. 212 THORACIC DISEASES. PATHOLOGY. In this disease, there must necessarily be, at the outset, congestion of the blood-vessels, to a greater or less extent ; but the hemorrhage which occurs is peculiar and characteristic. The blood, instead of passing into the bronchial tubes and being discharged by coughing, is lodged in the areolar tissue, and con- fined there, or is effused into the vesicles and the terminal bron- chial tubes which are situated within the lobules. Sometimes the blood is evidently extravasated, and the pulmonary tissue is broken down or torn. In this disease, there is a clear resem- blance between the injury and that which exists in the brain when there is cerebral hemorrhage. Ordinarily, however, there is no such laceration ; but the lobules are gorged with blood which has been somehow effused. Pathologists are not agreed to what extent the blood passes directly from the coats of the vessels into the areolar tissue, and to what extent it is poured into the air passages, at or near their terminations. Sometimes, with the induction of this disease, there is no hemoptysis, though oftener there is, at least, some slight discharge of blood, in connection with coughing. Now, if the blood is pent up in the areolar tissue, it of course cannot escape. The fact, that there is generally some haemopty- sis, proves that some blood does actually enter the air passages. If the blood mainly, or to any extent, is deposited in the air pas- sages, why is it not thrown out by the cough which the irritation must produce ? To this it is replied, that, in the compressed lobules, the nervous energy may be so deadened, by the pressure or other means, that no important degree of irritation is produced ; or the bronchial outlet from each lobule may become compressed or blocked up with coagulated blood so as not to allow of an evacua- tion. This disease, like the congestion already considered, has been very commonly referred to the effect of a contracted mitral orifice not allowing the blood to return, from the lungs, with sufficient rapidity. But, though this will account for the congestion of the pulmonary apoplexy, except the ordinary pulmonary hemorrhage and hasmoptysis, yet if the blood is effused directly into the areolar tissue, the cause must be sought in the pulmonary parenchyma, and not in the heart ; and, if the effusion is direct into the term- PULMONARY APOPLEXY. 213 inal air passages, and yet there is little or no tendency to hasmoptysis, the cause of that peculiarity must be sought for in the lungs themselves. Some consider that the disease is con- nected with the capillaries rather than with the larger blood- vessels, and that it differs from inflammation mainly in the blood's lacking the phlogistic and reactive character of inflammation. It appears that there is a weakness in the vessels and the tissues concerned, by which the blood leaks or oozes into its place of deposit, and little or no vital reaction is established. Dr. Thomas Watson thinks there is sufficient reason for con- sidering the blood in pulmonary apoplexy to have been first poured into one or more of the larger branches of the bronchial tubes, and then to be driven backward into the pulmonary lobules by the convulsive efforts which the patient makes in respiring, or by paroxysms of coughing. He thinks that clots of blood found to exist in different and distinct parts of the lung, at the same time, are phenomena to be explained in this manner. When the texture in some of the lobules is lacerated, he thinks that the lesion happens through the violence of regurgitation on the part of the blood in the bronchi. In support of this view, he relies mainly on the fact that the body of a person who died of a rup- ture of the lingual branch of the carotid artery, while suffering from tonsillitis, exhibited, at the post mortem examination, hard, dark and small masses of blood, scattered through the parenchyma of the lungs, as well as clots about the trachea and glottis. The doctor takes it for granted that the blood forming these masses in the parenchyma passed there, from the lingual artery through the trachea and bronchi, and hence concludes, that all such masses are formed from blood received through the bronchi leading to the places of their existence. According to this theory, it might be inquired, how the engorged condition of the lung should take place, and yet no hemoptysis whatever occur, as sometimes happens ; but the subject is one on which, it seems to me, we need more light. When the lung in the condition of pulmonary apoplexy is ex- amined, there are generally found hard knots or compact masses, situated here and there, mainly in the lower lobe and towards its posterior surface. These knots are of a dark red or brown color, 214 THORACIC DISEASES. and are of different sizes, ranging from the size of a pea or small marble to that of a hen's egg. When cat through, they show a circumscribed surface, in strong contrast with the surrounding tissue. They are evidently composed mainly of deposited and coagulated blood. As the different lobules have no direct com- munication with each other when the masses become large, they are evidently formed by the engorgement of several lobules in proximity. Sometimes there are but few small masses or nuclei. The dis- ease consists mainly in the existence of one large diffused mass, occupying nearly the whole of one tube, but having limits ob- scurely defined, the color gradually deepening in the course from the border to the centre. In this case, the central portion is' obviously formed almost solely of a black clot of blood ; while, at a distance from the centre, the sanguineous deposit is more diffused and intermingled with the pulmonary tissue. DIAGNOSIS. The symptoms of pulmonary apoplexy are not con- stant. Among those which more generally appear, are dyspnoea, a sense of tightness or a dull pain in the chest, a cough, and he- moptysis. The blood expectorated may be a mere tinging of the sputa, or a little pure blood raised in coughing. Often, however, in this disease, there is little, sometimes no haemoptysis, the ef- fused blood coagulating and remaining undisturbed in its place of deposit. Among the physical signs is feebleness or absence of the vesic- ular sound over the part affected. If the disease is extensive, the sound will be almost entirely wanting in the lung. At the same time, the respiration may partake decidedly of the shrill bronchial character, especially towards the root of the lungs. In one remarkable case which came under my treatment, the air- passages of the right lung were so completely blocked up, that no sound of respiration whatever was heard, except over the largest bronchi, and the superior lobe. Of course, what sound there was, was of the shrill bronchial character. When sufficient hemorrhage takes place, or blood is found in sufficient quantity in the medium-sized bronchi, the sub-crepitant rale is heard ; arid, in the largest bronchi the mucous is also heard, if there is sufficient PULMONARY APOPLEXY. 215 liquid there to produce it. These rales, of course, have the pecu- liar character given them by the thinness of the liquid. If the disease is slight, there will be, on percussion, a slight dullness only ; but, in graver cases, the dullness will be consider- able. In the unusual case to which I have just alluded, there was dullness amounting almost to flatness, all over the lower half or more of the lung, anteriorly, posteriorly, and laterally. Indeed, the percussion was hardly normal on any portion of the right side of the thorax. This case commenced suddenly in the night, after exposing the chest and taking cold the previous evening. There was, at first, a slight haemoptysis, but hardly enough to create the sub-crepitant rale ; and some febrile symptoms lasted for a few- days. In one year, symptoms of tuberculous disease developed themselves; and in six months more the patient died of phthisis. Whether this disease, in its incipient state, was there in the first place, cannot be known. Possibly latent arid incipient tubercles might have assisted in producing the pulmonary apoplexy. PROGNOSIS. The prognosis, in the case of pulmonary apoplexy, is not very favorable. The disease supposes an antecedent seri- ous affection of some sort, or perhaps a complication of affections. By its irritation, also, and its disturbance of the function of respi- ration, it almost necessarily leads to other ill results. TREATMENT. If there is haemoptysis, that is to be arrested, as described in the treatment of congestion. If febrile action is ex- cited, that should be treated as in other cases. But, in regard to the removal of the coagulated blood, remedial means can accom- plish but little. Simple expectorants and demulcents to relieve the air passages and allay irritation, may prove palliative. If there are complications of other diseases, they should receive prop- er attention, and so should the general health of the patient. 216 THOUACIC DISEASES. CHAPTER IX. PULMONARY GANGRENE. I use the phrase pulmonary gangrene, in accordance with com- mon professional usage. Pulmonary mortification, however, would be a more appropriate designation, as the phrase is not intended to be limited to a partial destruction of the parts, but simply to an entire loss of vitality and sloughing. PATHOLOGY. Pulmonary gangrene may occur either as a pri- mary or a secondary affection. When it is primary, it results from a reduced state of the blood, in which the vitality or nutrition of the part is not sustained. As a secondary affection, it occurs some- times in asthenic pneumonitis. In the primary form, the diseased part is, at first, infiltrated with a thin serous liquid which is an exudation dependent on the incipient gangrene. In the seconda- ry forai) the tissue in the beginning, is hard and congested, and situated in the midst of an inflamed portion of the parenchyma, This difference of anatomical character in the part affected, at the outset of the disease, is essentially all that distinguishes the pri- mary form from the secondary. They soon assume essentially the same appearance. Sometimes the disease occupies a large portion of the lung ; and sometimes it is quite limited. Like pneumonitis, it generally begins in the lower half of the lung. The color of the part that has perished, is mostly a dirty olive color or greenish brown,, The part becomes moist and of the consistence of an engorged lung, or softer. Sometimes, it is even diffluent. Sometimes the disease of pulmonary gangrene has been divi- ded into three stages. The first embraces the period in which the mortification is just fully established ; the second, that in which the tissue begins to break down ; and the third, that during which a cavity exists. After the explanation which I have elsewhere given of the nature of mortification, the pathology of pulmonary gangrene needs no further illustration, except to say, that, recov- ery takes place from the third stage only ; and, when it begins, a PULMONARY GANGRENE. 217 line of separation and a kind of membrane forms between the healthy and the mortified tissue. As the gangrenous portion sloughs, this membrane becomes a kind of lining to the cavity; and, while the cavity communicates with the bronchi, the mem- brane gives origin to the formation of pus ; and, though delicate as a serous membrane, it has rather the character of a mucous. After the communication is closed, the membrane assumes a char- acter more distinctly serous ; and then the cavity is gradually ob- literated by the formation of areolar tissue within the cyst, or else it remains, without closing, during the individual's life. After a cure of the gangrene, the portion of the lung which has been in- volved in the disease, is liable to remain for a long time, more or less dense, and to receive somewhat less than the normal propor- tion of air. As a cavity is forming, the bronchial tubes resist the destructive process longer than the areolar tissue ; but the bloodvessels gener- ally hold out long after the bronchi have yielded. On a post mortem examination, they are frequently seen traversing the cav- ity. At length, however, they too are destroyed ; and, sometimes, their destruction gives rise to hemorrhage, though generally, they do not slough, till after the blood lias ceased to circulate in them. The immediate cause of primary pulmonary gangrene, is, doubt* less, the influence of vitiated and poorly vitalized blood. In the secondary affection, too, there must be substantially the same con- dition. The remote or ultimate causes are intemperate habits, neglect of nutritious and wholesome diet, and all such circumstan- ces as tend to diminish vitality or break down the general health of the patient. DIAGNOSIS. -The general signs of pulmonary gangrene are fever, with a small, frequent, irritable, and sometimes exceedingly feeble pulse ; loss of appetite from the nauseating character of the gangrenous liquid which is swallowed ; sometimes diarrhoea from the effect of the same liquid ; dyspnoea often extreme ; and a pe- culiar pale or lead colored condition of the whole skin of the patient. The more local signs of this disease, are cough, expectoration, and fetor of breath. The cough, at first, resembles that of ordi- 28 218 THORACIC DISEASES. nary bronchitis, but becomes more loose and paroxysmal, with the progress of the disease. The paroxysms are caused by an accum- ulation of fluid in the bronchi, inducing an effort to throw it off; and hence, as soon as the object is gained, the effort ceases, until a new accumulation renders another effort necessary. These par- oxysms of coughing, are sometimes very disturbing. The sputa in the second stage begin to contain gangrenous matter ; and, during the third stage, they remain about the same, until that matter is all discharged. They consist of a thin fetid liquid which not unfrequently is stained with blood that flows from sphacelated vessels. This liquid is pathognomonic of the disease. If the case proceeds to a fatal termination, the sputa in- crease in quantity, while the patient is gradually sinking. Dr. Ger- hard says, " there are two principal varieties of the gangrenous sputa. One consists of a dark thin liquid which sometimes re- sembles tobacco juice or the infusion of licorice, occasionally containing small pieces of black gangrenous lung. The other consists of a grayish-yellow pasty fluid which is probably a mix- ture of pus and gangrenous liquid. The latter occurs most fre- quently in cases following pneumonia. Both, however, are ex- tremely fetid, though the odor differs slightly." The fetor of the breath is peculiar, and it begins to appear even in the first stage of the disease. It is greater, however, in the second and the third stages, in which the sloughing process is going on. This fetor, as well as the sputa, is pathognomonic of the affection ; and the former is sometimes so extreme, as to ren- der the room of the patient scarcely endurable. The physical signs, previous to the third stage, are very limited. The thin serous liquid which exudes, in primary gangrene, from the affected portion of the lung, may be sufficient to give a sub- crepitant and a mucous rale, as it passes through the tubes ; but if the disease be limited to a small space, and that deep-seated in the lung, the healthy sounds of respiration will be heard as usual. If the disease be extensive, the current of air in the air passages being prevented, the respiratory sounds at the part will be sup- pressed. Percussion generally maintains about the normal reson- ance, though the pulmonary tissue, infiltrated with serosity, may yield a considerable degree of dullness. PULMONARY GANGRENE. 219 After a cavity has formed, the auscultatory signs are the gur- gling rale, cavernous respiration, and pectoriloquy. Besides the gangrenous exudation already referred to, and which continues till the mortifying process is arrested, there is the formation of pus, as soon as the vital powers get the ascendency. Of course, when the cavity is of considerable size especially, the quantity of liquid exuding from the walls is sufficient to give a loud and constant gurgling, one the extent of which is scarcely equalled in tuber- culous disease, as in that cavities are rarely so large and do not give rise to so much liquid. When the gangrenous matter is expectorated and the cavity is evacuated, cavernous respiration and pectoriloquy appear. The former is generally full and distinct ; but the latter, unless the cav- ity is large and near the surface, has not as clear a resonance as is afforded by the harder walls of a tuberculous cavity. Such, how- ever, may be the size and situation of a cavity, as to give am- phoric respiration and full pectoriloquy. Percussion is resonant in proportion to the size of the cavity over which it is made, and the proximity of the cavity to the sur- face. If a considerable portion of the lower lobe of the lung is destroyed by the gangrene, the resonance will be very great. When gangrene of the lungs is being cured and cicatrization is taking place, the signs of a cavity disappear, and are replaced by the sub-crepitant and mucous rales made by the muco-purulent matter in the tubes. Bronchial respiration and bronchophony next appear, and finally give place to sounds nearly normal. The vesicular murmur, however, remains for a long time feeble, and very commonly never fully returns. The normal resonance on percussion, in due time, re-appears. PROGNOSIS. The prognosis in this disease depends very much on the situation of the patient. In private practice, the patient being properly treated and nursed, recovery is effected in a major- ity of cases ; but, in hospitals and other places in which proper attention is not paid, the chances are on the side of death. TREATIMENT. In primary pulmonary gangrene, the treatment must be of a supporting character. Hence tonics and stimulants, 220 THORACIC DISEASES. in connection with expectorants, are indicated. As an expector- ant, nothing is better than the compound sirup of lobelia and san- guinaria. As tonics and stimulants, peruvian bark, polygala sen- ega, and asarum canadense are good. Even wine, porter, and nu- tritious food may be freely given. When gangrene succeeds inflammation of the lungs, or comes on in the course of pneumonitis, more regard must be had to the febrile symptoms. Indeed, the ordinary treatment of pneumon- itis must be adopted, with some modifications. The active ton- ics and stimulants will not, to a great extent, be well borne. The anti-febrile corroborants should be freely employed, such as ascle- pias tuberosa, corallorhiza odontorhiza, and agents of that class are of great importance. In this disease anti-septics are valuable, such as charcoal, yeast, &c. A solution of chlorinated soda, unless it proves too lax- ative, may be given, in doses of ten or twenty drops, every three or four hours. Chloride of lime, too, may be placed in the pa- tient's apartment and near his head. It will add to his comfort, and favor his recovery. The lisual regard should be paid to the secretions generally; and, in some cases, an irritating plaster or other external stimu- lant is of service. In general, however, but little reliance can be placed on external applications. CHAPTER X. PULMONARY (EDEMA. PATHOLOGY. This is generally described as an effusion of serum into the areolar tissue of the lungs. It is doubtless true, howev- er, that a portion of the effusion is into the vesicles and the small- est bronchial tubes. In general, the characteristics of pulmonary redema are like those of dropsy in the areolar tissue, in any other portion of the system. In fact, the disease is a form of anasarca. When it exists, it generally affects both lungs nearly equally ; and, like anasarca elsewhere, it is first discovered in the most de- pendent portion of tlie tissue concerned. This is simply the effect PULMONARY (EDEMA. 221 of gravitation, the meshes of the tissue not forming perfect cells, but containing interstices communicating with one another. When a portion of an oedematous lung is examined, it is found to be of a pale gray or yellowish color ; it is heavier than healthy lung it pits on pressure ; and it has a peculiar crepitation. When incised, it emits a spurious and transparent liquid which, when fully expressed, leaves the lung in an apparently healthy condi- tion. The texture of the organ is thus proved sound ; while its increased density and diminished ability to contain air, are shown to result from the presence of the contained fluid. Pulmonary O3dema is a lesion not very unfrequent with the aged, though it is often to be regarded only as a part of general dropsy. It sometimes, however, appears, not, perhaps, as an id- iopathic disease, but as the principal manifestation of a dropsi- cal tendency. It has sometimes proved the immediate cause of death at the termination of a fever which has been badly treated and in which the blood has become watery and deprived of its vital properties. DIAGNOSIS. Dyspnoea is a general symptom of this disease ; and the evidence from this of existing pulmonary oedema is strengthened, if there is anarsaca or evident dropsy of other parts of the system. Generally, the expectoration is not great. What is raised is chiefly aqueous fluid, a little foamy, and containing some floating mucus. Sometimes, however, a very considerable .amount of liquid is coughed up and otherwise expectorated. In one marked case of the disease, ending fatally, I saw the patient a little before arid after death, which was sudden. There was general dropsy ; and, after death, a good deal of watery fluid was pressed from the lungs out of the mouth. The prominent physical sign is a coarse crepitant rale, heard at the base of the lungs, or, if the disease is extensive, over a con- siderable portion of them. The bubbles of this rale are some- what coarser than those heard in pneumonitis ; but they break even more rapidly, arid do not extend in long trains, from one point to another. Percussion is but little altered. With the liquid, there is suffi- cient air in the lungs to give nearly the ordinary resonance. At 222 THORACIC DISEASES. any rate, as both sides are alike affected, we have not the advan- tage of comparing a diseased with a healthy lung, and cannot, therefore, as well judge what is the normal sound. PROGNOSIS. -The prognosis in this disease is generally unfavor- able. If the lungs are extensively affected, as shown specially by the peculiar crepitant rale, there is but little room to hope for essential improvement. TREATMENT. Like other dropsies, pulmonary oedema generally arises from disease of the heart, or obstruction of some large blood- vessels. The immediate cause, therefore, must bfe sought out, and, if possible, removed. As palliative, rather than curative means, diuretic and diaphoretic medicines may be administered : also, if the debility of the patient does not contra-indicate, hydra- gogue cathartics. Of course, his strength must be sustained by vegetable bitter tonics, so far as they are well borne. CHAPTER XL PLEURITIS. v, The term pleuritis, synonymous with the more common word pleurisy, signifies inflammation of the pleura; and pleura, in Greek, -/rXsupa, signifies the serous membrane which lines the in- ternal surface of the thorax and covers the viscera. Like pneu- monitis, pleuritis never takes on a form so distinctly chronic, as that which bronchitis sometimes assumes. It sometimes, howev- er, becomes an asthenic and latent disease, and sometimes comes on as the sequela of some other affection. In its usual form, it may be regarded as a primary or idiopathic, and a sthenic disease. As such, it is properly called primary sthenic pleuritis. PLEUR1TIS. 223 SECTION I. PRIMARY STHENIC PLEURITIS. As the simple term pleuritis, without any qualifying epithet, is generally employed in this sense, I shall, for brevity's sake, so use it ; and only use qualifying words to express other modifications- of the disease. PATHOLOGY. Pleuritis, in the sense of a primary and sthenic disease, is divided into two stages. The first is the stage of in- flammation. When it commences, the small blood-vessels be- neath the pleura, are distinctly visible" through that transparent membrane, being interwoven in various directions, and forming a thick net-work of a bright red color. When this membrane is detached, it is found to be but slightly changed in appearance, - the development of the inflammation being really, in the main, in the sub-serous areolar tissue, rather than in the serous itself. The truth is, serous tissues generally differ from mucous, in being thin- ner, more delicate, and supplied only with the very smallest blood- vessels, such as do not transmit the red globules of the blood ; whereas some of the branchings of the arteries of such size as to convey the red globules, and be easily traced, pass into mucous tissues. As in all cases of inflammation, effusion or extravasation is liable to occur ; so in pleuritis, bright red spots of blood, ef- fused or extravasated from the vessels, are sometimes quite nu- merously seen. In pleuritis, we cannot trace the gradual progress 'of the in- flammation and the consequent change of the symptoms, ajs in bronchitis. The delicacy of the parts concerned, and their con- nection with the nervo-vital fluid, cause the inflammation rapidly to reach its height; and then the reparative .process, mostly in the granulating form, is soon established. The second stage, which is that of effusion, commences at this point. If my readers have made themselves familiar with my views of the reparative process, and its connection with inflamma- tion, as illustrated in the first Division of the first Part of this work, they will see how beautifully the pathology there given is 224 THORACIC DISEASES. illustrated in the progress of the disease, pleuritis. Authors have generally spoken of a secretion of two kinds of matter, at the commencement of the second stage. They speak of a liquid serous secretion, and a secretion of albuminous matter or plastic lymph, deposited upon the pleura in little flocculi, but liable to be rubbed off and to sink, with the serum, to the most dependent portion of the thorax. The serum and the lymph are supposed to be secreted in different proportions, in different cases of pleuritis, the former being very small in amount, in some cases, called those of dry pleuritis, while, in other cases, it is very abundant, and fills almost the r whole pleural sac. The serum is of a whit- ish or yellowish color, and never perfectly limpid. It is clearly the watery or essentially the unorganized portion of the blood. In regard to the " effusion of lymph," as it has been called, Dr. Gerhard speaks particularly, in connection with some reference to the serous deposit. He says, " This effusion, the effusion of lymph, is at first deposited on the serous surface, in minute points, which are transparent and scarcely visible, but may be readily de- tected by the touch. These points, as they become more numer- ous, gradually collect into groups which, finally coalescing, form a continuous membrane. The deposit of lymph has received the name of a false membrane, and is more abundant at the lower portions, where it is, in some cases, as much as a fourth or even half of an inch in thickness, while, at the upper portion, it sel- dom exceeds an eighth of an inch. The character and the amount of the effusion vary, according to the form of the disease and the constitution of the individual affected. In cases of local pleurisy, especially if occurring in robust persons, the amount of serum effused is very small, while there is a considerable deposit of lymph. The same, also, occurs in persons who are not robust, when the inflammation is confined to a small portion of the mem- brane. On the contrary, if the patient be thin, and of a lym- phatic temperament, and the inflammation diffused, the effusion of serum will be very great, with but a slight trace of lymph. The thin and serous part of the effusion tends to diffuse itself over the surface of the pleura, gravitating to the most dependent portion, and shifting its position, with the movement of the pa- tient. When, however, it is principally composed of lymph, it is PLEURITIS. 225 confined to the part of the lung which is affected, and exhibits no such tendency. The serum increases in quantity, as the disease advances, and decreases with its decline. But the lymph is more persistent in character ; and, instead of being removed, becomes organized, and assumes the character of a serous or cellular mem- ^ ' brane, according to the circumstances in which it is placed." This quotation from Dr. Gerhard, contains substantially the views of pathologists generally on this subject ; and to my own mind, it seems strange, that they could have mistaken the truth for so long a time, and yet not have fallen upon it, in all its sim- plicity. In the deposit of the hyaline fluid, and the formation of new tissue, it will be remembered, that the liquor sanguinis is at first secreted. This is composed of a little less than three parts of fibrin, and more than eight hundred and fifty of serum in one thousand parts of blood. The fibrin is essentially the only portion used in forming the hyaline deposit, while the serum, not entering into the vital economy, has to be otherwise disposed of. When a surface exposed to the external world heals, the serum is mainly evaporated ; but in a shut sac, like that of the pleura, it must either be absorbed or fall to the bottom. In persons possess- ing a good deal of vital energy, the absorption may go on nearly or quite as fast - as the serum is 'separated -from the fibrin; and hence the pleuritis is called dry. In persons of a lymphatic tem- perament or those whose general health has become much im- paired, the power of absorption will be diminished, while the blood itself, from which the hyaline fluid is taken, is liable to have too small a proportion of fibrin, and too large a proportion of serum. Of course, under these circumstances, there must nec- essarily be a collection of serum in the pleural sac. In the formation of false membrane, as it is called, I have else- where explained, that the process is only the granulating process, or union of the parts by granulations. This, too, I have said, is mainly a vital, though in part a chemical process. It shows the disposition of tissues to heal, not by means of inflammation, but in spite of the existing inflammation. In the case of the pleura, the exudation corpuscles appear on the surface, at first in distinct .points ; but they accumulate near together, and finally form a 29 226 THOKACIC DISEASES. membrane. The rubbing of the two parts of the pleura together, fritters away a portion of these exudations, and they mingle with the serum collected in the sac. The fact that the pulmonary and the costal portions of the pleura often unite, is strictly an accident. They bejmg in contact, while the reparative process is going on, cannot escape the accident, except the rubbing of the parts to- gether in respiration, prevents ; but this is not likely to obviate that result. While there is a collection of water in a portion of the cavity, that prevents the accident ; but, after the water is absorbed, it generally occurs. As the serum is absorbed in the progress of recovery, the pres- sure of the atmosphere without, forces the parietes of the thorax towards the lung, and adhesion takes place between the two sur- faces of the pleura. The lung is compressed against the spine, and, in that position is covered with exudations or false membrane, so that it cannot afterwards rise to meet the ribs. When the pleuritis is slight and the effusion small, there is little or no con- traction of the chest. If there is some, at the time, it does not remain permanent, but, after a while, the lung expands in a good degree.* But when the pleuritis is severe, and the effusion great, the size of the lung by the pressure of the effused fluid, is greatly dimin- ished. To its normal dimensions after a very great compression, it seldom returns. And yet, by this, its structure is often unaf- fected. In appearance, it is wrinkled and flaccid, not crepitating, and containing but little blood. By surrounding inflammation, it is but little affected. For the tendency of serous inflammations to implicate subjacent tissues, is but slight. Air forcibly blown into its branches, readily distends it nearly to its original size. Some- times, however, its vesicles adhere, and thus the ingress of air is prevented. Then it looks like apiece of flesh, and is said to be carnified. The small size to which the lung in the chronic form of the disease, is sometimes reduced by the effusion, and its con- cealment beneath thick layers of false membrane, led the ancient pathologists to conclude, that the lung itself was entirely destroyed by suppuration. * Here ends the writing of Dr. Newton. PLEUR1TIS. 227 Such a degree of atrophy remaining permanent, after the ab- sorption of effusion, would, of course, cause a vacant space in the chest, and this gives rise to contraction of its walls, and to an el- evation of the subjacent viscera, the degree of which will depend upon the size of the space, left vacant by the removal of effused fluids. The quantity of effused fluid varies from a few ounces to sev- eral pints. When very copious, it fills the cavity of the pleura, and, in some cases, has been known in the course of a few days, largely to distend the chest, to cause the intercostal spaces to be- come more prominent than usual, and by its pressure to displace the adjacent viscera, whether of the thorax or abdomen. But these results more frequently take place in the more protracted cases which more properly may be described under the head of chronic pleurisy. In the sthenic form of the disease, the distension is rarely very great. In character the liquid is usually yellowish, limpid, or slightly clouded with flocculi of concrete albumen floating in it. Often it is turbid, like whey, sometimes bloody with or without coagula. In short, its color generally varies according to the va- riable quantity of its contained blood or of its red globules. In the progress of the disease, there are, moreover, mingled in the effusion, more or less of coagulable lymph and pus. In ordinary cases it has but little odor. This, however, is not always the case. Gangrene of a portion of the lung, or the admission of air into the pleural sac, constituting pneumothorax, often makes its odor most offensive from the generation as some suppose, of sulphure- ted hydrogen gas by decomposition. During the progress of the disease, the proper serous membrane, or the epithelium upon the areolo-fibrous layer, is not thickened or materially softened. In fact, the inflammation of serous mem- branes generally is located in the areolo-fibrous layer, because this is vesicular, and, therefore, more subject to inflammation. Whether or not the pleura pulmonalis is more liable to take on inflammatory action than the pleura costalis, authors, generally, to my knowledge, do not express an opinion. That pneurnonitis often extends inflammatory action to the pleura, and that tubercu- lar deposits, adjacent to the surface of the lung, often cause a sim- 228 THORACIC DISEASES. ilar effect, are facts well known to medical men. And hence, it seems reasonable to conclude, that inflammation at first more often affects the pleura pulmonalis, and that the affection of the costal membrane is secondary. The adhesions of some parts of the lung are more strong, and more often occur than those of others. Whether or not adhesion shall take place at all, will depend on the quantity of serous effu- sion, and the character of its coagulable lymph poured out on the pleural surfaces. Of course, the fluid would ponderate to the low- est part of the chest, and pressing apart the two surfaces of the pleura, would prevent adhesion. If the upper portion is inflamed, and the fluid is not so copious as to fill the entire pleural sac, the part of the lung above the surface of the fluid, will adhere, while the parts below will remain free. But if the pleura? be inflamed in their lower portions only, a moderate quantity of liquid will be enough to keep their surfaces separate ; and, if the lymph then be- comes organized, it forms, not an adhesion, but a false membrane coating the lung, which may have effects in modifying the remains, or the products of previous inflammation. A second condition modifying the liability to adhesion, is the composition of the coagalable lymph. If this contains a large proportion of xvhat Mr. Paget calls the fibrinons lymph, or, in other words, if the lymph partakes more of the jibrinous, than of the corpuscular character, the liability to early adhesion will be increased. When little or no liquid exists to prevent contact of sur- faces, the union, when the fibrinous lymph is exuded, takes place in a short time. As absorption removes the fluid, the lymph becomes organized, adhesion is the result, and in this man- ner, many times nearly the whole pleural sac is obliterated. When this is the case, that side so affected is not liable afterward to take on pleuritic inflammation. In some cases, the adhesion is only partial. Sometimes filiaments of cellular membrane are seen ex- tending from one surface to the other, having been formed, prob- ably, during the plastic state of the effused lymph, by the move- ment of the lung upon the side of the chest in respiration, draw- ing out the lymph into slender connecting bands. There are cases in which, contrary to common experience, the lower parts of' the lung are firmly bound down to the parietes of PLEURITIS. 229 the chest, while the upper parts are free. A new attack of pleuri- sy on the same side, under these circumstances will, of course, cause effusion from the upper and free surface of the lung, and in this way give rise to abnormal sounds on percussion, in a locality, where by the inexperienced physician, they would not be suspected. Another effect of pleuritis is the formation of pus. This, how- ever, in cases of sthenic pleurisy, is gradual. In the advanced stages only, it assumes the character of pure pus. In fatal cases terminating after a few weeks, the effusion is thin, and is evident- ly composed in part of serum. And hence it has received the very appropriate name, sero-purulent effusion. It is probable, also that in the earlier stage of the disease, a certain nmnber of pus globules exist in the effused serum. " Sometimes, in persons of feeble constitution," says Dr. Swett, " there are cases which, if measured by the time the disease had existed, would be called cases of chronic pleurisy, but, in which after death an abundant serous effusion, and but very little lymph or pus exist." Such cases seem to be developed by the existence of a low de- gree of inflammatory action which does not advance much beyond the effusion of serum, but which, occurring in feeble constitutions, and developed insidiously, is protracted to a fatal termination. On the contrary, the formation of pus is not always so protracted as before described. When the inflammation is violent, in its char- acter, pus may be secreted in the acute stage of the disease, and a fatal termination is quickly the result. The existence of pus alone in the cavity of the chest, cannot, therefore, be justly con- sidered as a sure indication of the stage of the disease. For the time of its formation depends very much upon the constitution and temperament of the patient. Casteris paribus early adhesions, instead of copious effusion of serum, or the formation of pus, take place in mild cases, and in the young, strong and healthy. On the contrary, in the feeble, old, and scrofulous, the effusion of serum of a puriform character more frequently occurs early in the disease. The cause of this is found in the varied character of the effused lymph. In the young and plethoric, in those whose blood is rich in fibrin, the fibrinous lymph using the division of lymph as made by Mr. Paget is most commonly effused. While 230 THORACIC DISEASES. in persons having blood of an opposite character, the effused lymph partakes more of the corpuscular or less vitalized form which, very readily, and with but little change, degenerates into pus. DIAGNOSIS. General and rational symptoms. Acute sthenic pleuritis usually commences with a chill, soon succeeded by an acute lancinating pain in the side, cough, short and quick breath- ing, and fever. Each of these will receive a particular notice. The pain may come on either before, at the same time, or a short time after the chill. In character, it is severe as if resulting from the thrust of an instrument, and hence, it is often called a stitch in the side. Usually it is felt somewhere in the mammary region. But sometimes, elsewhere ; sometimes near the lower margin of the chest, in which case it is, probably, the result of inflammation of that part of the pleura which covers the dia- phragm. In most cases it is confined to one place, but it may be diffused over the surface of the chest, when it is sudden, very sharp and severe. It is so nearly simulated by the nervous pains of hysteria, that it may lead to error in diagnosis. By inspiration, cough and motion, it is increased. Generally, lying on the af- fected side, and pressure over the intercostal spaces, aggravate it. There is, a day or two after the occurrence of the most severe pain, a greater degree of soreness externally, than when early in the disease, the pain is most acute. As the effusion increases, the pain decreases in consequence of the separation of the inflamed membranes by the fluid, and the prevention of friction. It is, in some cases, almost entirely wanting, being perceptible only as soreness on pressure. The cough is usually short and dry, attended with but little expectoration of mucus or frothy matter. Sometimes a more co- pious expectoration is present. When the pleuritis is complicated with a degree of bronchitis, it is occasionally, somewhat bloody. Severe pain often attends it, to avoid which, the patient tries to suppress the cough, and to a certain extent he succeeds by the effort. This, however, in some cases is wanting. When such is the fact, and there is at the same time no pain, the disease by some au- thors is called latent pleurisy. PLEURITIS. 231 The breathing, in most cases, is more or less difficult. The pain prevents a full, deep inspiration. The patient is said to have a catch in his breath. In consequence of this, less air is taken into the lung when the pleura is affected, and the frequency of res- piration is therefore increased inversely as the quantity of inspired air at each inspiration decreases. The dyspno3a, unlike the pain, increases as the disease advances. The effused fluid filling up the space, usually occupied by the lung, causes this symptom. The function of one lung is more or less suspended, and the ac- tion of the other is increased beyond its normal degree ; so that the breathing of the patient becomes painful, and difficult. This is more particularly the case, when the effusion is both sudden and copious. When gradual, the system accustoms itself to the abnormal conditions of the respiratory organs. In the latter stag- es it is most severe. The decubitus has been considered as a pathognomonic sign of the disease. Yet there is much variance among the opinions of observers in respect to this symptom. This results from the va- riation of the decubitus in the different stages of pleuritis. At first, the patient cannot lay upon the affected side, on account of the increase of pain which that position produces. At a later pe- riod, when the effusion separates the inflamed surfaces, the pain, resulting from the position of the two portions of the pleurae, be- comes less, and sometimes is entirely wanting. When the decu- bitus is on the sound lung, the weight of the effused fluid, press- ing upon the mediastinum, and forcing this beyond the median line, preventing the ingress of air into the sound lung, causes pain from dyspnosa. And, consequently, at this period of the dis- ease, the decubitus is most free from unpleasant sensations on the affected side. The fever is usually considerable, and attended with the most common phenomena of febrile affections. The pulse is quick, sometimes rising to over a hundred beats in a minute, hard, full and tense. The skin is dry and hot, particularly over the chest, or the seat of the disease. The tongue is parched ; the urine is scanty and high colored ; and occasionally there are cerebral symptoms. Of the fever there are often daily remissions and exacerbations, the former coming 232 THORACIC DISEASES. on in the morning, the latter in the afternoon or evening. In four or five days it moderates considerably. " The physical signs , at the commencement of the attack, are nearly normal. Before effusion has taken place, percussion is quite clear, and no auscultatory sign is given, except a slight di- minution of the respiratory murmur, consequent upon the defi- cient expansion of the lung, which is rendered more evident by a comparison of the two sides. As this depends nearly upon the pain of inspiration, it is obvious that the same result must take place in all other cases in which the pain is equally acute, and es- pecially in pleurodynia; so that the sign is of no great value. But very soon after the onset of the disease, when the concrete exudation has had time to cover in some degree, the surface of the membrane, a peculiar and characteristic sound may often be heard, in the middle portion of the chest. Sometimes it is ac- companied by a tremor when the hand is applied to the affected side. This is the friction sound, produced by the rubbing of the opposite roughened surfaces against each other. It is thought that the sound may be developed even before the commencement of exudation by the rubbing together of the pleuritic surfaces, rendered dry by the commencing inflammation, or unequal by the enlarged vessels. The grating movement which gives rise to the sound, may be felt by the hand applied to the side. As the con- ditions upon which the sound depends, are of short duration, the sign must be evanescent. It must vanish whenever a union of the opposite surfaces takes place, or as soon as they are separated by the liquid effusion. Although, from its uncertain occurrence, and its fugitive character, it cannot always be depended on, yet, when observed, it is a valuable sign, especially, in cases unattended with liquid effusion, such as have sometimes been called dry pleurisy. " The most decisive signs are those afforded after liquid effusion has commenced. A diminution of the healthy resonance on percussion may very soon be perceived by a comparison of the opposite sides, and the dullness goes on increasing with the in- crease of the effusion, until at length it often amounts to perfect flatness. At first, it is observed in the most dependant parts of the chest, and rises higher and higher with the advance of the disease. It usually varies with the position of the patient, fol- 233 lowing, of course, the position of the liquid which necessarily gravitates to the most dependent part, while the lung, which is lighter, has a tendency to float above it. The only exceptions to this rule, are cases in which the lung, and, consequently, the liquid, are confined by adhesions, and those in which the whole cavity is filled with the effusion. In the latter case flatness is universal over the affected side of the chest. Sometimes, when a small portion of the lung is in contact with the walls of the chest, while all the rest is separated from them by effusion, a tympanitic sound is yielded on percussion, which might be mis- taken as the sign of pneumothorax or of a pulmonary cavity. " The respiratory murmur, somewhat enfeebled by the defective movement of the lung from pain, is still more so when liquid ef- fusion takes place, and goes on diminishing with the increase of effusion, and of the consequent compression of the lung, until it entirely ceases in those cases in which the liquid is abundant. In parts in which the lung is still in contact with the chest, the healthy murmur is often superseded by bronchial respiration, de- pendent upon the compression of the air-cells, which thus more readily convey the vibrations of the bronchi to the surface. This sound is usually greatest near the root of the lung, and diminish- es as we recede from that part, though it often extends more or less over the whole side of the chest. But, when the effusion is very abundant, this sound alone is quite lost, except in the region between the scapulae, and sometimes even there. On the opposite side of the chest, the respiration is louder than is usual in health, and often becomes puerile. " The vocal resonance, increased at first while the exudation is plastic, becomes, at a somewhat more advanced stage of the dis- ease, quite peculiar. When a moderate effusion has taken place, and a thin stratum of liquid intervenes between the lung arid side of the chest, the tremulous, quivering, or _bleating sound of the voice denominated egophony is heard. The bronchial sound, con- veyed outward by the compressed parenchyma, is modified as it passes through the trembling liquid, and acquires the striking character alluded to, before it reaches the ear. This^modified sound is heard, especially between the third and sixth ribs, in the 30 234 THORACIC OfSEASES. interscapular regions, and between the scapulae and mammse. It is most obvious in women and children, in consequence of the higher tone of their voice. Over the larger bronchi, near the spine, for example, it is often mingled with the bronchial reson- ance, and the sound acquires a peculiar complex character. As the effusion increases, egophony diminishes, and at length ceases altogether. Dr. Williams is of opinion, that little sound of the voice is transmitted when the stratum of intervening liquid ex- ceeds an inch in thickness, except over the larger tubes. When the quantity of liquid is very great, no vocal resonance is heard, except in a narrow space upon the side of the spine. " These results are of course modified, when the lung adheres more or less extensively to the sides of the chest. In such cases, the bronchial resonance is usually loud and distinct at the adher- ing parts in consequence of the compression of the air-cells. When the extent of adhesion is small, the compressed lung forms a column, or kind of internal stethoscope, for conveying the sound to the ear. The vibratory movements of the walls of the chest are affected similarly with the sound of the voice, being somewhat increased so long as the effusion is plastic, gradually diminished with the increase of liquid, and entirely suppressed where the intervening effusion is copious, but still distinctly ob- servable where the lung adheres. Hence, when one hand is placed upon the sound side, and the other upon the diseased one, and the patient is told to speak, little or no movement is felt in the latter, with the exception just mentioned, while in the former the thrill is distinct. " Besides the above signs, there are others derived from the movements and shape of the chest, and the relative positions of neighboring organs. Thus, the affected side may be observed to be quiescent, while the other moves in respiration. When effu- sion is great, the chest may be visibly distended, and, if meas- ured by a tape, in the direction of a line around the body at the scrobiculus cordis, it will be found to be larger on the diseased than on the sound side. This, however, is not common, to any great extent, in acute pleurisy. Any difference that may exist will be most readily detected by making the measurement at the moment of full expiration, as it is then greatest in consequence PLEUB.ITIS. 235 of the non-contraction of the distended side. But the fact must always be taken into account, that the right side in health ordin- arily measures from a quarter to a half an inch more than the left. The displacement of the heart, liver, etc., is much more frequently to be observed in the chronic than in the acute form of the disease. " The course of acute or sthenic pleuritis is very variable and uncertain. There is reason to believe that, if the disease is vig- orously treated at the beginning, it may often be arrested almost at the threshold, before it has exhibited any other signs of its existence than pain, decubitus on the sound side, a little cough, and a chill followed by fever. Exudation not having yet taken place, the physical signs are wanting. Should a catarrhal cough have preceded the attack, or should no cough exist, as sometimes happens, there are no means by which the disease could be cer- tainly distinguished from febrile pleurodynia. which has the general symptoms above mentioned, and the same diminution of the respiratory murmur, arising from the restrained movements of the chest. Hence, the doubt, in these cases, whether it was pleurisy or rheumatism of the intercostals, that was cured. " In other cases, along with the general symptoms mentioned, there is the friction sound upon auscultation, which is sufficiently decisive as to the nature of the complaint. The effusion of coagulable lymph has probably taken place, and a longer period is necessary for the cure. . Sometimes, however, the morbid phe- nomena wholly disappear in from three to five days, leaving no unhealthy sound in the chest. In such cases, the opposite sur- faces of the pleura have united, and the friction sound ceases, because the surfaces do not move on each other. "In a third class of cases, the signs of liquid effusion are per- ceived sometimes on the first day ; sometimes not until the second, third, or even fourth day, when the severe pain abates. In these cases, the friction sound, if observed at all, is soon fol- lowed by feebleness and gradual cessation of the respiratory mur- mur, by bronchial respiration, egophony, and dullness or percus- sion. Should the progress of the disease be now arrested, the general symptoms abate, and the morbid sounds gradually give way to the healthy, as the fluid producing them is absorbed. 236 THORACIC DISEASES. The friction sound is sometimes heard for a brief period after absorption has taken place, and before union between the opposite surfaces has been effected. The disease is usually cured in five or seven days. " But, instead of the favorable turn at the period above alluded to, there is often a continued advance of the disease ; the effusion goes on increasing :,egophony ceases; the bronchial respiration becomes more and more distant, until this also ceases, or is but faintly heard ; flatness upon percussion prevails to a greater or less extent over the chest, generally varying with the position of the patient; the dimensions of the affected side of the chest are sometimes even visibly enlarged ; and the healthy vibratory movement of its walls in speaking is much lessened or quite want- ing, as may be ascertained by applying the hand to the surface. The pain has nearly ceased, and the fever moderated, but the dyspnoea is often great, and the patient is unable to lie upon the sound side. The disease, in this form, continues for a variable period. Sometimes recovery takes place in two or three weeks, sometimes not for months ; and the complaint not unfrequently assumes the chronic form. Should it terminate favorably, the fever, cough, and dyspnoea gradually disappear, the dullness on percussion diminishes, egophony occasionally returns in the pro- gress of the absorption, the respiratory murmur is again heard, the friction sound may be noticed for two or three days or more, and health is at length re-established. The clearness on percussion, and the healthy respiratory sound, return usually first in the upper part of the chest and afterward in the lower. "As the lung has not been sufficiently long compressed to have lost its expansibility, it is generally dilated as the fluid is absorbed ; but sometimes, either from its own altered state, or because bound down by false membrane, it does not completely resume its orig- inal dimensions, and a degree of contraction in the diseased side of the chest ensues, which, however, generally diminishes, or dis- appears with time. The favorable termination is often attended or preceded by certain critical affections, as urinary sediment, co- pious perspiration, diarrhoea, eruptive affections of the lips and skin, plegmonous tumors, and rheumatic pains. After convalesc- ence, the patient not unfrequently 'complains of a stitch in the PLEURKTIS. 237 side upon taking a long breath ; and sometimes a degree of cough, dyspnoea, and frequency of pulse remains for a considerable time. " When acute pleurisy is about to terminate fatally, which very seldom happens in the uncomplicated disease if well treated, the effusion increases, the breathing becomes very greatly oppressed, the countenance assumes a pale hue and anxious expression, the pulse increases in frequency, and at length becomes small and feeble, and the heart ceases to beat, in consequence of the imper- fect performance of the respiratory function. In the advanced stages, death sometimes results from a gradual failure of the pow- ers of the system, caused by the irritation of the diseased struc- ture. In double pleurisy, according to Andral, a fatal issue may take place from the mere influence of the inflamed membrane, without any discoverable amount of fluid secretions." [Wood's Practice of Medicine.] The most common terminations of this form of pleurisy are, 1st by resolution ; 2nd, by passing into a chronic state ; and 3d, by fatal asphyxia. Resolution may be complete, the effused fluid and false membranes being absorbed, cellular adhesions being the only traces left of the disease, or it may be incomplete. In the latter case, the fluid is absorbed, but the false membranes remain, and are subject to various pathological changes. The second of these terminations will be considered under the head of Chronic Pleurisy. Death by asphyxia occurs only in the most severe cases, and is the result of great and sudden effusion. This termination is more frequent in pleurisy than in pneumonia. It is very rare, in the acute stage, and in those cases not compli- cated with other diseases. It more often occurs in the chronic form of the disease. PROGNOSIS. In primary sthenic' pleuritis, affecting only one lung, there is seldom much danger, if treated in the early stages with proper remedies. After copiouseflusion the cure, of course, is liable to become protracted, but is generally effected, in uncom- plicated cases, without much difficulty. In short, the mortality from this disease, when not associated with others, is comparative- ly small. According to the report of the City Inspector of New York, the whole number of deaths from pleuritis during three sue- 238 THORACIC DISEASES. cessive years, was only one hundred and six, while during the same period of time, the deaths from pneumonitis, were two thousand five hundred and fifty-eight. TREATMENT. In laying down the treatment of particular dis- eases, I will endeavor to recommend the pursuit of that course, which to me and to my medical brethren, seems most necessary and effectual. My object will be to adapt the treatment to the different stages of disease and to its various forms whether sthenic or asthenie; changing the remedies according to the pathological changes of the organs affected. In the inflammatory stage of sthenic pleuritis, when the pain in the side is severe, the skin dry and hot, the pulse fall and tense, a decided impression should speedily be made upon the circula- tion of the blood. To accomplish this, and to relSx the muscu- lar system and to favor cutaneous secretion, the vapor bath, is an efficient means of cure. It should be continued until a degree of prostration bordering on syncope is produced. When the bath cannot be used, sinapisms, stimulating lini- ments, warm fomentations should be substituted. And, in cases where the bath is applied, the latter means should also be used as valuable accessory treatment. The contact of air, a thing always to be avoided in pleurisy, is prevented by these external applications. For the same pur- pose, and to supersede entirely the use of other external means, there is used in Bellevue Hospital, New York, a jacket or waist- coat of oiled silk. This, when it can be applied, has many ad- vantages, over other applications. It is less troublesome to the patient, more neat, and permits a change of position, without be- smearing or wetting the bed clothes. The internal remedy upon which the most reliance should be placed, is lobelia. I prefer the extract. Ordinarily this should at first be given in small and increasing doses, in order that the re- laxing and sedative effect may precede the production of free emesis. Cases may occur in the treatment of which the remedy should be administered in common emetic doses. My manner of giving it, is to administer an extract pill, containing from gr. ii, to gr. v, once in half an hour, and to continue so to do,. PLEURITIS. 239 Until perspiration, relaxation and free emesis are the result. The degree to which the remedy should be carried in its application, must depend upon the violence of the disease, and the difficulty of obtaining relief. The pain may be removed, in part, at least, by applying tight around the thorax, a bandage. The object of this is to stop the friction of the lung on the parietes of the chest, and to throw the labor of respiration mostly upon the abdominal muscles. After the stomach has been thoroughly evacuated, the patient should have an interval of rest, and should take freely of gum acacia water in order to sustain the system. After the stomach has become quiet, in case a cathartic is indi- cated, one should be administered. The following in most cases is as serviceable as any. The proportions of the articles in the formula should be varied according to the exigencies of the case : * R Leptandrias* gr. v., Or leptandriBB virginicas 5 i., Podophyllia3 gr. i. ad gr. ii. Misce. To be taken in sirup or molasses. In using the termination CK of the genitive singular of Latin nouns in the first declension, I pursue what seems to me the most reasonable course. Nearly all the names of concentrated remedies terminate in ine or in. If they be considered as Latin nouns of the third declension, terminating in the nominative singular in ine, then, like sedile, their genitive must end in is. For example podophylline (nomina- tive), podophyllinif (genitive). Against this method of termination, though, so far as 1 can see perfectly proper, these objections may be brought : In the first place it makes the words longer : In the second place, it does not conform to the termination of other names of medicines. Thus, from quinine, we have quinia in the nominative, and consequently quinicc in the genitive, the termination of which case is the proper one to be used in writing Latin recipes. The same may be said of morphine and strychnine. In these examples the last n, with the last vowel, is eli- ded, and the letter a forming the correct termination of Latin nouns of the first declension, is substituted for the last n in these words. What objection, then, can there be to the adoption of the same rule in forming terminations to the concentra- ted remedies ? I can see none, except it be this ; that in three words, leptandria, sanguinaria, lobelia, meaning, these articles in a crude state, these are the same terminations, as would be found appended to the names of those articles in a con- centrated state, in case the above rule were adopted. Thus, leptandrine, dropping the termination ne, and adding a becomes leptandria, the name of the crude article. This, I believe, is the only reason which at first might seem to militate, against the 240 THORACIC DISEASES. After the operation of the cathartic, in order to produce diapho-* resis, and lessen the inflammation, administer once in four hours, a pill containing of the extract of lobelia, from gr. i. to gr. iv. al- ternately with the following powder : - ft Asclepias gr. xv., Or asclepiadis tuberoses 9ii-> Pulveris camphoras gr. xii., Pulveris opii gr. iii., Pulveris ipecacuanhas gr. vi., Potasses sulphatis 9j. Misce. Dose from gr. v. to gr. x. once in four hours alternately with the pills. If the above treatment, after twenty-four or forty-eight hours, fails to give relief which it will seldom fail to do inflammatory symptoms still continuing, the whole chest should be fomented with flannels, wet in water so hot as to almost blister the surface. This is usually very effectual in removing the pain. The ex- tremities may with a good effect, be bathed in some cooling li- quids, either water alone, or weak ley water, or alcohol and water. Some prefer cold water applied directly to the affected side. Whether or not this is belter than warm water, or fomentations, is not as yet fully decided. To me- it seems too dangerous an application to be left to the discretion of a nurse. In the purely sthenic variety of the disease, its effect is probably best But in asthenic cases, it would be liable to produce a permanent chill, and thus become a source of new difficulty in th'e cure of the patient. adoption of the above rule. A little consideration, however, Trill remove this ob- jection. Whenever the crude article is meant, in writing the Latin formulae, by append- ing to the generic terms, the specific names of those three articles^ a clear distinc- tion can be made between the crude and concentrated remedies. No such difficulty, in the great majority of cases, occurs. Out of twenty-six articles, there are only three in which there is any need, in order to perspicuity, of using the specific name. I shall, therefore, in all formulae, in this work, adopt the above rule ; and, in order that there may be symmetry and uniformity in the nomenclature of concen- trated remedies, I would recommend others, in case the above suggestions shall seem proper and useful, " To go and do likewise." PLEURITIS. 241 In case these means do not have the desired effect, as a " der- nier resort" an enema of lobelia retiined until emesis is produced, and relaxation is complete, will, in persons of strong constitutions, and of plethoric habit, be the most effectual means of subduing the inflammation. " The application to the side," says Dr. J. A. Andrews, "of a poultice composed of equal parts of podophyllum and ictodes foetida will in most cases produce sufficient counter irritation to effect the desired object." When copious effusion is evinced by the physical signs, and the object is to excite the action of the absorbents, a blister pro- duced by an adhesive plaster, sprinkled over with podophyllin, will be useful. By high authority, which to be sure is not always to be obeyed, unless that authority be clad in the garb of reason and science, the common mode of vesicating in the stage when effusion is copious, is highly recommended. Concerning the pro- priety of this, the scientific practitioner should exercise his judg- ment, rather than yield to the bias of preconceived opinions. The above course of treatment is the one most frequently adopted in the inflammatory stages by eclectic practitioners. Dif- ferent physicians have different methods of applying remedies. Dr. J. A. Andrews who, during nearly twenty years of practice has had almost universal success in the cure of this disease pur- sues the following course of medication. * At first he adminis- ters an emetic compounded after this formula : R Asclepiadis 3 ii., Lobelise inflatag 5vi., Capsici E)i. Mi see. Dose, gr. xxx., once in fifteen minutes, until free emesis en- sues. After the effect of the emetic has subsided, he. then adminis- ters, once in three hours, a powder of the following compound: ft Asclepiadis 5v., Lobeliae inflataB 5 ii., Ictodis fo3tida3 3 i., Capsici 9 i. 31 242 THORACIC DISEASES. To be administered in infusion, and in doses sufficiently large to produce diaphoresis and relaxation. In case an expectorant is needed, he uses the following : Senegas pulveris gr. x., Lobelise inflatse pulveris gr. v., CorallorhizEe odontorhizae pulveris gr. v. Misce. This should be administered as often as its effects are desirable. On the third day he usually prescribes a mild cathartic, moving the bowels, if necessary, before that day by enemas. Whenever the common nervines, such as cypripedium, scutell- aria, fail to produce the necessary repose of the patient, he prescribes as a " dernier resort " an opiate : R: Asclepias 3 i., Potassas bitartratis 5 i., Opii sss., Ari triphylli 5i. Misce. Dose, from gr. v. to gr. vii., as occasion requires. All of these anti-inflammatory means should be repeated as the case demands. In the second stage of simple sthenic pleuritis, or that of effu- sion, diuretics are often of great value. In case the quantity of effused fluid is great and the patient sufficiently strong, hydra- gogue cathartics, are also effectual means of exciting absorption. The articles most useful for this purpose are podophyllin, jalap, and cream of tartar. When catarrhal symptoms coexist with those of pleurisy, sene- ga is useful. Diuretics are also valuable to fulfil similar indica- tions. Among the best are galium aperine, eupatorium purpureum, aralia hispida, the seed of arctiurn lappa. These latter remedies are much more safe than others. Of the aralia hispida, Dr. H. Jacobs, an experienced and successful practitioner, makes frequent use for the purpose of producing the absorption of serous effusion. In the treatment of pleuritis, reference must always be had to the state of the system, and when this is asthenic the relaxing PLEURITIS. 243 and sedative means must be employed with more caution. In bilious pleuritis, cholagogues should be administered early in the disease. If there are typhoid symptoms, or if the disease assumes an intermittent form, quinine should be freely given. When pleu- ritis is complicated with tubercular disease, care should be taken that the relaxing remedies are not carried too far, lest their effects by producing debility, tend to excite the further deposition of tu- bercles. The diet in acute pleuritis should be very low, consisting in the early stages chiefly of mucilaginous or farinaceous liquids. Gum acacia water is almost the only food allowed in the Hospitals in Paris. This, by French physicians, is considered perfectly safe , for diet, and a very useful medicament, even when given in large quantities. Refreshing acidulated drinks may be freely allowed. Lemon juice, added to acacia water, or to an infusion of flax-seed, makes an excellent compound. Sometimes, the addition to the above drink of licorice is useful. The patient should avoid mo- tion and speaking, or coughing as much as possible. The shoul- ders and chest should be somewhat elevated with pillows. The temperature of the room should be uniform, both day and night. In making any physical exploration, the chest should not be un- necessarily exposed to the contact of air. " When we find the pleuritis nearly well," says Dr. Gerhard, " but the patient still complaining of some dyspnoea, or a little feverishness, and we discover on examination that a portion of the liquid remains unabsorbed, nothing is so efficacious as a jour- ney, with its necessary consequence, change of air. Although the sea-air is not always adapted to pectoral diseases, it is often of decided advantage in chronic pleuritis, especially if combined with a voyage. This is generally the surest means of dissipating the remains of the disease, and insuring a restoration to entire health. Of course, the usual hygienic precautions as to dress should be attended to." 244 THORACIC DISEASES. SECTION II. ASTHENIC PLETJRITIS. PATHOLOGY. This form of pleuritis is usually met with in per- sons who have been debilitated by previous acute or chronic dis- eases. Most frequently it occurs in the intemperate, or during con- valescence from febrile diseases of a typhoid type, from exanthe- matous and puerperal fevers, from erysipelas ; or it arises from or- ganic changes in the kidneys, from phlebitis and diffusive inflam- mation resulting in the formation of abcesses. With acute or painful local symptoms, this form of the disease is seldom attended. The disease is, for the most part, latent, ef- fusion often existing long before the disease is detected. Rarely a primary affection, it is most often associated with some other disease, or with some structural change. Its presence is indicated at first, by shortness of respiration, the position of the patient, and the sinking of the powers of life, more than by any severe local distress. The diagnosis, prognosis and treatment of this variety of pleuritis, are so similar to those of the chronic form of the dis- ease, that no separate description is necessary. SECTION III. CHRONIC PLEURITIS. Pleurisy varies greatly both in severity and in duration. It may be acute, in respect to the degree of suffering, and the rap- idity of its progress ; it may be latent in its character and slow in the progress of the successive changes attending and consequent upon it. Between these extremes, the intermediate grades of morbid action are almost innumerable. The term chronic, then, in respect to pleuritis, seems to be more of a conventional term, than when applied to most other diseases. In pleuritis the tran- sition of the acid; to the chronic state is so indefinite, and the symptoms of the recent disease sometimes have so little of an acute character, while that of a long duration occasionally rnani- PLEURITIS. 245 fests so much greater an intensity of irritation, that the terms acute and chronic would seem to be less applicable to pleuritis than to other diseases. This difficulty arises from the anatomical relations of the pleura. Being a shut sac, its acute inflammation is liable to be made chronic by the retention of inflammatory products. And the chronic is liable to be changed into the acute by the irritation of effused fluids. But, notwithstanding these difficulties, there seems to be no impropriety in ascribing to the disease, when highly inflammatory and until the inflammatory symptoms seem to arrive at an acme, the term acute. If after that period, lingering fever continues, evidently excited by the products of previous inflammatory ac- tion, then the term chronic may, with as much propriety, be ap- plied to the disease after, as the acute to the disease before the acme. In some cases, however, such an acme never seems to exist; and, to these the name sub acute may with propriety be applied. PATHOLOGY. The anatomical appearances caused by chronic pleuritis are very similar to those of the acute form of the disease. Of course, the influence of time would tend to produce certain modifications. In general we find the membranes thicker, often composed of several adherent layers, the earliest deposits being harder than those subsequently formed. The character of the liquid, too, is subject to various changes in the onward progress of the disease. It is less limpid, more prone to become turbid with flocculi of a fibrinous character. In some cases it even ap- pears in consistence like jelly. The quantity is greater, and con- sequently the displacement of adjacent viscera is much more ap- parent. The lung by continued compression is altered in its ap- pearance, and often becomes wholly destitute of its normal crepi- tation on pressure. Here and there adhesions are often formed, between which in some cases, little sacs of fluid are enclosed. Under the best treatment, the disease, when uncomplicated, will generally advance to a favorable termination. But it often is the case, that the morbid products cannot be absorbed, and, con- sequently, they remain and pass through a series of pathological changes, sometimes ending in gangrene. Cartilaginous laminae, 246 THORACIC DISEASES. bony plates, abscesses, tubercles and hemorrhagic effusions, are among the successive steps in the progress of chronic pleuritis. " Sometimes," says Dr. Wood, " the walls of the chest are forced inward contrary to their elasticity, so that, when a puncture is made from without, the air rushes in to supply the vacuity pro- duced by their resilience. In some instances secretion goes on as rapidly as absorption, and the liquid accumulation remains for a great length of time. This is especially the case in empyema, or collection of pus in the cavity of the pleura sometimes the pus makes its way into the substance of the lung, arid a fistulous communication is formed between the bronchi and the pleural cavity, through which pus is discharged and air admitted. " In other instances the liquid takes an external direction, and by means of ulceration escapes into the cellular tissue without the chest, and, traveling occasionally for a considerable distance, produces subcutaneous abscesses in various parts of the chest, which ultimately open, unless life is previously worn out. In thus traveling, the pus has been known to occasion caries of the ribs and vertebras, sometimes the purulent collection is found to be connected with a tuberculous vomica." It is sometimes difficult to determine the causes which change ordinary acute pleuritis into the chronic form. Evidently in many cases, too much depletion, the too free use of mercury and other articles making up the antiphlogistic regimen, tend to the production of chronic pleuritis. Often, when a case seems to be cured by such means, the impoverished state of the blood, caused by the use of the lancet, thus rendering the system more liable to be affected by low grades of inflammation, develops a new and unwelcome train of symptoms admonishing the physician that the supposed cure, was after all, delusive. Dr. Gallup, defining chronic rheumatism, says that it is acute rheumatism half cured. So it may with equal propriety be said, that chronic pleuritis is the acute variety half cured. DIAGNOSIS. The general inflammatory symptoms of acute pleu- ritis may gradually disappear, but, unless the morbid products of the diseased action are removed from the pleural sac, the fever will recur and change its type, now very closely resembling PLEtfRlTIS. 247 hectic, now becoming identical with it. This recurring fever is one of the most troublesome and alarming symptoms of chronic pleuritis; for in other respects the patient does not suffer in a manner proportionate to the extent or the duration of the effusion. Dr. Gerhard observes, " I once saw a patient who had performed the full duties of a sailor, going aloft, with an enormous pleuritic effusion. When he returned from sea, it amounted to two or three gallons. This is an exceptional case ; but it is very com- mon to find patients who can perform many laborious occupations without much inconvenience. This is generally the case if the dyspnoea is not severe ; and we find that some patients complain of little difficulty of breathing with an extent of pectoral disease which will give rise to great distress in other individuals. The symptoms which so frequently characterize chronic organic dis- eases, are extremely variable in this variety of pleurisy. These are emaciation, loss of the firmness of the muscles, harshness and dryness of the skin, and slight oedema of the legs. Sometimes they are nearly as well marked as in tuberculous disease of the lungs ; in other cases they are very slight ; hence, they consti- tute a diagnostic sign of the disease ; and, if we find them well characterized, we will do right to regard the case as one, probably, complicated with tubercles. If our impression be erroneous, we will soon rectify it, as the symptoms will gradually become more decided in the latter case, and slowly disappear if the pleurisy be followed by recovery." The diagnosis of chronic pleuritis without the aid of the phys- ical signs, is often very difficult. Its general symptoms simulate those of phthisis. But the physical signs are far more reliable. When these are present there is no difficulty in ascertaining the true character of the disease. If it is complicated with tubercu- lous deposition, the case should be regarded with much anxiety; for the diagnosis then becomes much more obscure, and the prog- nosis more unfavorable. PROGNOSIS. In this variety of pleuritis, when attended with copious effusion, the prognosis is doubtful. The liquid consisting mainly of pus, causes irritation, sometimes so severe as to produce marasmus, and to deprive the system of all that recuperative THORACIC DISEASES. power ever necessary in the progress of recovery. Sometimes it proves fatal in .consequence of the obstruction to respiration ; sometimes by the occurrence of metastatic abscesses in parenchy- matous organs. This latter result, however, is not very common. TREATMENT. The treatment of chronic pleuritis differs from that of the sthenic character, less in the kind of remedies used, than in the manner of their application. Whatever means are applied should be such as tend to prevent effusion and promote absorption. For these purposes gentle emetics, followed by the use of vegetable tonics, are very serviceable. Of the utility of occasional emetics of lobelia in chronic pleuritis, there is much evidence. Their operation, in my opinion, is more sure than any other means, to prevent effusion and promote absorption, and to prepare the digestive organs, for the successful administration of tonics. Those who are anasmic seldom bear well the effects of emetics, especially of thorough ones. But those whose digestive organs are inactive, accompanied with febrile excitement, with dry and hot skin, and headache, with derangetnent in the circula- tion of the blood, will receive benefit from their occasional use. In connection with them,~ the vapor bath, or in cases where proper reaction is sure to result, the pack sheet, may often successfully be applied. Counter irritation is useful in this variety of the disease. For this purpose podophyllum or podophyllin sprinkled upon the sur- face of an adhesive plaster and applied to the side, will, in a short time, produce free suppuration. The same and perhaps a better effect may be derived from the use of Dr. Hill's irritating plaster. Senega and squill may be employed with benefit. To promote absorption, the iodide of potassium has been highly praised. When hectic symptoms appear, they should be combatted with tonics. The infusion or the sirup of wild cherry, I have found more efficacious than many other tonics. I prescribe this, in connection with the sirup of the iodide of iron. One ounce of the latter, added to one pint of the sirup of the former article, makes a good compound. If there is great debility sulphate of quinine, salicine and hy- drastine should, either separately or in combination, be adminis- PLEURITIS. 249 lered. To allay cough and produce sleep in those cases attended with much fever, I am accustomed to use. in connection with other nervines, the following preparation : R Extract! lobelias gr. ij ad gr. iv., Morphia} acetatis gr. 1-8 ad gr. 1-4. Misce. Administer at bed time. This usually produces diaphoresis, allays febrile symptoms, and, by promoting expectoration and quieting nervous excitability, relieves the cough. If there is a tendency to tubercular disease with considerable debility, not attended with much fever, I direct the patient to use for diet, eggs, oysters, beef, with other nutritious and easily diges- tible articles, and to take as a beverage some pure wine, in quantities not large enough to excite febrile action, and for medi- cine to take some tonic sirup containing iodine in some of its forms. In very old pleurisy, tonics are sometimes necessary, especially when the suppuration is abundant. In such cases the chalybeate preparations are recommended by Dr. Gerhard. With these and vegetable tonics, acutancous tonic and alterative may with benefit be combined ; such as a stimulating bath, especially the sulpur and salt water bath. These are usually taken at their natural sources, by resorting to sulphur springs or to sea bathing. When the artificial baths are used they should be warm. Of cold sea bathing, and the cold sulphur bath for mere debility, after the sub- sidence of inflammation, Dr. Gerhard says, "that they are seldom appropriate, and that if used at all some caution should be ob- served in their management." "In chronic pleurisy" he continues, " it sometimes becomes a question whether the operation of paracentesis should be per- formed. This is, as is well known, one of the most simple oper- ations in surgery, and no one can meet with the least difficulty in performing it, but at the same time, it is often very serious in its consequences. There is a rule in surgery which is here strictly applicable ; that is, that the exposure of a large suppurating cavi- ty to the air, necessarily excites hectic fever, and sometimes fa- vors the development of secondary abscesses. The chances of 32 250 THORACIC DISEASES. recovery are not, therefore, on the whole increased by the opera- tion, and it is one which we should not perform, unless it be to relieve excessive dyspnoea, which may in itself be severe enough to threaten life." Concerning the safety and utility of this operation, authors ad- vance different opinions. To prove that many lives have been saved by the spontaneous, or by the artificial discharge of the purulent collection, much evidence can be advanced. ' In my own mind," says 'Dr. Swett, " there is no doubt that in many cases in which the discharge of pus occurred at a late period, and in which death finally ensued, recovery would have taken place, had the discharge of the purulent secretion taken place at an earlier period in the disease. " My decided impression is, that in all cases, after proper reme- dies have been tried in vain, the operation for empyema should be resorted to, and, if possible, before the vital powers are much exhausted. Because, notwithstanding the great and immediate relief experienced from the discharge of the pus, still, a great deal of it remains to tax the powers of life. A more or less copious purulent secretion continues often for a long time. " There are three classes of cases, in which the question as to the propriety of performing the operation may be discussed. First, there are the cases in which the side is much dilated, the intercostal spaces bulging and fluctuating, and in which pointing even has occurred. These are the cases in which the operation has most generally been performed. Before the discovery of aus- cultation, these were the only cases in which it could be performed with propriety, for in such cases only could the existence of mat- ter in the pleural sac be ascertained with any degree of certainty. Many cases in which the operation is performed under such cir- cumstances, recover, but death is by no means of rare occurrence. The patient is relieved, often very much relieved at first, but he soon dies of exhaustion. "Again, there is a class of cases in which the disease, having resisted all treatment, presents a different condition of things. The affected side is not at all dilated, or but slightly so ; the in- tercostal spaces may be a little dilated or not, but there is no fluc- tuation, and especially no pointing. Shall an operation be ad- PLEURITIS. 251 vised in this case ? I think so, and that the chances of success will be greater than in the first class of cases. There is one thing that you must endeavor to be certain about that is, the ac- tual existence of pus in the chest. The history of the case, the progress of the physical signs must be your guide, and your judg- ment must guard you against a hasty decision. " Finally, there is another class of cases, in which the effused pus has been absorbed partially, and in which the dilatation of the affected side, if it had existed, has given place to even a par- tial contraction. Yet the existence of great dullness, and the ab- sence of a respiratory murmur over the lower portion of the lung, the existence of hectic fever, and of other symptoms, must lead to the belief that the pus is still there, and that it refuses to be absorbed. The cause of thfs cessation of the absorption is prob- ably the compressed state of the lung, which refuses to expand. What shall be done in this case ? Open the chest ? I confess I have never seen the operation performed under these circumstan- ces, but I have examined fatal cases in which I wished it had been performed. " Another question presents itself in these cases. What is the condition of the lungs ? What is the condition of other organs ? It is certainly desirable to know that the lungs were probably healthy before the attack, and that no evidence exists of any sub- sequent disease. Suppose, after examining the chest, we suspect that an abscess is forming in the lung. Shall this make you hes- itate ? Shall you wait and see if nature will not open a commu- nication with a bronchus, and thus discharge the pus ? We may wait in vain for this result, and even if it should, in time occur, it is a far less agreeable and thorough mode of evacuating the chest than the operation of paracentesis. Suppose we have rea- son to fear that the patient may be tuberculous, should that deter us? I think not. Would we not open an abscess anywhere else in a tuberculous patient ? Would the discharge of pus exhaust him ? I think not. It would relieve him, and thus prolong his existence. "Even in cases in which a softened tubercle has ruptured into the pleural cavity, and a bronchial communication has been, at the same time established, constituting what is called hydro-pneu- 252 THORACIC DISEASES. mothorax, should this operation even then be performed ? I have never seen the operation performed under these circumstances but once, and then a fatal termination soon ensued. But I have re- cently met with two cases in this hospital, the New York Hos- pital in both of which the post-mortem examination made me hesitate as to the propriety of the course pursued. In one case, all the signs of hydro-pneumothorax continued until death, yet after death the lungs were found so nearly healthy, the tubercu- lous deposit was so small, that I could not help thinking, had the operation been performed this was decided against in consulta- tion the life of the patient might have been prolonged, and his condition rendered more comfortable. " Another case occurred, in which the signs of hydro-pneumo- thorax existed, but after a time the evidences of communication with a bronchus ceased, and this condition continued until death. In this case, also, the lungs were very little diseased, and the open- ing into the bronchus could not be detected by inflating the lung. It had no doubt been closed, perhaps by being covered by a coat- ing of lymph. In this case, and for a still stronger reason, the bronchial communication having ceased, the operation might have aided materially in prolonging life. " It is difficult to say what the precise condition of the lung is in such cases. But this we do know, that hydro-pneumothorax occurs most frequently when there are but few tubercles in the lung. A copious deposit of tubercles leads to a secondary pleuri- sy with effusion of lymph only, by which the cavity of the pleura tends to become obliterated, and the form of the disease I am now considering, is no longer likely to occur." [Swell's Lectures.] The operation for empyema, or for the evacuation of other liquids besides pus, from the cavity of the chest, is very ancient, being referred to by Hippocrates, B. C. 460, as well as by many others at different subsequent periods of time. Although a full description of this operation belongs more properly to works on surgery, yet following the example of several standard authors, I deem it best to insert its description, as given in Smith's Opera- tive Surgery. The diagnostic physical sigtis, indicating such a condition as would justify the operation, are enlargement of the side, dullness PLEURITIS. 253 on percussion, absence of free respiration, vocal resonance and a projection or fluctuation in the intercostal spaces. " The operation of paracentesis thoracis " says Dr. Smith, " has been variously performed, but the object of all the plans is to evacuate the liquid contents of the part, without admitting air into the pulmonary cavity. To accomplish this, it has been sug- gested to puncture the parietes of the chest with a trocar and can- ula, or with a trocar and syringe, or to make a direct dissection, layer by layer, from the skin to the pleura. In all the plans that have been recommended for the accomplishment of this object, surgeons have differed mainly in regard to the best point for the puncture ; but, as the patient is usually compelled to su) up. and as the general anatomical relations of the region especially favor a certain point, it is sufficient to state that, when circumstances admit of it, the space between the fourth and fifth, or fifth and sixth ribs, and a little posterior to their middle should be selected. In order to avoid wounding the diaphragm, which is presumed to be pushed up by the liver, it is generally advised to puncture the right pleura one rib higher than that advised for the left. Such a position is, however, far from being established as correct, the idea being based rather on the descriptions of the normal con- dition of the part than on the diseased state, and it is most prob- able that the weight of the fluid collected within the right pleura will more than counteract any elevation of the liver when the patient is in the erect position. In counting the ribs in a person of moderate flesh, but little difficulty will be found in tracing them from below, upward ; but in those who are fat, or in those who have the side mdematous and swollen, it may be impossible to distinguish these spaces, and under such circumstances the rule has been given to select a spot which is about six finger-breadths below the inferior angle of the scapula.*" " ORDINARY OPERATIONS OF PAKACENTESIS THORACIS. The pa- tient being propped up in bed, and a little inclined to the sound side, so as to separate the ribs as much as possible on the diseased side, the skin is to be divided to the extent of one and a half ''" Malgaigne. THORACIC DISEASES. inches in a direction parallel with the superior edge of the low- est rib on the intercostal space, that is selected for the puncture. After dividing the superficial fascia, and any portion of a muscle of the chest that may intervene, as well as the external and in- ternal intercostal muscles, the pleura will be found generally to bulge into the wound. After being distinctly felt by the fore- finger, so as to establish the fact that only fluid is behind it, the puncture should be made with the point of a bistoury, and the opening gradually enlarged as the liquid escapes.* " If the pleura is very much thickened, care will be requisite to avoid the error of pushing it before the instrument. Velpeau en- tertains the opinion that in cases which require the operation, the effused liquid, or even an abscess, will remove the lung from the point of puncture. He, therefore, objects to the details just given, and advises that the side of the chest be at once opened by a deep puncture with the bistoury in the same manner as an ordinary abscess. " AFTER TREATMENT. If circumstances render it desirable to keep the wound open, a tent may be introduced, and removed from day to day ; but if the whole of the liquid be evacuated, the opening may be at once closed with adhesive strips, a com- press, and bandage. " If the subsequent discharge continues copious, or becomes very fetid, advantage may be derived from washing out the cavi- ty with warm water, or warm barley water ; weak astringent washes, or those of an anti-septic character, being subsequently employed. In order to evacuate the liquid, and yet prevent the entrance of air, various contrivances have been employed. Pelle- tan employed a syringe for this purpose, and Reybard placed a piece of gold-beater's skin, or the intestine of the cat. over a canula introduced into the pulmonary cavity, by means of a per- foration in the rib, so that the matter might flow out and yet the air not enter. " Dr. Wyman, of Cambridge, Mass., has invented a brass suc- tion-pump with an exploring canula, in order to permit the evac- " Yelpeau's Op. Surg., by Mott, p. olo, v. iii. PLEURITIS. 255 nation of the fluid without allowing the air to enter the pleura, and has reported numerous instances of the success of this mode of operating, which he thinks is preferable to the ordinary mode of incising the soft parts. " REMARKS. The value of the operation of paracentesis tho- racis has been differently estimated at various periods ; most of the surgeons, up to the time of Laennec, having regarded it' as a doubtful or dangerous operation, especially from the difficulties attendant on the diagnosis. Since the more general resort to aus- cultation, many of these difficulties have been removed. " But, though the cases can now be better selected than they were formerly, a successful result is not always obtained. The true results of the operation may, it is thought, be correctly stated thus : Paracentesis always affords temporary relief, and almost one- half of the cases recover ; but whether these patients would have died without it, it is diflicult to tell. " The idea is certainly erroneous that paracentesis thoracis is an eminently successful operation, and though its results have been such as to justify its performance, the prognosis should be guarded. From statistics collected from various sources, it appears that the mortality is considerable, and the objections that have been raised against the operation in former days should be regard- ed. They are thus stated by Velpeau : "If the lung has been forcibly compressed by the liquid, and yet is permeable, the evacuation of the liquid without the en- trance of air into the pulmonary cavity may distend it so rapidly as to excite violent inflammation. If, on the contrary, the lung has shrunk so much as to yield but slowly to the entrance of air, the void which is immediately left about the parts, is very liable to derange the respiration and pectoral circulation. The intro- duction of air into the cavity of the pleura, though obviating this, yet exposes the patient to danger by exciting the inflammation, and creating unhealthy pus, thus giving rise to adynamic symp- toms, under which many have died. " KSTIMATE OF THE OPERATION. In estimating the value of O ^ any of these modes of operating, the difficulties or objections 2 50 THORACIC DISEASES. applicable to each should not be overlooked. When the intei> costal spaces are prominent, and the presence of liquid certain, the direct puncture of Yelpeau is best. " When there is any doubt of the position of the liquid, then the ordinary operation by dissection of layers would be prefera- ble. Where, however, the diagnosis is positive, and the chances of failure from the accident of pushing forward the thickened membrane, instead of perforating it, is guarded against, the in- strument of Dr. Wyman of Massachusetts may prove advan- tageous. In Boston, the experience of the profession is said to be favorable to it. " Under all circumstances, the surgeon may anticipate an anx- ious and long-continued convalescence of the patient, and one which will exact all his skill as a practitioner, to conduct the case to a favorable result. " The employment of a trocar is the most objectionable of the various instruments employed, as it is not so shaped as to obtain a keen edge, whilst the point of the cannula, even when closely fitted to the shoulder of the instrument, is very liable to tear or push the pleura before it, as is occasionally seen in cases of hydro- cele, accompanied with thickening of the tunica vaginalis. " When the surgeon recalls the constitutional effects liable to result from opening closed cavities, and especially those contain- ing pus, and covered by a pyogenic membrane, he can readily foresee the consequences of opening the pleura in cases of em- pyema. The natural tendency of such collections is either to be absorbed or discharged by the efforts of nature. If discharged by nature the inflammation of the surrounding parts, and the character of the opening made by ulceration, are well known to be more favorable to a cure than is- the case when the surgeon punctures it. I would, therefore, express the opinion that this operation should not be resorted to until the latest possible mo- ment ; that, when done, air should be prevented from entering the cavity of the chest ; that the pus should be slowly and only partially discharged, the wound closed, and the operation repeated, if necessary. If, however, the entrance of air cannot be pre- vented, it will be better to evacuate the whole of the liquid, and treat the case subsequently like one of abscess." PLEURIT1S. 257 Prom statistics, it appears that nearly two-thirds of the cases operated on have been cured. [Smith's Operative Surgery.] The result of the operation, though more favorable than some authors represent, should teach the importance of using all possi- ble preventive means, in order to avoid the necessity of its per- formance. The question, then, very naturally arises, can any means more efficient than those in common use among allopathic physicians, be used to prevent the recurrence of its necessity ? I think so. The object, as has been before stated, is to promote ab- sorption, and to sustain the strength of the system while the cur- ative process is going on. Ordinarily physicians depend, for the most part, upon diuretics and tonics; seldom using as curative agents emetics. But notwithstanding this, these when properly used, and composed of such articles as produce temporary debil- ity only, are in rny opinion of great service. In acute pleurisy they have had the sanction of Riverius, Ruland, Blegny, Mur- sinna, Morgagni, Wright, Stoll, Tissot, Ackermann, and Schel- hammer. And Dr. Copeland adds that, when discreetly pre- scribed, they are important aids in the treatment of most of the forms of the disease. Dr. Gallup observes " that the character of the chronic morbid habit leads us to infer, that certain operations which may bring into exercise the minute circulations, may be useful to restore their integrity of function. One adjuvant has been found in the exercise of vomiting ; and we make it a substitute for corporeal exercise for those not in a condition for this. Not only so, but it exercises every minute tissue more effectually than any mere mus- cular exercise. It is necessary that this, with other processes, should precede, and prepare the system to endure muscular mo- tion with benefit by removing the morbid derangements. " The lungs as well as all the internal organs, are exercised by emesis, and their functions promoted by it. The exhalents and mucous follicles discharge more freely, and the internal infarc- tions of the blood vessels are agitated, and absorptions promoted. The centrifugal and exhaling surfaces are excited, not by direct stimulants, which would add to the diseased state, but by a train of associate motions restoring or exciting their lost functions. Even the exercise of nausea is extended very considerably to all 258 THOllACIC DISEASES. the tissues, and in many conditions may, where there is much lowness, be used as an occasional substitute for emesis. These processes may be so conducted as not to exhaust overmuch. Like corporeal exercise, they may be extended to the point of fa- tigue but not of exhaustion. " It is not a single emesis that will be of much use, to remove a fixed state of disease of slow access ; but it must be reiterated, and in connection with other auxiliaries. The patient should always be in a warm condition during the process, so as to pro- mote dermoid action, and sometimes moderate sweats." Emetics, it seems to me, are for another reason, useful in chron- ic pleuritis. One object is to produce expansion of the com- pressed lung. While the emesis promotes absorption of the ef- fused fluids, it also, by producing deep inspirations, expands the lung, which, in consequence of its sudden increase in size, excites still more the function of absorption. They, also, when com- posed of proper articles, and properly administered, prepare the system for the effectual application of tonic remedies. To pre- scribe this latter class of curative agents, when the mucous mem- branes are coated with morbid secretions, is worse than useless. I have 'seen patients laboring under some chronic disease of the pleura, who had been treated with tonics with.no benefit, rapidly recover after the administration of an emetic, followed by the use of those very remedies, which they had before been using with no salutary effect. They should be repeated once a day, or once in two or three days, according to the degree of benefit received from them. A very good lime is in the evening about an hour after coming from a warm bath. Some who suffer much in the morning from col- lections of muco-purulent matter, receive the most benefit by using the emetic at this time. The intervals between their administration should be sufficient- ly long to afford rest and refreshment to the patient. Nor should he, in the interval be continually harrassed by other medicines of doubtful utility. A nutritious diet should be used, and all food containing but little nutriment in a large bulk should be avoided. My manner of administering the emetic in very feeble patients is this: I give, after the patient is warm in bed, and his stom- PLEURITIS. 259 ach is somewhat distended with warm water, at suitable inter- vals, a pill containing from gr. ii to gr. iv. of extract of lobelia, until considerable nausea is produced. Then I direct the copious drinking of warm water which in a few moments is usually fol- lowed by an easy and free evacuation of the contents of the stomach. In other cases, when the patient can bear more heroic treatment, the pursuit of the above course is not necessary, but the emetic may be given in the ordinary way. In case much distress results from the effects of the emetic, administer, in cold water, and repeat the same, acetic, or citric acid. The means chiefly to be relied upon, in warding off the neces- sity for an operation, are the vapor bath followed by brisk fric- tion, gentle' and repeated emetics, followed by the strongest ton- ics, and nourishing food, and vegetable diuretics. Inhaling tubes for the purpose of expanding the compressed lung, are by some highly recommended. When the effusion has a purulent charac- ter, the hydriodate of potassa in the dose of two or three grains, three times a day is often useful ; in more asthenic cases, the iodide of iron, in rather small doses may bo given. For a diu- retic, when the vegetable diuretics before mentioned, fail to give relief, the tartrate of iron is serviceable, especially where a dropsi- cal diathesis prevails. SECTION IV. LATENT P L E U R I T I S . This variety differs from others mainly in the absence of the more common rational symptoms, such as Tlyspnoea, congh and pain. These are cither entirely wanting or are so imperfectly de- veloped as to make it impossible to found upon them an accurate diagnosis. The disease passes so insidiously through its different stages, that the patient is seldom aware of the nature of the mal- ady with which he is atiectcd. After recovery he often forgets the trifling indisposition which he felt during its progress. In this form of pleuritis adhesions of the lungs to the costal pleura often become extensive. In rare cases the general symptoms are more marked, attended with a gradual wasting of the vital forces. In general such cases are complicated with phthisis. 260 THORACIC DISEASE?. PATHOLOGY. The anatomical lesions in latent pleuritis differ so little from, those already described, that their consideration in this place would be but a useless repetition. DIAGNOSIS. The absence of the rational symptoms, makes the diagnosis dependent almost wholly upon the physical signs. In case there is considerable effusion, we have dullness on percussion, feeble respiration and egophony. Additional evidence of the pleuritic character of the disease is afforded by the existence of the friction sound. In case this is absent and the other signs above referred to are but imperfectly developed, there is danger of confounding the disease with enlarge- ment of the liver, or with consolidation of the lung. In the ma- jority of cases, however, the physical signs are so well marked that a correct diagnosis may be made. With tuberculous disease it is often so intimately connected that it is difficult to determine how many of the morbid phenomena proceed from the tubercular deposits, and how many from the pleuritic inflammation. Almost always in those of a scrofulous diathesis, these two diseases are more or less mingled together ; and hence, in such persons, the slightest symptoms of phthisis occurring in pleuritis should be closely observed. PROGNOSIS. The prognosis is favorable or unfavorable accord- ing to the nature of its complicating diseases, and the condition of the constitution. When associated with phthisis there is but little reason to hope for recovery ; when isolated and occurring in a healthy constitution, it generally, under proper treatment, ter- minates favorably. i TREATMENT. The treatment does not materially differ from that of other chronic forms of the disease. There is, therefore, no need of any repetition in this place, of that which, under the head of Chronic Pleurisy, is fully described. The remedies should, of course, be continued until all physical signs of the disease dis- appear, and the general healthy appearance of the patient is indi- cative of complete recovery. PLEUR1TIS. 261 SECTION V. SECONDARY AND COMPLICATED PLEURITIS. PATHOLOGY. Pleuritis is often associated with inflammation of an adjoining tissue or organ, or with some other lesion or malady. It may be either primary or secondary. With inflammation of the parenchyma of the lung it is frequently complicated ; the dis- ease sometimes beginning in the pleura and extending to the sub- stance of the lung ; at other times, on the contrary, beginning in the lung and extending to the pleura. This complication is usu- ally termed pleuro-pneumonia, and by older writers was known by the name peripneumonia. In such cases the inflammation usu- ally assumes a sthenic character. The pleuritic and the pulmonic inflammation may be coetaneous. More often, however, the pul- monic, is antecedent to the pleuritic than the reverse. Some writers assert that the complication of pneumonitis with pleuritis lessens instead of increasing the danger. The reason given is derived from the idea that the pneumonia is lessened by the pressure of the effused fluids of pleuritis. The lung also by its increased size, in consequence of the engorgement of its ves- sels, presses upon the fluids, and this excites a degree of activity in the absorbents, which under other circumstances would not exist. There is, then, according to this theory, a reciprocity of action, whose tendency is to the cure of the disease. Pleurisy is sometimes complicated with exanthematous and con- tinued fevers. Unless it occurs in the period of convalescence from these maladies, it is prone to assume the sthenic form, but when during recovery the fluids of the body are contaminated, and the vitality of the system depressed, the asthenic form is most common. Whenever, in fevers, the breathing becomes very short and frequent, whether or not accompanied with pain in the side and cough, then pleuritic inflammation may be suspected, and an examination should be immediately made in order to arrive at a correct diagnosis, and predict with certainty the nature of the termination. 262 THORACIC DISEASES. Another very frequent complication of pleurisy is with phthisis and chronic tubercular pneumonitis. Tubercles existing near the surface of the lung, often excite inflammation in the circumjacent tissues, which is readily extended to the pleura pulmonalis. On its free surface lymph is effused, which, coming in contact with the pleura costal is, excites on it inflammation. Adhesion usually is the result. Sometimes, however, a different state of things takes place. A cavity, by the .softening of tubercular deposits, is formed near the surface of the lung before adhesion is effected. This, in some cases, producing a perforation of the pleura pul- monalis, and at the same time communicating with the bronchial tubes, admits into the cavity of the pleural sac, the atmosphere. This kind of lesion is called pneumothorax, which, in another place, will be more fully considered. Tuberculous pleurisy may be consecutive to tubercular depos- its in the parenchyma of the lungs, and then it is strictly secon- dary. Again, in the second place, it may arise from the deposit of tubercles in the pleura itself; and, lastly, the inflammation of the pleura is antecedent to the tubercular deposit, the pleuritis thus becoming an exciting cause of phthisis. The latter effect of pleuritic inflammation should then be considered in this con- nection. Why is pleuritis more prone to produce tubercular dis- ease, than pneumonitis ? To answer this may be difficult ; and yet such is the fact. May not the absorption of pus into the blood be one prominent cause ? This, like all other impure mat- ter in the blood, must tend to produce more or less debility, must excite an irritative fever simulating the hectic of phthisis. That febrile action which most nearly resembles the hectic of phthisis, should cseteris paribus be most likely to afford conditions most favorable to the development of tubercles. This may be one cause of the tendency of pleuritis to generate phthisis. Pleuritis is also complicated with many other diseases, with pericarditis, hepatitis, peritonitis, and rheumatism. These com- plications, however, are not sufficiently common to be made sub- jects of separate consideration. DIAGNOSIS. The diagnosis in complicated pleuritis, must de- pend upon that accurate discrimination in the balance of symp- PLEURITIS. 263 toms, which is the possession of every close observer of disease. Each symptom is often a complex phenomenon, divisible into a number of separate signs. If in the course of pneumonitis, the friction sound occurs, if there is great dullness on percussion, the limits of which change on every change of posture, if there is egophony, if either one or all of these physical signs, are com- bined with those of pneumonitis, the diagnosis will be evident. Complications with phthisis will of course, give the signs of both diseases ; with pericarditis, will give the friction sound of pleu- ritis heard only during respiration ; while the friction sound of pericarditis is heard during the suspension of respiration. The effusion, and consequent dullness of pericarditis is confined to a small space the preecordia ; that of pleuritis extends over the base and sides of the lung and is in general changed by any change of posture. When both these trains of symptoms are coetaneous, the nature of the complication will be evident. The diagnosis of other complications must depend upon principles similar to those already suggested. The PROGNOSIS will depend upon three conditions, the nature of the complicating disease, the extent of the pleuritis and the constitutional state of the patient. Pleuro- pneumonitis, has al- ready been referred to. Pleuritis complicated with phthisis is always very dangerous ; with pericarditis it is unfavorable. TREATMENT. The complications of pleuritis necessarily involve the same principles of treatment as the more distinct forms of the disease. Regard must be had to the nature of the malady with which the pleuritis is associated. If its complication be with some other sthenic inflammatory disease, the anti-inflammatory means must be used in the process of cure. If associated with pneumonitis, all narcotics should be used with more caution than in its simple form. When arising from the retrocession of eruptions from the surface, warm bathing with stimulants and diaphoretics should be used. When complicated with phthisis, the treatment for the latter disease is most appropriate. 264 THORACIC DISEASES. SECTION VI. PLEURITIS OF CHILDREN. Pleurisy is common in children of all ages ; but is most fre- quent in its uncomplicated forms after the age of five years. Anterior to that period it is, in general, associated with pneumon- itis and bronchitis. Sometimes it is a sequela of eruptive fevers. During the whole period of convalescence from them, while the functions of the skin are but partially restored, this disease in children is prone to occur. PATHOLOGY. Primitive pleurisy in young children does not present any striking anatomical characteristics which distinguish it from the disease in adults, as in the case of pneumomtis. There is, however, one fact in those cases, which points out the affection. It is a want of compressibility in the lung from the liquid effusion. The effect of this is seen in the modification of the physical signs which it produces. DIAGNOSIS. Dullness on percussion presents its usual charac- teristics. But the respiratory murmur, on the contrary, instead of being feeble or absent, assumes a bronchial character, equally as distinct as that of pneumonitis, but far more extensive, accom- panying the dullness on percussion, and being often heard all over the affected side, and without crepitation or rhonchus. "This bronchial respiration" says Dr. Swett, "as connected with pleuritis, is the rule, in the pleurisy of young children, not the exception, as in that of adults." PROGNOSIS. Pleuritis in children is far more dangerous than in adults ; more especially when it occurs as the sequela of eruptive fevers, of pneumonitis, or pertussis. In infants this disease, whether simple or complicated with pneumonitis, bronchitis or whooping-cough, is often fatal. In twenty-four hours, by caus- ing suffocation, it may end in death. In very young children it seldom assumes a chronic form ; for in them the later stages of the disease are less liable to occur. PNEUMOTHOKAX. 265 TREATMENT. Pleurisy in children requires the same measures which are recommended for adults, modified according to age and to the susceptibility of infancy to the influence of reme- dies. Relaxing enema should be more frequently directed, and the use of the more harsh and debilitating means, more cautiously prescribed. Warm demulcent poultices, instead of irritants or ves- icants, should be employed. In the chronic form, the frequent sponging of the surface with warm salt water, as an external ap- plication, is excellent. For an internal remedy, the sirup of the iodide of iron, administered in simple sirup of sugar, is sometimes serviceable as a tonic. Other varieties and modifications of pleurisy are described by some authors. But they are for the most part, unimportant, and their consideration is of no practical utility. CHAPTER XII. P N E U M T II 11 A X . The_ term pneumothorax from the Greek TTVSU^OC air and chest, which would, according to its etymology, mean any collec- tion of air in the chest, is at present, used to designate more es- pecially the effusion of aeriform fluids in the cavity of the pleura, whether the air exists alone, or whether/there is sometimes a cer- tain quantity of liquid mingled with it. In the first instance the collection receives the name of pneumothorax, in the latter that of hydro-pncumothorax. Notwithstanding the distinctive use of these terms, the name pneumothorax is in general applied to both of these phenomena. Before the commencement of the present century, it had not been made a subject of thorough investigation. To Laennec be- longs the honor of first making it an object of scientific study. PATHOLOGY. Pneumothorax is a consequence of lesions of both the lungs and pleura. In most cases it is the result of tubercular disease perforating the pleura pulmonalis, before it adheres to the .pleura costalis. The cavity formed by tubercles communicating 34 266 THORACIC DISEASES. with the pleural sac, and at the same time with the bronchial tubes, gives rise to this affection. Sometimes pneumothorax oc- curs in gangrene of the lungs. A gangrenous eschar may break into the pleural sac, and a communication be formed with the bronchi. It is possible for an emphysematous vesicle in the lung to rupture the pleura covering it, and thus produce a pneu- mothorax. Another way by which this has been supposed to be produced, is the secretion of air by the absorbing surfaces of the pleura, or by the decomposition of inflammatory products. A fistulous opening or wounds produced by accident or by the hand of the surgeon sometimes are its immediate cause. When the air enters the cavity, it compresses the lung and gives- rise to the physical signs of this organic lesion. Perforations of the pleura, as we should expect from the more frequent location of tubercles in the left lung, oftener are found on the left than on the right side. Reynaud found in forty cases of perforation, twenty- seven on the left lung, and thirteen on the right. DIAGNOSIS. General symptoms. These are very equivocal, and altogether insufficient to serve as the basis of a confident di- agnosis. Dyspnoea caused by the compression of the lung is a very constant symptom. Its degree depends upon the amount of air and liquid in the cavity of the pleura, upon the rapidity and permanence of the accumulation, and upon the condition of the opposite lung. Casteris paribus the dyspnoea will be less, when the admission of air or the collection of other fluids, is gradual ; because the organs of respiration and circulation, to a certain ex- 1 tent, accommodate themselves to the new condition. Most frequently it happens that the entrance of the air is sud- den, and as a consequence, dyspnoea quickly becomes severe at- tended with acute pain, and sometimes with a sensation as if something had given way in the chest. In case the pleural sac is distended with pus, a copious expectoration of a puriform charac- ter suddenly supervenes as a result of the opening into the pleura. Sometimes it so happens that the pleural opening is so large as> to permit a ready egress of the air admitted into the pleura, in which case the dyspnoea will be less violent. On the contrary, if PNEUMOTHORAX. 267 the opening be such as to permit the passage of air only one way, like the valve of a pump, then at every inspiration more air is ad- mitted than is expired, until the accumulation is so great as to cause suffocation.' Very soon, under such circumstances, death may occur, preceded by the most painful and laborious breathing, intense anxiety and general prostration. When one lung from the effects of the disease is unfitted alone to arterialize sufficient blood to sustain life, and the pneumothorax occurs on the other side, sudden death is almost inevitable. When communication first takes place between the lung and pleural cavity, there is not only dyspnoea, but also sharp pain and cough, in consequence of the irritation of the pleura. This is sometimes very severe ; so much so as to cause a great depres- sion of the vital powers. This, however, is usually followed by reaction, giving rise to the ordinary symptoms of fever. The cause of this irritation, by many, has been supposed to arise di- rectly from the contact of air with the serous membrane, the pleura. Concerning this, there is, however, some doubt. A prob- ability exists, that the acid matter from vomicse, drawn into the pleural sac with the air, produces much of the effect usually as- cribed to another cause, [ti case liquid exists in the pleura, ante- rior to the ingress of air, its admission would be very apt to pro- duce chemical changes in the effused substances, and thus secon- darily cause irritation. In general, the sitting posture is most agreeable to the patient, or if he lies down, the decubitus, after the pleuritic pain has subsided, is on the affected side. Special symptoms. Without some more sure means of detect- ing the existence of pneumothorax than the general symptoms, a correct diagnosis could not without great difficulty, if at all, be determined. Of all the diseases affecting the chest, this, though once so obscure, has now become by the aid of the physical signs, the most easily detected. As soon as the air enters the pleural sac, the lung collapses, and consequently less air is inspired. The effect of this, is to lessen the respiratory murmur on the affected side. Under such circumstances, what does percussion reveal ? The pleura distended with gas, and the lung collapsed, afford condi. tions which, from reason we should expect to favor the production 268 THORACIC DISEASES. of great resonance. And thus we find it to be. On the diseased side, we get the drum-like sound on striking the chest, while on the opposite side we have more flatness on percussion, but a louder respiratory murmur. So that the physical signs on the two lungs, are opposite. On the diseased side there is great res- onance, but very feeble if any respiratory murmur. On the healthy lung, the resonance is less than on the other, but the res- piratory murmur is more distinct than natural. As the disease ad- vances, and pus collects, or if there is at first water in the pleura with the air, the percussion detects the exact extent of the liquid collection, it draws the line of demarkation between the water and the air. Whenever the patient changes his position, the loca- tion of the flatness is likewise changed, and the metallic tinkling is heard when the patient, after lying in one position, suddenly changes it ; so that the liquid adherent to the sides of the pleura falls in drops upon the surface of the liquid below. The produc- tion of this sound, however, is a matter concerning which there is not among physicians a full agreement. There are according to some two methods by which it is produced ; the first by the fall- ing of the liquid drops as above described, the second, by the passage of air, which, entering the liquid in the pleural sac beneath its surface, causes, as it perforates the surface of the liquid, little bubbles to rise, that burst and produce the sound. This bursting of bubbles, makes a sound, which, on being reflected from one side of the cavity to the other, comes to the ear so modified, as to produce that peculiar tinkle, which authors describe. Sometimes this occurs when there is no liquid in the pleural sac. In this case how can it be produced? Mr. Castelnau's views will explain the phenomenon. The metallic tinkling, according to his theory, may be caused by the bursting of air-bubbles in the tuberculous abscess itself, just at or near the point of perforation, and the sound thus generated resounding in the large air-chamber formed in the pleural sac, changes a rattle which would otherwise be a mucous rale, into metallic tinkling. The metallic tinkling is by no means a constant sign, therefore it should be considered as of less importance than amphoric respiration, and resonance of the voice. To detect the presence of liquid in the pleural sac, the Hippo- PNEUMOTHORAX. 269 cratic method of succussion is useful. The mode of procedure is simple. The patient is placed in a sitting posture, and while the body is quickly though moderately shaken by applying the hands upon his shoulders, the agitation of the fluid thus produced, is very clearly heard. Another morbid sound heard in this disease, is the amphoric respiration, that buzzing sound caused on blowing into a bottle. The cavity of the pleura may be compared to the bottle, arid the perforation of the pleura, to the opening into it. As soon as the pleural sac becomes somewhat distended with pus, the amphoric respiration ceases, or if the opening is covered with false mem- brane, so as to prevent the exit of air from the cavity, after hav- ing entered it in inspiration, the amphoric sound is not heard, and there is either no morbid sound, or a slight bronchial respiration. Attendant upon the amphoric respiration is a corresponding res- onance of the voice, which follows the same course and ceases at the same time. As pneumothorax passes into empyema, the physical signs de- cline, and there is then dullness on percussion, with almost entire absence of the respiratory murmur. The accumulation of pus is then much greater than in ordinary cases of pleurisy, sometimes amounting to several gallons, causing extreme difficulty of breathing. By the general symptoms of pneumothorax, certainty cannot be obtained in diagnosis. With the physical signs, however, there is no difficulty in detecting the nature of the lesion. These are not only pathognomonic of the existence of the disease under consideration, but they go farther, and enable us to point out its different stages, its degrees of severity, and its gradual passage into empyema. PROGNOSIS. The prognosis is generally unfavorable. In gen- eral, it is speedily fatal. But this result depends as much upon the disease which causes the pneumothorax, as upon the degree of the existing lesion. In case one lung is affected by tubercular disease, or in any way prevented from performing its functions, and the healthy lung is so perforated as to produce on that side, pneumothorax, the effect is necessarily fatal. In such a case the 270 THORACIC DISEASES. patient dies in a few hours or days, from exhaustion and or- thopnoea. In forming the prognosis, therefore, the condition of the lung, not the seat of perforation, should be made an object of special study. If one lung is healthy it may carry on the functions of both. Whenever, then, we have one healthy lung and the other is not the location of tuberculous disease, the prognosis is more favorable. But if the diseased lung is tuberculous, although the other is comparatively healthy, the probability of recovery is small, for the phthisical disease soon extends to the healthy lung, and de- stroys it. If the pleura is completely filled with pus, the effect is to develop hectic fever, and therefore the physical condition is worse than when the pleural sac is filled with air alone. Under the most favorable circumstances, we should consider the progno- sis uncertain, and in those cases complicated with phthisis, there is no hope of a cure. Pneumothorax has no fixed period of duration. In a short time it may prove fatal. Dr. Gerhard relates one case in which death took place in less than an hour, and two other cases in which life was prolonged until the lapse of fifteen or eighteen months. In one of these latter cases, the patient made two long voyages, and, according to his own statement, did full duty as a seaman while his pleura was enormously distended with pus. TREATMENT. The means which art is able to employ in the cure of this disease, are limited. There are, however, certain general indications to fulfill, a knowledge of which is serviceable to the practitioner. If the pain is severe and if dependent upon a perforation of the pleura with inflammation of that membrane, local means, such as warm fomentations, or sinapisms applied over the painful region may be employed with advantage. The de- gree to which general relaxants should be carried must be propor- tionate to the intensity of the symptoms. Some preparation of lobelia, or the employment of some other diaphoretic and seda- tive agent administered according to the necessities of the case, will be useful to allay inflammation. Cough preparations sometimes are useful. In cases in which there is but little hope of permanent relief from medicine, and in PNEUMOTHORAX. 271 which other nervines are not found sufficiently potent to allay pain, opiates should be given to quiet the system, and procure sleep. If prieumothorax caused by a wound, should suddenly arise in a strong and vigorous constitution, the most active relax- ants in the materia medica should be immediately employed in order to keep down the inflammation. To prevent febrile excitement, and to promote absorption of effused liquids, those means should be used which, in the article on Chronic Pleuritis, are recommended. To sustain the strength, the most efficient tonics and nutritive diet, should also be used, In case these do not have any good effect in consequence of the disease of the digestive functions, gentle emetics should be occa- sionally prescribed. If remedies fail to prove at all salutary, and the disease should threaten immediate suffocation from the quantity of air and liquids in the pleural sac, the gas and liquid should be evacuated by the operation for empyema. Experience proveSj that, under certain circumstances, the opening of the chest may be made with a good effect. Successful cases are reported by Laennec, by Riolan and Ponteau. In case the opening is made without the admission of air, the disease under favorable circumstances admits of cure. [The operation, according to Dr. Gerhard, is allowable when the object is to favor the escape of gas, or the pus which is after- wards secreted. Immediately after the perforation of the pleura, the dyspnoea may suddenly become so great that immediate death is to be feared. The side may be punctured in the usual mari- ner, and the gas be allowed to escape ; but, as in this case, the subsequent dangers of the disease are certainly increased by ex- posing the cavity of the pleura so freely to the air, the operation cannot be justified except it be a measure of absolute necessity , J at best, it relieves the patient only for a short time. In the cases of advanced empyema which follow pneumothorax, paracentesis may be performed when the oppression is extreme, and the inter- costal spaces are much bulged out. The operation is, however, very far from being devoid of danger ; for the free entrance of the air into the cavity, tends to increse the inflammation, and to aggravate the hectic fever. The usual precautions should be carefully attended to after the operation, 272 THORACIC DISEASES. If it be thought advisable to perforate the chest, the best mode is perhaps the one performed by Dr. Bowditch of Boston, who states that he has several times performed the operation without difficulty, or subsequent suffering to the patient. He uses a very small trocar, and allows the fluid to flow through it ; the instru* ment is too small to allow of the entrance of any notable quan- tity of air, and in that manner all mischievous results from the operation are prevented.] CHAPTER XIII. HYDROTHORAX. Although generally applied at present exclusively to dropsical collections in the pleura, the term hydrothorax, may from its ori- gin u5wp, water, and dwp|, chest, be applied to any case of serous effusion within the cavity of the chest. In this cavity three kinds of dropsy may exist. In the first place, there may be dropsy of the parenchyma of the lungs, called pulmonary oedema ; secondly, dropsy in the pleural sac, and thirdly, dropsy of the per- icardium. The former of these varieties is already treated of; the latter will be considered when I treat of diseases of the heart. Only of that serous effusion, therefore, which distends the pleura! cavity, I shall speak in this place. PATHOLOGY. The pathology of the pleural variety of hydro- thorax, is, in some respects, similar to that of chronic pleurisy. The liquid effusion, however, is serous and not purulent. In color it is more frequently yellowish or brownish, and sometimes is tinged with blood. The pleura is not, in many cases diseased and in this respect, it differs from chronic pleurisy. It is apt to be associated with tubercles in their earlier stages of develop- ment. Like other forms of dropsy the effusion often depends upon inflammation of the secreting membrane. Some authors consider the effusion arising from this cause as distinct from dropsy ; but they fail to assign a good reason for the distinction. Whatever is its origin, when the effusion is serous in its character. HYDROTHORAX. 273 it must be considered dropsical. A very reasonable explanation of the phenomenon is, that the plenral membrane is irritated, arid that the congestion of the blood-vessels, is relieved by the serous effusion, before the inflammatory process is far advanced. In the pleural sac more or less serous fluid after death is fre- quently found, which, during life had caused but little disturb- ance. This may be the result of effusion in the dying state, or of chemical changes occurring after death. To constitute dropsy the effusion must be sufficient to derange in some degree the functions of life. Whenever existing in this manner, it causes extreme difficulty of breathing, always increased, by exertion, by walking, running or ascending heights, or by the horizontal posture. DIAGNOSIS. General symptoms. When the effusion is small, the dyspnoea is not great, but as fluid collects, the difficulty of breathing increases. In general, the patient lies on the side af- fected, and is most comfortable when the shoulders and chest are elevated. In the advanced stage the horizontal position causes great suf- focation, from the tendency of the fluid when the patient lies down, to impede the pulmonary functions. Sometimes placing the patient, during a few moments on his back, may cause sudden death. Preceding such a result, there are a livid or purplish hue of the face, and an almost black appearance of the lips, caused by a deficient oxydation of the blood. In many cases, it is associated with other forms of dropsy. Anasarca, dropsical swelling of the eye lids, especially in the morning, and in the evening cedematous swelling of the feet, frequently accompany it through most of its progressive changes. Special symptoms. The affected side is dilated so much in some cases, as to be apparent to the eye, and easily known by measurement of the corresponding parts of the chest on oppo- site sides. The heart, mediastinum, diaphragm, in fine, all adja- cent organs, are more or less displaced when the effusion is very copious. The intercostal spaces are bulging, and the ribs farther separated than natural. By succession, a splashing sound may sometimes be produced. The vibrations of the chest caused by 35 274 THORACIC DISEASES. the voice, over the side in which the effusion exists, are less easi- ly felt by the application of the hand. Fluctuation is sometimes perceptible on placing the left hand on the chest, and with the other percussing near to the position of the former, and over an intercostal space. Bichat considers increased dyspnoea caused by pressure upon the abdomen, a useful diagnostic sign. From chronic pleuritis it may be, in general, distinguished by the absence of acute pain, and of the general and local signs of inflammation ; and by the extreme difficulty of breathing, which at times, comes on in paroxysms. It is attended by dropsy of some other part of the system, much more frequently than pleuritis. The physical signs of hydrothorax resemble very much those of effusion from pleuritis. " There will be less dullness on per- cussion, and diminution of the respiratory murmur in the depend- ent parts of the chest ; and afterwards we have egophony in the middle regions ; but as the effusion is seldom so extensive in hy- drothorax as in pleuritis, or so much confined to one side, we do not get that abolition of the sound on percussion, and of the res- piration and voice, or the displacements of organs, or the peurile respiration on the opposite side, which occur in the latter disease." PROGNOSIS. The prognosis depends to a great extent, upon the nature of the exciting cause of the effusion. If this can be re- moved, or if a recurrence of the same causes can be prevented, hope of recovery may be entertained. Spontaneous cures are re- corded. Some critical evacuation may be the means of effecting a radical cure. Dr. Watson relates a case in which hydrothorax was greatly relieved by the copions expectoration of a limpid fluid. Instances are recorded in which dropsical effusions have been cured by profuse vomiting of serous matter. When not dependent upon tubercular disease, the hope of a cure should be much greater. If the pleural sac be simply distended by an infusion caused by a congested state of the pleura, appro- priate treatment will generally produce recovery. Under more adverse circumstances remedial agents will for some time give re- lief, so great and durable, as to lead the patient to hope for com- plete restoration. But after the temporary removal of the liquid,, HYDROTHORAX. 275 it continues to return again and again, until the ordinary evacuents are not admissible in the treatment on account of the increase of debility which they induce. Under such circumstances, of course, the prognosis must be almost hopeless. TREATMENT. In this disease the remedies should be adapted to the particular exigencies of each case. There are, however, cer- tain general considerations to which the practitioner should have reference in the application of curative agents. In the first place, the object should be to correct, as far as practicable, the patholog- ical condition on which the effusion depends. Secondly, to re- move by absorption or otherwise, the effusion, by means which, while they attain the desired object, debilitate but little the pa- tient. And thirdly, to support the strength of the system, under the exhausting influence of the disease, or of remedial agents. The same remedy sometimes fulfills more than one of these indications. When the effusion is the result of an irritation of the pleura, and strong inflammatory symptoms arise, the relax- ing remedies should be immediately prescribed. Diaphoretics and sudorifics, and, if there is very much febrile excitement, emetics, and the use of the vapor bath or warm bath, all these means are to be applied as necessity requires. This kind of medication fulfills two indications. It tends to remove from the irritated membrane, by restoring an equilibrium in the circulation, the congestion, and by exciting to activity those vessels which remove from the system detrita, it also tends on the well established principle, that " the fulness of the blood-vessels and the activity of absorption are in an inverse ratio to each other," to remove from the pleural sac, the serous accumulation. These means may be employed with much more efficiency, than the ordinary anti-phlogistic treatment which, while it is the cause of present relief, produces such an anasmic state, as to ren- der the patient more susceptible to another attack than before. Another advantage arising from the course of treatment above di- rected, is the fact, that it prepares the system for the application of other remedies, and for the reception of strength from the ready and good digestion of food. To the side affected a large irritating plaster should be applied, 276 THORACIC DISEASES. and kept on until a free discharge of sero-purulent matter is pro- duced. The kind recommended in the chapter on pleuritis may be used. Cathartics, if rightly administered, proper care being taken during their operation, to keep up a free diaphoresis, are use- ful. The following is perhaps as good as any : R Podophylliae gr. i. ad gr. ii., Jalapae pulveris gr. x., Capsici gr. ii., Pottassse bitartratis gr. x. Misce. Give in sirup or molasses. When, instead of irritation of the serous tissues, we have re- laxation or debility with an anasmic state of the blood, or when tubercular disease is the exciting cause of the pleural irritation, the treatment must be modified according to the indications. If the former condition exists, then tonics are the most useful means! These should consist of preparations of iron, or of peruvian bark. Five grains of the pill of carbonate of iron of the U. S. Pharma- copoea, conjoined with sulphate of quinia, may be given three or four times per day ; and it will be found convenient to unite in the same mass some diuretic which the case may require ; such as squills, or some other of which the dose is sufficiently small to admit of easy combination. To these means, the vegetable diu- retics should be added as very important adjuncts. Juniper, eu- patorium purpureum, aralia hispida, galium aperine, apocynum androsemifolium, and asparagus. The erigeron canadense, a diu- retic and tonic, is considered by some, as preferable to the above mentioned articles. "Among the remedies employed," says Dr. Wood, "is the decoction of pipsisewa which is, at the same time mildly tonic, astringent, and diuretic, and is admirably adapted to mild cases of this kind requiring a gentle impression very long continued." Hydrastin salicin, apocynin or apocynum androsemifolium are among the best tonics. The latter article is both tonic diuretic and laxative, and is, therefore, better adapted to these cases than almost any other remedy. In case tonics cause difficulty of breathing, and are not well borne, on account of the inactive state of the digestive organs, the most effectual HYDROTHORAX. 277 means of removing the difficulty, is to give two or three times a day, alternately with the tonic remedies, the compound lobelia pills. To the above treatment, the use of the vapor bath should be added. This should be continued until the extremities become warm, and the pulse full, and strong at the wrist, and then, before its full relaxing power is felt, which might cause too much debil- ity, the patient should be thoroughly rubbed by assistants, in order to produce capillary circulation. In case there is a deficiency of biliary secretion attended with constipation and feeble circulation of the blood, I have found the folio wing preparation very useful : R Capsici Hydrastis a a 5 i. Fellis inspissati bovum q. s. Make a mass, and divide into four grain pills. Dose, from three to five three times a day. In some cases podophyllin may be added. When there is no evidence of excitement and none of debility or anosmia, the remedies should be directed to the removal of the effused fluid. [For this purpose no remedies according to Dr. Wood, are more effectual than diuretics. From this class he se- lects as the most efficient, the bitartrate of potassa. Even when the disease is the effect of tubercular deposits, he u when the strength of the patient will permit, prescribes this in small, but frequent doses, in order by its manner of administration to secure a more potent effect upon the kidneys. His method of giving the remedy is to direct a certain quantity of the salt to be added to a pint of water, or other vehicle in a bottle, and the whole to be taken in wine-glass doses, at certain intervals in twenty-four hours ; the caution always being observed to shake well the bot- tle before using, and then to take the sediment with the superna- tant liquid. Half an ounce during the day is usually sufficient ; but sometimes it will be necessary to increase to an ounce, an dunce and a half, or even two ounces, in the same period of time. In case it acts too much upon the bowels, it may be proper to check its action by astringents. If there be dyspeptic symptoms, to the bitartrate of potassa there should be added an infusion of 278 THOUACIC DISEASES. juniper berries of wild carrot seed or some aromatic, as cardamom, fennel or ginger. By Black-well, squill is considered as peculiarly useful in dropsy of the chest. Beginning with two or three grains three times a day, the dose should be quickly increased, either in quantity or frequency of repetition, until it produces nausea. After this effect is obtained, the remedy should be less- ened in quantity and subsequently kept within the nauseating point. Dandelion is useful when the dropsy of the chest is complicated with disease of the liver. Various stimulating diuretics have been used; such as horse-radish, mustard, garlic, buchu, and copaiba. The following formula for a stimulating diuretic infusion was much employed by the late Dr. Parrish : Take of juniper ber- ries, mustard seeds, ginger roots, each bruised i ; horse-radish, parsely-root, each bruised, ii ; hard cider, Oiv; A wineglassful to be taken four times a day.] Emetico-cathartic remedies, possessing diuretic properties, have been much used in dropsy. The different articles recommended for this purpose, are the bark of the different species of sambucus, the root of black elder, the broom(scoparus) and hedge-hyssop (gratiola officinalis.) The cathartic should be repeated according to the strength of the patient. In general its administration two or three times a week is sufficiently often to secure all the bene- fit derivable from its use. Diaphoresis, at present, is not so much depended upon in the cure of dropsy as cathartics and diuretics. But, in hydrothorax caused by disease of the lungs, or pleura, it is of greater ser- vice than has been supposed. One reason why its use has been so much abandoned, is the fact, that too much dependence has been placed upon the common means of exciting capillary action, and when these means to a great extent had failed of accomplishing the desired effect, the conclusion was hastily drawn, that no rem- edies tending to produce copious and long continued diaphoresis, were of much utility. The means upon which the practitioner can, with the most confidence rely in the fulfilment of this de- sign, are the warm or vapor bath, the hot-air bath, followed by the administration of nauseating doses of lobelia, gradually increased HYDROTHORAX. 270 in frequency and quantity, until emesis is produced. The gel- seminum, also, promises to be a useful auxiliary remedy in bring- ing about the same result. In several cases I have succeeded in effecting diaphoresis by the use of minute doses of aconitum fre- quently repeated. The wet sheet, is also in many cases avi easy and most effectual means of producing diaphoresis. The time and manner of its application must of course be left to the dis- cretion of the physician. Immediately after the use of evacuents, strong tonics should be given to prevent a return of the effusion. Diet and drinks. The diet should be nutritious. That which is at the same time easily digested, and which contains a large amount of nutriment, is in general best for the patiem. All un- necessary interference with the habits of the patient should be avoided. Drinks may be given to patients in this disease in small quantities often repeated, according to the intensity of the thirst. No general rule can be laid down in regard to the quantity allow- able. In some cases, -copious drinking of water or other liquids, tends to produce diaphoresis, and thus acts as a curative agent. But it is in general best to be governed somewhat by the desires of the patient ; directing him to use such drinks as tend to act either upon the skin or kidneys. Cold infusions of diuretic arti- cles, old cider, the potus imperials,* cream of tartar whey, and in some cases of debility, gin, all these drinks may be used to quench thirst. For the same purpose, I have directed patients to drink freely of Congress water. After the evacuation of the flu- ids, if the patient is debilitated, a residence near the sea, and fre- quent bathing in salt water, are very excellent to tone up the sys- tem and fortify it against the aggression of new attacks. In one case which came under my care, and in which the use of di- uretics was not followed with very salutary effects, the frequent use of the vapor bath and mild emetics of lobelia, together with hydragogue cathartics soon removed the dropsical effusion. De- bility, remaining a long time, although the most active tonics were prescribed, I recommended a residence near the sea, and fre- quent bathing in its water. Improvement immediately com- menced, and a radical cure was soon effected. ' Vide mode of preparation, U. S. Dispensatory, p. oG-. 280 THORACIC DISEASES. In case the remedies above described fail, paracentesis may be Resorted to with some benefit, when there is reason to believe, that the disease has originated in mere vascular irritation, or inilam- mation of the pleura. In other cases it would be a desperate re- sort, calculated to afford only temporary relief, and yet endanger- ing the life of the patient by exciting fatal inflammation. But when sudden death threatens from suffocation, the practi- tioner might perhaps be justified in resorting to a temporary ex- pedient. In all cases it should be employed as a last resort. Di- rections for the operation are found in the chapter on Chronic Pleurisy. CHAPTER XIV. EMPYEMA. This word from its etymology ev in, -ruov pu"s, signifies a collection of pus in any part of the body. Among the ancients, however, it had a signification more extensive than it now has among the moderns. The former applied it to those purulent collections which form in the cavities of the viscera, or in the interior of the principal organs. The latter apply the term empyema to effusions of blood, of pus, or of serum into the cavities of the pleurae, as well as to that operation by means of which those liquids are re- moved from the interior of the chest. The effusions in the chest, whether serous, bloody or purulent, are the results of diverse dis- eases, of which the pathology, symptoms, causes and general prin- ciples of treatment have, in the chapter on pleuritis, been consid- ered. I shall, therefore, consider its diagnosis, prognosis, and some of the more specific points of treatment. DIAGNOSIS. The diagnosis of this disease, by the ancients, and the moderns, until after the discovery of the physical signs has been considered very uncertain. With pneumonitis, the ancients confounded it. Its sputum they described as "bilious, bloody, yel- lowish, viscous, greenish or blackish." The deficiency of the common signs of this disease, was ac- knowledged by Cullen in his work on pneumonia. " Under this EMPYEMA. 281 head, I mean to comprehend the whole of the inflammations affecting cither the viscera of the thorax, or the membrane lining the interior surface of that cavity; for neither do our diagnostics serve to ascertain .exactly the seat of the disease, nor does the dif- ference in the seat of the disease exhibit any considerable varia- tion in the state of the symptoms." PHYSICAL SIGNS. The diagnosis must depend upon the physi- cal signs ; the dullness on percussion, the absence of respiratory murmur over the affected side ; while on the opposite lung, the respiration is more loud, and somewhat peurile ; the metallic tink- ling arid amphoric respiration are sometimes heard. Fluctuation caused by succussion and the other general and special symptoms described in the chapter on Chronic Pleuritis, are often present. PROGNOSIS. In the majority of cases, this is unfavorable. The character of the effused fluid, the constitutional disturbance, the degree of strength, and condition of the lung opposite the dis- eased one, should be considered in forming the prognosis. Some- times, the pus spontaneously perforates the parietes of the chest, and is discharged during a long time. The cases of recovery are rare. But sometimes they occur, and therefore, some hope may be entertained of relief and cure either spontaneously or from an operation. TREATMENT. In case the spontaneous discharge of pus is great, and the system shows signs of depression, means should be used to keep up the strength. For this purpose nourishing diet and the strongest tonics should be used. If there is a purulent expectora- tion, this should be promoted by expectorants, and if there is evi- dence that the digestive organs suffer from any collection of mor- bid matter, an emetic adapted in thoroughness or mildness to the exigencies of the case should be administered. In all cases in which purulent or sero-purulent matter is absorbed in large quan- tities into the blood, the emunctories should be stimulated to ac- tion. This effect is produced by the use of the vapor bath. In caso there is not much febrile excitement, alcoholic drinks when combined with tonics, expectorants, and nourishing food, are not 36 282 THORACIC DISEASES. inadmissible. Pure wine, porter, or ale, and if the kidneys are inactive, gin may be given to keep up the strength of the system, while the suppurative process is going on. These last means are most serviceable, when the empyema is the result of tuberculosis. In such cases, even when the hectic fever is considerable, their use may be persevered in. If, however, there be fear of produc- ing over-excitement, alternately with the administration of alco- holic stimulants, a pill of extract of lobelia, or some other relax- ing and sedative agent should be given. Mr. MacDonnell has written an interesting article on empyema, in which he relates several cases wherein tumors appeared on the surface of the chest. These were red, tense, pulsating, and shin- ing. At length they burst, giving exit to a large quantity of pus. The empyema attended with these pulsating tumors, he calls the Pulsating Empyema of Necessity. Mr. MacDonnell relates several cases of much interest. In one of them, two tumors appeared on the left side, one near the spot occupied by the apex of the heart, the other between the tenth and eleventh ribs near the spine. The opening of the tumors gave relief, but the patient subsequently died of phthisis. In another case, two tumors, each about the size of a hen's egg were observed, one just below the nipple, the other between the tenth' and eleventh ribs, about two inches from the spinal column. These tumors were rather tender to the touch, a few turgid veins surrounded their bases, the integument covering them was discol- ored, and reddish, and they both possessed a well-marked fluctua- tion, and a distinct, perceptible, and diastolic pulsation. Other cases of a similar nature are related by Mr. MacDonnell. In one case of empyema, the pus made its way into the bronchial tubes, and was removed by expectoration. These tumors arising from the " Pulsating Empyema of Nec- essity^ may be distinguished from Thoracic aneurism, by (a), The history of the case, (b), The dullness extending over the whole side, the pulsation being felt only in the external tumor, (c), The absence of thrill, (d), The absence of bruit of soufflet. (e), The extent and nature of the fluctuation. Froniencephaloid dis- ease of the lungs and mediastinum, by (a), The absence of ex- pectoration resembling black currant jelly, (b), The absence of PHTHISIS. 283 persistent bronchitis. Such cases as above described are not often found. Occasionally they may supervene in consequence of badly treated acute pleuritis. I have seen one case similar to those de- scribed by Mr. MacDonnell. The fistulous opening was upon the left side of the spine, about an inch exterior, and between the tenth and eleventh ribs. From a gill to a pint of pus was dis- charged daily for about a month, gradually diminishing in quan- tity, until at the end of three months it ceased. By the use of mild emetics and tonics, of which the wild cherry, and sirup of the iodide of iron were the most important, a comfortable degree of health was obtained. The affected side was left permanently contracted. Empyema has a peculiar effect upon the functions of the liver. This organ is enlarged from an engorgement with blood. This enlargement is evidently identical with that which takes place in other affections of the lungs and heart, where, in consequence of the partial suspension of their functions, an addi- tional amount of labor is thrown upon the liver. The removal of this enlargement is one of the first signs which indicate the subsidence of the effusion, and the return of the compressed lung to the performance of its normal functions. CHAPTER XV. PHTHISIS. The word phthisis, from the Greek i PATHOLOGY. The general appearance of encephaloid disease, is that of -a brain-white solid of varying consistence, with a pinker hue than that of tubercle, occurring in tumors sometimes en- cysted, or infiltrated through the tissue of the lung. Sometimes, the tumors are soft, and cellular ; sometimes tough, resembling the pancreas in appearance. A predominance of the vascular, and cellular structure, with patches of extravasated blood, constitutes the fungus hasmatocles. Encephaloid matter infiltrated into the parenchyma of the lung, in some cases, presents an appearance intermediate between those of tuberculous and hepatized consoli- dations. Sometimes inelanosis is combined with encephaloid dis- ease. The black matter may occur infiltrated in a natural struc- ture or in distinct tumors or deposits of an irregular cellular or- ganization. Care is necessary, in order not to confound with inelanosis, the accumulations of black, pulmonary matter, which take place to a great extent in the lungs of old people, especially among the inhabitants of large towns. This black appearance- is supposed to be caused by the inhalation of particles of dust, of a carbonaceous nature from the atmosphere. DIAGNOSIS. In the commencement of this disease there are no very manifest symptoms developed. There may bd a little dyspnoea, slight cough, and a little expectoration. With the advance of PULMONARY CANCER. 371 the disease the symptoms become more marked, the cough is in- creased, the expectoration is more copious, and there is an almost constant pain in the chest. Haemoptysis, too. may occur, in con- sequence of the lesion of the pulmonary vessels. The constitu- tion sympathizes with the local disease ; the pulse is excited, there are emaciation, increasing debility, and a peculiar straw color to the countenance, and the superficial veins become enlarged. Dropsical swelling is observable in the extremities, and the system gradually sinks under a low. asthenie form of inflammation going on in the chest or abdomen. The cancerous deposit, gives rise to dull- ness on percussion, sometimes to bronchial respiration, and vocal re- sonance, or to a ronchus and mucous rale. The cancerous disease tends to produce contraction of the affected side, which, of course, is porportioned to the extent to which the disease has progressed. The pulmonary tissue becomes condensed and the bronchi some- times are obliterated, in which cases there will be no respiratory murmur. CANCER OF THE MEDIASTINUM. PATHOLOGY. The growth of the tumor may be so great as to compress the vessels of the heart, and induce sinus of valvular disease, or by retarding the free cir- culation of the blood may produce oedema, or may fill so large a space in the chest as to cause the physical signs of an empycma. These cancerous tumors vary in size, sometimes weighing several pounds. They present the three forms of cancerous growths. THE DIAGNOSIS of cancer of the mediastinum is difficult. There are only a lew distinctive symptoms, among which are the straw color of the skin, the codema of the face, and upper extremities, a tendency to anasarca in the lower limbs: cancerous tumors on other parts of the body, the contraction of the side accompanied by bronchial respiration, heard over it, instead of the dilatation so characteristic of hydrothorax, and empyema. Phthisis usually affects -the upper parts of the lungs: cancer may attack any portion, although it oftener affects the upper por- tions, than the lower. Neuralgic pain often extends down the arm. which is not the case in phthisis. The pulse is also less ex- cited, hectic seldom severe, cavities arc not formed. Tubercles in general before the case terminates fatally, affect both lungs, 372 THOHACIC DISEASES. while cancer usually affects one only. Cancerous tumors are usually larger than those of a tubercular nature. This disease may simulate thoracic aneurism or even disease of the heart. This results from its location near some large blood-vessel, in which case it may obstruct the flow of blood, and hence, produce those physical conditions which excite the bellows murmur. Its recognition under such circumstances must depend upon the exis- tence of the cancerous tendency in the general system. The heart is not so enlarged as in hypertrophy. From aneurism it may sometimes be distinguished by its location : aneurism being on the course of the aorta, and being attended by pulsation, a thrill and bellows murmur ; cancer is not prone to give rise to these phenomena. It is evident, however, that nothing very defi- nite can be determined by the symptoms in those cases in which complications exist ; and under the most favorable circumstances the diagnosis must be uncertain. The Prognosis may lie readily inferred from the fatal results following cancerous disease in other parts of the body. The Treatment must be almost wholly palliative ; the great object is this ; to remove urgent symptoms by sedative and re- laxing agents. Complications should be treated according to the nature of the disease with which it is associated. Dyspeptic symptoms should be removed by gentle emetics of lobelia, and by tonics. To purify the blood the best alteratives may be used in conjunction with other means, to produce a normal action of the cutaneous vessels. DISEASES OF THE HEART. 373 DIVISION II. DISEASES OF THE HEART. Formerly, diseases of the heart were very imperfectly under- stood. In their organic forms they have been considered very rare, and their results almost always fatal. Very frequently they have been confounded with other diseases of the thorax, such as pulmonary congestion, and hydrothorax, and sometimes with those of other parts of the system, such as dropsy and apoplexy, and va- rious other affections. By the discoveries of Corvisart, Laennec, Louis, Cullen, and Bouillaud, in France ; of Hope, Williams, La- tham and Stokes of Great Britain, and of Dr. Pennock of this country, the nature of cardiac diseases, and their diagnosis and treatment, are now made as intelligible as that of the majority of other diseases. Before the discovery of auscultation, diseases of the heart could not without great difficulty be distinguished from those ot the lungs. But physical exploration, and pathological anatomy have to a considerable extent removed the impediments to their diagnosis. The investigations into their causes have also pro- duced many valuable results, and have clearly shown, that in a majority of cases especially in young persons they arise from in- flammation. General symptoms. The pulse is nearly synchronous with the pulsation of the heart, following it at a very slight interval. Sub- ject to all the irregularities of the cardiac pulsations in relation to duration and irregularity of beat, it often enables us to detect the derangement of the central organ of the circulation. But it is not always a sure indication. Intermission of the pulse may exist, when there is none in the heart. The ventricu- lar contraction may be too feeble to transmit the impulse along the arteries of the extremities. The quantity of blood in the heart may be so small as not to cause vigorous contraction, and a feeble, irregular pulse may be the consequence. Irregularities of 374 THORACIC DISEASES. the pulse independent of cardiac disease may exist for a long time, but caeteris paribus they are more apt to occur in connection with it, than independent of it. Dyspnoea is another symptom of cardiac disease. Sometimes it is partly dependent upon nervous derangements, bat more often upon direct interference with the functions of the lungs, either by pressure upon that organ, or effusion into the parenchy- /natous tissue or pleural sac. Pain. In disease of the heart, painful or disagreeable sensations often occur in the cardiac region. Sometimes it is very acute, felt near the left nipple or at the extremity of the sternum. This is sometimes attended with dyspnoea ; sometimes extending across the chest and passing down the left arm. Palpitations, which are pulsations so violent as to be trouble- some to the patient, are often experienced in disease of the heart. They arise from nervous irritability in which case they are often the cause of needless fear to the patient, and sometimes of per- plexity to the physician. This symptom, unless attended with other indications of cardiac disease should not be much depended upon ; for when alone, it presages no certain organic derange- ment, and should excite suspicion only when it continues for a long time. The secondary symptoms resulting from cardiac disease are nu- merous, and such as would naturally result from irregularities of the circulation of the blood. The blood may be driven with too great force into the brain, as in hypertrophy of the left ventricle, into the lungs in a similar condition of the right ventricle, or it may be retarded in its return from the abdominal viscera by im- pediments in the right side of the heart, and finally it may be feebly propelled throughout the entire system in consequence of the cardiac obstruction. Hence, congestions in one organ, and 'anaemia in others ; hence apoplexy, vertigo, cpistaxis and haema- temesis occur. These symptoms vary according to Urn nature of the cardiac disease, the constitution of the patient, and various other modifying circumstances. If active congestion is present, \vo have the turgid, distended state of the blood-vessels, the prom- inent eye, the flushed and swollen face; if the passive, then we have the purple lips, livid complexion, and the general tendency DISEASES OF THE HEART. 375 to oedema. The whole heart is seldom diseased at once. It may be confined to a single valve or cavity. 'Causes of Heart Disease. Inflammation, attacking the mem- branes of the heart, whether external or internal, becomes a fre- quent cause of cardiac lesions. Pericarditis has but little tendency to produce organic changes, while endocarditis is very prone to produce such a result. Of all the causes tending to produce dis- ease of the heart, acute articular rheumatism is the most frequent. More than half the cases of this variety of rheumatism, accord- ing to Dr. Gerhard, are more or less complicated with cardiac dis- ease. There are other causes, which, although not so important as the one above mentioned, arc, nevertheless, worthy of notice. These are violent nervous excitement, sudden injuries inflicted by a strain, a sudden propulsion of the blood into the heart in an ab- normal quantity and with great force, advanced age, ossific deposits in the valves or internal membranes. Functional diseases of the heart are produced by causes as vari- ous as those of all nervous disorders. In general anaemia, ner- vous irritability, gastric derangements, and a suppression, or inter- ruption of the menstrual discharge, give rise to violent palpita- tions. In young men. particularly those of a nervous tempera- ment, of studious habits, accustoming themselves to excess in study, the same scries of symptoms is sometimes developed. Termination of Heart Disease. Inflammatory affections of the heart may terminate in recovery, and the patient experience a complete restoration to health. Dr. Hope remarks: "Many think that the expectation of effecting an improvement in the treatment of diseases of the heart, is chimerical ; and they think so. because, not being, accustomed to recognize the diseases in question before they have attained an advanced stage, they are preoccupied with the old and popular idea of their incurability. To such it might, perhaps, be a sufficiently philosophical answer to reply, that an improved knowledge of the nature and causes of a disease, must alone necessarily lead to an improvement in the treatment, and that therapeutic weapons are dangerous, when wielded in the dark. Rut here we may go much farther ; we may say that, by the improved means of diagnosis, the maladies under 376 THORACIC DISEASES. consideration, may be recognized, not only in their advanced, but in their incipient stages, and even, when so slight as to constitute little more than a tendency. We may say, on the ground of in- contestable experience, that, in their early stages, they are, in a large proportion of instances, susceptible of a perfect cure, and that, when not, they may in general be so far counteracted as not materially, and sometimes not at all, to curtail the existence of the patient. We may, accordingly, predict that the term " dis- ease of the heart." which at present sounds like a death knell when uttered by the physician, will hereafter become by familiar- ity, not more alarming than the term asthma, under which it is frequently disguised." This description of the curability of disease of the heart, is somewhat too hopeful. Chronic organic affections in "general do not terminate so favorably. They may continue for years, not increasing in severity, until some exciting cause adds new force to the disease and causes sudden death. When once the disease has commenced on the internal membrane, it is prone to extend ; one difficulty leads on to another; hypertrophy produces valvular disease and inflammation of the endocardium. So that, when endocarditis in the young ends in apparent recovery from the acute attack, it leaves behind in most cases a disease in the valves which, by impeding the circulation of the blood, produces an un- natural action of the heart, and at last terminates in disease of the muscular tissue. Functional disease of the heart is seldom dangerous, except in those cases in which it generates organic affections. The influ- ence of age is considerable in the production of cardiac disease. Cardiac affections are usually slow in their access, and consequently they are more often observed in the old than in the young. They also depend for their production, upon that feeble circulation of the blood arising from deficient nutrition, which is more frequent in the aged. On account of their greater exposure, males are more subject to organic diseases of the heart than females. Their frequent muscular exertions both in labor and amusement, tend to produce permanent lesions. , The functional derangements of the heart, are more common in females than in males, because they are more subject to symptomatic affections, on account of their greater nervous irritability. EXAMINATION OF THE HEART. 377 GENERAL DIAGNOSIS. The nature of the origin of the disease, has important bearings on its diagnosis. If inflammation of a rheumatic character preceded the attack, if disease of the heart is hereditary, or if the gouty or rheumatic diathesis is fully devel- oped, then, the existence of organic affections of the heart should very strongly be suspected. But if, on the other hand, there were peculiar marks of deranged nervous action preceding the cardiac symptoms, a probability exists, that the case is one of functional, not of organic-disease. To this probability is added more evidence, if the patient presents strong signs of a nervous temperament. Pain in the region of the prascordia, and a sensation of weight and stricture there felt, are indications of this disease ; likewise, orthopncea. fullness of the cervical veins, increased dyspnoea in ascending a hight, blueness or lividity of the lips. A thrilling pulse, and cedematous effusions are also somewhat characteristic. < GENERAL PROGNOSIS. In organic disease of the heart the prog- nosis is unfavorable. The effects of extensive disorganization of the valves, and of the internal membrane of the heart and aorta, and of hypertrophy and dilatation must from the nature of all such changes be attended with danger to life. In acute inflam- matory cases, the proper application of appropriate remedies gen- erally gives relief; sometimes very soon, sometimes after a longer period. In those cases which seem to presage a fatal termination, the symptoms sometimes abate by degrees, until the disease is finally, so far as external phenomena can be perceived, verging on towards a cure. The prognosis then must depend upon the character of the modifying circumstances, and not upon any one symptom exclusively. CHAPTER I. EXAMINATION OF THE HEART, In making an examination of the heart, several points need par- ticular attention. The most important of these are its positioa 48 378 THORACIC DISEASES. size, impulsion, sounds, rhythm, and the mode in which the heart acts, whether regularly or spasmodically. , POSITION or THE HEART.- The heart lies in the centre of the chest, inclining a little to the left side and to the lower portion of the sternum. Its direction is oblique from right to left. Superi- orly, it extends to the intercostal space between the third and fourth ribs ; inferiorly to the base of the thorax, or to about the ninth dorsal vertebra. To the left it extends nearly or quite to the nipple, to the right it extends a little beyond the edge of the sternum. The apex is between the cartilages of the fifth and sixth left ribs, at a point about two inches below the nipple, and one inch on its sternal side. The base of the ventricles corresponds nearly with the middle of the third rib. According to Dr. Pen- nock, the only fixed and stationary point is at the valves of the aorta ; other parts being movable more or less around that as a centre. And, therefore, the exact situation of those valves the aortic semilunar becomes of some importance. A needle pierc- ing the middle of the sternum opposite to the middle of the car- tilages of the third ribs, and perpendicular to the plane of the sternum will pierce them. A needle introduced perpendicular to the tangent of the curved surface of the thorax, between the car- tilages of the second and third ribs, half an inch from the left margin of the sternum, pierces the semilunar valves of the pul- monary artery. " The septum between the ventricles, coincides with the osse- ous extremities of the third and fourth and fifth ribs, and on the fourth rib is midway between the left margin of the sternum and nipple." The positions of the orifices of the aorta and pulmonary artery, of course, correspond very nearly with those of their valves, the valves being situated a little superior. The left auric- ulo ventricular orifice, is under the lower edge of the cartilage of the third rib, and a little to the left of the median line. The memory of these facts is very necessary in the diagnosis of valv- ular disease. The heart is in contact with the diaphragm below, and the lungs, on its right and left sides overlap it, leaving a small triangular space uncovered, of variable dimensions, under the car- tilages of the fourth and fifth ribs of the left side. EXAMINATION OF THE HEART. 379 Size of the Heart. Much care has been taken to obtain by ac- curate observation the exact size of the heart. Laennec com- pared its size with that of the fist of the individual. This, though a simple comparison, and one which may always be easily made, is by no means accurate. Others have with great precision, weighed the heart, and brought forth the conclusion that its weight is about seven or eight ounces. It is always greater in males, than in females.* Bizot in order to arrive at a still greater degree of precision, has adopted the method of measuring the heart. His conclu- sions are, that the heart increases in size as age advances, that its size corresponds with the breadth of the shoulders, and not with the height of the individual, that it is larger in males than in females. To ascertain the normal size of the orifices, is very important. Dr. Taylor has suggested a method of very easy application. The mitral orifice just admits according to his measurement, the first two fingers of the hand ; the tricuspid orifice, the three first fingers. This, like the comparison of Laennec, is not accurate, but is of some practical utility, where great precision is not nec- essary. In order to ascertain whether the valves will close the orifices the experiment suggested by Dr. Swett, is useful and conclusive. Having removed an inch or two of the aorta and pulmonary arte- ry with the heart, he then makes a transverse section of the heart near the apex, so as to open the cavities of both ventricles. The heart being suspended by hooks passed into three different points of the aorta, so as to keep the vessel open, water is poured into it. If the valves are in a perfectly normal condition, they will shut, completely closing the orifice against the passage of the liquid. The same experiment may be successfully tried with the pulmonary artery ; likewise, with the mitral valve, it is equally satisfactory, but not completely so with the tricuspid. Through The normal heart may be assumed to average for the whole life, above puberty, about 9 oz. iii absolute weight, and 8J oz. in bulk, for the male; aiid 8 oz. or a little more in weight, and 7 oz. or a little more in bulk for the female; and to bear after death, to the weight of the person, for the male, the proportion of about 1 to 160, and for the female, of 1 to loO. [Clendinning, Croonian, Lectures for 1838.] 380 THORACIC DISEASES. this latter valve, Dr. King of London contends that regurgitation even in health, takes place. The size of the heart is modified by disease, and consequently the physical signs, especially percussion, are changed. Impulsion. The beating of the heart may be felt by placing the hand upon the chest, as nearly as possible over the apex of the organ. The impulsion is caused by the striking of the apex against the ribs, and is generally supposed to arise from the con- traction of the ventricles, and to be synchronous with the systole. The truth of this opinion, however, is disputed by Dr. Alfred Stille. On the contrary he contends that the impulse of the heart is synchronous with, and produced by the diastole of the ventri- cle. [Vide Stille's Elem. Gen. Path. p. 319.] The impulse is given almost exclusively by the apex of the heart. The sensa- tion is, therefore, sharp as if caused by the quick stroke of a small hammer. Exercise or nervous irritability, increase its violence. Hypertrophy also tends to make the impulse greater, and by the increase of the bulk of the heart, extends the shock over a much greater surface. Great muscular debility, arising from asthenic diseases, may cause the impulse of an hypertrophied heart to be less powerful than natural. Its degree varies even in health, according to the activity of the circulation. In those of a phlegmatic tempera- ment, and the corpulent, it is often almost imperceptible, while in those of a nervous temperament, and not fleshy, it is very strong. In pregnancy, too, it is subject to great variation. It corresponds with the beating of the arteries, both being dependent upon the same cause. The radial pulse, as well as the pulse of the larger arteries, is nearly synchronous with the beating of the heart, there being a very short interval between them. The number of pul- sations bears a relation to the number of respirations, the former being to the latter as four and a half to one. Irregularities in the cardiac pulsations are sometimes observed in healthy persons ; and this phenomenon often ceases when the patient is laboring under an attack of disease, and returns again with the return of health. A very feeble systolic contraction oc- curring in connection with a stronger one, may give rise to inter- missions in the radial pulse when there is none in the heart. The EXAMINATION OF THE HEART. 381 heart, however, is subject to true intermissions. Its impulse is much changed by disease ; sometimes becoming very frequent, strong or weak, or frequent and irregular. Hypertrophy is thought to augment its force ; in some cases to such a degree as to make the impulse seem like the stroke of a hammer within the chest. Debility diminishes it, and the removal of the heart from the surface of the thorax by pleuritic effusions or by other similar causes. The location of the impulse is changed by any cause which can displace the heart. Its character varies greatly. Among these common variations is the " short, sharp, quick stroke of irritation which is wholly different from mere frequency of beat ; the former referring to the individual pulsations, the latter to their succession. Instead of re- sulting from the striking of the apex of the heart against the ribs, the impulse is sometimes produced by the whole organ rising up, as it were, under the hand, and giving rise to the sense of a slow heavy motion, rather than of a blow. This happens in dilatation and hypertrophy." In relation to the repetition of the impulse, it may become so frequent that it cannot be counted, even exceeding 200 strokes in a minute, or may be reduced even as low as 15 or 20, in the same length of time. The relation of the successive impulses to each other, is liable to excessive irregularity. Sometimes a stroke is now and then omitted, either at stated intervals or quite irregularly. In such cases, the pulsation is said to be intermittent. Occasionally, it is remittent, one or several strokes being more feeble than those which precede and follow. " Not unfrequently the rapidity of succession varies greatly ; the pulsations being now very short and rapid, almost running into one another, then again prolonged, slow, and distinct; and all these diversities may be combined in the same case. " The double or triple impulse which is sometimes in quick succession, may be owing to as many partial contractions of the ventricle, before the full systole is accomplished. Some have sup- posed that the diastole is concerned in these irregularities, as there is at that period a sudden and apparently active swelling out of the ventricle, which must make some impression upon the parie- 382 THORACIC DISEASES. tes of the chest. It has been maintained, that there is in health a double impulse of the heart, scarcely sensible in its ordinary state, but becoming obvious in excitement, the first impulse being dependent upon the systole, the second, much feebler, upon the diastole, and felt between the second and third ribs." [Belling- ham and Sibson, Lond. Med. Gaz., March 1850, p. 445.] "Palpitation sometimes gives the peculiar thrill called fremisse- ment cataire," or the purring tremor. It is so called because it gives to the hand when applied to the thorax, that peculiar sensa- tion felt on the chest of a cat while purring. Over .aneurisms of the arch of the aorta, it is most distinctly perceived In valvular diseases it is also felt. It may be excited in nervous persons by agitation of mind. Unless the origin of this symptom can be traced to that cause, serious obstruction to the passage of the blood through the heart should be considered as very probable. 1. PHYSICAL SIGNS. Signs by Inspection. Inspection alone is of little value in the diagnosis of diseases of the heart. In health a slight movement over its apex may be seen. In disease sometimes this becomes very manifest, being visible through the clothing. This abnormal movement sometimes extends to the carotids and jugulars, and even the body seems to be jarred by the cardiac impulse. But the difficulty is, to distinguish between the causes of the palpitation, whether they arise from organic lesions or from functional derangements. In cases of great effusion into the pericardium, the external form of the chest may be somewhat altered. In the prascordial region a prominence is then often seen, and the left nipple is a little more projecting than the rigit. 2. Signs by Percussion. "In percussing the prascordial re- gion, the best pleximeter is the fore finger of the left hand, and the best hammer, the first two fingers of the right hand." Over that part of the thorax with which the heart is in contact, there is dullness on percussion. But as the margins of the lungs extend over a part of the surface of the heart, the percussion is modified, as we recede from the portion of the heart in contact with the chest, becoming gradually less and less dull, until the normal resonance of the parts of the chest over the lungs is heard. EXAMINATION OF THE HEART. 383 This change is gradual ; so that the precise boundary line cannot be marked out by the sounds of percussion. The sound elicited by percussion over the praccordial region, varies according to the position of the body, the degree of expan- sion of the chest, and the nature of the diseases which affect ad- jacent organs. Before deducing any practical inference, \ve should, therefore, take into consideration all these circumstances. The dullness is increased by pronation of the body, decreased by supination. Certain affections directly interfere with the indications on percus- sion. On the one hand, pleuritic effusion, hepatization of the lung, tumors and enlargement of the left lobe of the liver increase the dullness ; on the other, emphysema, pneumothorax and great gastric flatulence, decrease it. After making proper allowances for all these conditions, percussion may be of practical utility by indicating the existence of hypertrophy of the heart, cr of effu- sion into the pericardium. But how does percussion indicate the existence of that condition of the heart, or of hydropericardium ? " In the natural state, the extent of dullness does not exceed a space of about three inches in length, measured along the ster- num, and about two and a half inches laterally; that is, the dull- ness extends to a short distance within the nipple, and at about the middle of this space, just at the left margin of the sternum, it amounts in most persons almost to perfect flatness. The great- est dullness of sound extends over a breadth of one inch and a half to two inches; that is, over the space which the lung does not overlap ; so that there are two sounds of percussion, one nearest the sternum which is flat, and the other more external, which is simply dull. The difference depends upon the percus- sion being made in the latter case over both the tissue of the lungs and heart." [Dr. Gerhard.] Now if the heart be enlarged, or if there is any effusion into the pericardial cavity, the dullness is increased in. the direct pro- portion to the increased enlargement. When the dullness results from hypertrophy of the heart, it is more rounded in shape, the heart preserving for the most part its original form than when it depends upon pericardial effusion. In the latter case the peri, cardium, though distended with liquid, still preserves its pyramid- 384 THORACIC DISEASES. al form, the apex being towards the upper part of the chest, With these preliminary remarks, I now answer the question above proposed. Hypertrophy is indicated by the extension of dullness over a space larger than that over which it is perceptible in health, and also by the form of that space which by percussion, and per- haps in some cases, by inspection also, is proved to be nearly round. Pericardial effusion is indicated by the abnormal exten- sion of dullness, and by the pyramidal form, apex upward, base downward, of the space over which the dullness is perceptible. 3. Signs by Auscultation. The action of the heart gives rise to sounds which, though not audible in health, are so by the ear when applied to the chest. Some persons especially after exer- cise can hear the beating of their hearts. In making examina- tions of this organ, a stethoscope should be used, whenever the sound from a very limited space is desired. But the ear should be applied directly to the chest, whenever we wish to detect all the slightest murmurs. In order to prevent the interference of the pulmonary sounds we should, during a very limited interval, di- rect the patient to stop respiration. Dr. Swett prefers the solid stethoscope. During the examination the position of the patient should be fixed and erect, and the prEecordial region fully exposed. In fe- males a very thin covering may be allowed. The sounds of the heart may be divided into normal and ab- normal. These in some cases so blend together, as to make it difficult to detect the precise limit of the former, and the begin- ning of the latter. A full acquaintance with the former, must al- ways precede all practical knowledge of the latter. And I cannot too strongly urge the necessity of studying the physical condition of the heart in health, and of becoming familiar with all the phe- nomena of its normal action, before beginning the study of the diseased heart. 1. Normal /Sounds. The normal sounds of the heart are two : the first synchronous with the impulse, and, in vessels near the heart, with the pulse is duller and longer ; the second is shorter and clearer. The latter immediately follows the former; and af- ter the second, an interval of silence succeeds. The first sound, heard during the systole, and hence often called systolic, is most EXAMINATION OF THE HEART. 385 distinct over that part of the chest in contact with the ventricles. The first sound has been compared to that produced by jerking a cord as thick as a swan-quill. The second sound, accompanying the dilatation of the ventri- cles, and the contraction of the auricles, and hence sometimes called the diastolic, bears a close resemblance to that produced " by lightly tapping with the soft extremity of the finger of one hand near the ear, the knuckle of a bent finger of the other hand." It is heard most distinctly over the semilunar valves; that is "upon the sternum opposite to the inferior margin of the third rib, and thence for about two inches upwards, along the diverging courses of the aorta and pulmonary artery respectively, the sound high up the aorta proceeding mainly from the aortic valves, and that high up the pulmonary artery, being mainly from the pulmonic." The causes which produce the first sound, have been the sub- ject of discussion, and much theorizing. Of their true nature, Lnennec was comparatively ignorant, and Magendie broached a theory, not founded en facts, Mr. Turner, of Edinburgh, first pointed out the true connection of the sounds with the move- ments of the heart. He maintained that the first sound occurred during the systole, the second during the diastole. Magendie maintained, that the first sound was caused by the striking of the heart against the ribs; Rona met, that the two sounds were valv- ular, the first caused by the tension of the auriculo-ventricular valves; the second by that of the semilunar or sigmoid valves. In relation to the cause of the second sound, nearly all patholo- gists agree with Ronannet ; in relation to that of the first sound, authors, in general, agree, that it is compound, the result of sever- al causes, among which the principal is the muscular contraction of the ventricles. That muscular contraction generates sound, is not a matter of theory, but of fact. Dr. Wolloston and many others, have demon- strated it. A stethoscope, applied over a contracting muscle, brings sound to the ear. By applying the stethoscope to the heart of a c:ilf, taken from the body after sensation is destroyed, but before the animal is quite dead, a sound may be distinctly hoard. A cause of minor importance, is the friction of the blcod against the semilunar valves, 49 386 THORACIC DISEASES. The other causes, adduced by authors, the tension of the anri- culo-ventricular valves, the striking of the heart against the ribs, the auricular contractions, may have some tendency in conjunc- tion with the more important causes, to produce the systolic sound. The second sound of the heart is simple, and caused, as is fully demonstrated by experiments* by the tension of the semiluriar valves of the aorta and pulmonary artery during the diastole of the ventricles. "From the commencement of the first sound until its return, a little less than a second of time is occupied. The duration of the several parts of the series which constitutes what may be called a beat, is the rhythm of the heart. The beat, as described by Laennec, consists of three periods : -1. The ventricular systole which occupies nearly half of the time of a whole beat. (Mr. Bryan says a third only.) 2. The ventricular diastole occupies a fourth ; or at most a third. 3. The interval of ventricular repose occupies a fourth or rather less, during the latter half of which the auricular systole takes place. [Hope on the Heart.] The first and second sounds together are compared by Dr. Wil- liams, to that produced by the pronunciation of the monosyllables lubb dup. Dr. Bowditch prefers this alteration, lubb tuk. The French have used a very wrong sounding word tic-tac, to repre- sent the double sound. In duration, extent and loudness, the sounds of the heart differ in health. It is probable that the sounds produced by the two ventricles are not identical; but since the contraciions of both sides of the heart are synchronous, nothing very definite in rela- tion to this can be easily determined. The quicker, and more energetic the ventricular contractions* the louder is the sound. The thickness of the thoracic parietes has a modifying influence. The loudness of the ventricular con- tractions, ca3teris paribus, is inversely proportional to the thickness of the parietes of the chest. By the influence of mental emotion, or bodily exertion, the in- terval of repose may sometimes be almost annihilated. Hepatiza- In the New York Journal of Medicine and Surgery for April, 18-10, is a detailed account of experiments establishing the mechanism of the sounds of the heart. EXAMINATION OF THE HEART. 387 tion of the portions of the lung contiguous to, and overlaping the heart may cause its sound to extend over a space unnaturally lame. ABNORMAL SOUNDS: The sounds of the heart may be altered in character, or increased in intensity. The alteration may con- sist in a slight abnormal harshness, or the natural tone may be wholly changed. The first sound is most frequently altered. A nervous temperament may increase its loudness, or a hardening in its muscular structure, conjoined perhaps with slight ob- struction of the semilunar valves. In the former case, the symp- tom is temporary, in the latter it is continuous. The phrase " in- creased loudness," and the word "roughness," are, as used by Dr. Gerhard, nearly identical in meaning. "If the roughness is in- creased," he continues, "it passes into the bellows or rasping sound. The former of these is less marked than the latter. A bellows sound is generally described as a prolonged and purring sound, usually heard in the first sound of the heart, and, there- fore, produced chiefly by muscular contraction, although it may also arise from alterations at the auriculo-ventricular valves, in which case it occurs during the diastole of the heart." The term bellows has been applied to this sound on account of its resem- blance to that produced by blowing strongly into a bellows. It differs in the degree of its harshness. In its simplest form it is "slight, short and breezy," the slightest prolongation of either sound of the heart (bruit de souffle, Fr.]. A stili greater degree of harshness constitutes the pure bellows sound (bruit de soufftet, Fr.]. Next is the filing or ?*aspin